Why psychotherapy?

August 16, 2018

This short video clip from the London-based School of Life is really excellent. I’ve never actually heard of the School of Life until I click on the link and am enlightened that they are a “global organisation dedicated to developing emotional intelligence”. I see that they have a whole complex (is that the collective noun for therapists? how about a whole interpretation) of therapists and teachers etc. Very professional-looking.

But that is all by the way. What psychotherapy videos do you like?



For and against psychoanalysis

June 13, 2012

Freud’s couch

One of the biggest debates in psychology is that between the psychodynamic school of thought and the cognitive behavioural school. I remember as an undergraduate participating in just such a debate and arguing for the CBT side. Unfortunately the other debater on my side didn’t consult with me beforehand and used her speech to attack Freud for all the reasons that people usually criticize him. She said he was sex-obsessed and addicted to cocaine. I was trying to put forward a more nuanced position, that while the psychodynamic school has a lot to offer, the CBT proponents are more relevant and focused on the present rather than the past. It was not that I strongly believed in this position but I was interested to debate the merits of both forms of psychotherapy.

Which brings me to the 44th Maudsley debate held quite recently at University College London. Peter Fonagy and Allessandra Lemma were in favour of the motion that “psychoanalysis has a valuable place in modern mental health services” while Paul Salkovskis and Lewis Wolpert were against.

Here’s the summary from the University College London website:

The debate opened with a striking majority in favour of psychoanalysis with 251 pro the motion, 36 abstainers and 44 against.

Prof. Peter Fonagy reviewed the evidence base for psychotherapies, noting that psychodynamic therapies fared no worse than CBT. He emphasised the convergence of psychodynamic and neuroscientific accounts of development.

Opposing the motion, Prof. Paul Salkovskis likened psychoanalytic schools to cults, criticised the absence of a symptom-based approach and some of the theories underpinning psychoanalysis.

Prof. Alessandra Lemma drew on her experience in psychoanalysis and CBT to argue for an eclectic approach, but argued that psychoanalysis provides an unrivalled framework for understanding interactional processes.

Prof Lewis Wolpert shared his personal negative experience with psychoanalysis when suffering from severe depression, and described it as a pseudoscience with no evidence to back it up. He also accused his opponents of conflating psychodynamic therapies with psychoanalysis.

It closed with 260 in favour of the motion, 33 abstainers and 38 against.

Listening to a podcast of the debate, I was struck initially by how the two sides seemed to be debating different things. Fonagy and Lemma argued for the value of psychodynamic psychotherapies while Salkovskis and Wolpert focused their attack on the practice of psychoanalysis itself.

As a psychologist with several years of experience I realized that I was still not entirely sure what psychoanalysis is and how it differs from psychodynamic psychotherapy. I had an idea that psychoanalysis involves four sessions a week on the couch with a trained analyst and that this goes on for a few years. Psychodynamic therapy by contrast usually involves once or twice weekly sessions and the client and therapist sit facing each other in comfortable chairs. I’ve always thought that this was a better way of doing therapy than lying down with the psychotherapist sitting behind you. Just because Freud practiced in this way doesn’t mean that this is the way that therapy should be done. Analysis also seemed to me to be a much harsher and less friendly way of doing therapy since there is less interaction and the analyst is not encouraged to bring their subjectivity to the therapy. Of course this is all just what I’ve read or heard and so I was hoping to be a bit more enlightened by this debate.

Well no. As I said, Fonagy and Lemma argued, very convincingly I thought, that psychodynamic therapy has a valuable role in modern mental health services while the other two raised some valuable points about the problems with classic psychoanalysis. In the general discussion that followed, members of the audience commented that they would like to see a greater dialogue between psychodynamic therapies and CBT. I’m aware of two examples of how both sides have incorporated methods and insights from the other. Psychodynamic therapists do challenge irrational beliefs and thoughts while CBT therapists at times try and uncover deep-seated (or unconscious) beliefs about the self (called schemas).

I was disappointed that Fonagy and Lemma didn’t address the perceived shortcomings of the practice of psychoanalysis itself but I can also see why they would consciously choose not to. At a time when the NHS is cutting back on psychodynamic psychotherapies (and other therapies), it would be foolish to provide any ammunition for this. But I suspect that many psychodynamically-oriented psychologists are slightly suspicious of the apparently elite psychoanalytic guilds. Within the psychodynamic school, those who can claim to be analysts are afforded greater respect (it seems) and sometimes appear to speak with more authority.

Moving to the broader issue of psychoanalysis as a body of knowledge and a theory of human motivation, behaviour and personality development, this has been invaluable in many disciplines and not just psychotherapy. As Lemma put it, psychoanalysis offers us a way of understanding personal interactions which is unrivalled by any other theory.

But I still find it rather intimidating to be confronted with the weight of psychoanalytic thought. Just researching this post, for example, I found an essay on Lacan and realised that I know almost nothing about him. Perhaps I need to do a “Lacan for beginners” post in order to educate myself.

But I’m also interested in broader debates around psychoanalysis and psychodynamic therapies and interventions. In South Africa we don’t even have a national health system and so psychotherapy is often out of reach of the majority of the population. There are also issues of elitism when we compare clinical psychology, counselling psychology, community psychology and social work. I certainly see the value of a clinical training and one that encompasses psychodynamic training. But even that is no guarantee that the therapy will be a good one.

I certainly came away from the debate with my belief in an eclectic approach intact. The only trouble with this is that an eclectic approach can be rather unfocused. But if being eclectic means being flexible enough to respond to the needs of our clients, then I’m all for it.