Commentary

Is empiricism a false promise, or does the cure lie within ourselves?


By Tamara M. Greenberg, PsyD

Many of us who are engaged in the world of psychoanalysis and psychoanalytic therapy feel like underdogs. We feel that our theories have been devalued, dismissed by managed care, American medicine, and are ignored by the public who increasingly want simple cures to complex problems. One possible manifestation of our insecurity is that the 2011 Division 39 meeting in New York City carries the title, “How we Matter.” It seems curious that a field so filled with ideas, evidenced by journals overflowing with clinical material and scientific research, not to mention theoretical disputes, would need to hold a conference with a title that begs such recognition. We do matter, but whether or not anyone else besides us recognize how we matter is apparently an open question.

In a world in which analysts and analytic clinicians can feel lonely and misunderstood, the news about empirical research supporting psychodynamic therapy[1] can be met like the only water available in the midst of a severe drought. Indeed, psychodynamic psychotherapy has recently been viewed as vindicated, largely in response to Jonathan Shedler’s 2010 American Psychologist article, “The Efficacy of Psychodynamic Psychotherapy”. And while any public acknowledgement of psychoanalytic therapy can nourish those of us who feel marginalized, I have found myself intrigued by the jubilation this publication has brought to some of our colleagues; research suggesting the efficacy of psychodynamic therapy is not new. I remember reading about the efficacy of psychoanalytically oriented approaches in a book published by Anthony Ross and Peter Fonagy in the 90’s (though now in it’s second edition), What Works for Whom? There has, in fact, been a lot of research over the last couple of decades on the efficacy of psychodynamic psychotherapy, much of which shows that it works, especially for complicated patients.

Is it the case that we seem to care more about this research now? Some may currently be attuned to the research cited in the Shedler article because they have not been aware of earlier studies. Others may care because they feel more trivialized than ever before. Still, some may pay attention to this research because it is harder to find patients to fill practices and are looking for ways to justify what they do.

Fortunately, we have a few talented, articulate authors touting what psychoanalytic treatment can provide—some of whom are even doing research that challenges the dominant paradigm of what is expected of psychotherapy research. Among these authors are Wilma Bucci, Glen Gabbard, Peter Fonagy, Jonathan Shedler, Paul Wachtel, to name but a few. Additionally, two new books, “Psychotherapy is Worth It” (2010) and “Psychodynamic Therapy: A Guide to Evidence-Based Practice” (2010) offer more ammunition in the war on dominant views of how psychoanalytic treatments work.

The first title, edited by Susan Lazar, is replete with psychotherapy outcome research studies and the cost effectiveness of therapy regarding various treatments with a number of diverse populations. The volume includes a stellar chapter by the late Allan Rosenblatt on the efficacy and cost saving aspects of psychodynamic therapies and psychoanalysis. Far from relying on the Holy Grail of randomized controlled trials, Rosenblatt includes naturalistic studies, and those in which random assignment to groups has not been met. The reasons for including these studies is that it is extremely difficult to accurately study long-term treatments because of problems with control groups, randomization of patients, varying and long duration of treatment, follow-up, and cost. Several of these studies offer quite impressive results regarding both psychodynamic therapy and psychoanalysis. For example, one study described in the volume by Rudolf, Manz, and Ori (1994) looked at 44 patients and found psychoanalysis to be superior to psychotherapy. This study, conducted as part of the Stockholm Outcome of Psychoanalysis and Psychotherapy Project, found that increased frequency of sessions corresponded with the most positive outcomes.

Psychodynamic Therapy: A Guide to Evidence-Based Practice, edited by Richard F. Summers and Jaques P. Barber offers a slightly different kind of tonic to the beleaguered analytic clinician, though not quite as gratifying as the Rosenblatt chapter in the aforementioned book. Their approach tends to be pragmatic in a way that might not be as useful to those trained in more traditional analytic schools of thought. Additionally, the book appears to be written for an audience with varying levels of psychoanalytic education. Nevertheless, the authors accurately lament the loss of training in psychodynamic approaches within academia. For example, they state, “For every pearl of psychodynamic wisdom that is taught, there is a critical comment made by another esteemed faculty (p.7).” Regarding research, the authors advocate for including other kinds of data--beyond randomized controlled trials and the inclusion of naturalistic studies, which offer a fuller view of what actually happens in the analytic encounter. Again, these authors highlight the ways that psychodynamic therapy works, through the use of case studies, as well as utilizing variable methods of empirical research.

I recommend both of these books highly, as they add to the growing body of literature and acknowledge the efficacy of psychodynamic psychotherapy and psychoanalysis.

However, despite the victories of authors who have been able to communicate their ideas as well as multiple forms of scientific research to the wider academic and popular press world, there have been flags of caution raised by some of our colleagues. For example, see McKinley (this issue); Hoffman (2009). These authors, as well as many others, have been hesitant to embrace empiricism because of the possible limitations it might bring to the understanding of the analytic process. McKinley also raises the astute point that embracing empiricism might mean dogmatic manualization of our techniques and process, which would likely be a disservice to our patients, as well as ourselves.

Of course there are limitations to empiricism, and especially limits to randomized controlled trials, but as Shedler has pointed out, scientific research is not an either/or proposition.

Shedler (2004) states: “Without a credible context of justification, a discipline becomes a hodgepodge of competing theories with no systematic method for sifting sound from unsound beliefs. The progress of knowledge requires both contexts: it is a matter of both/and, not either/or” (p.613).

In other words, revering randomized controlled trials carries many limitations, including a blind adherence to reductionism and positivism. But when advocates of psychoanalysis throw away empiricism and act as if we live in an impermeable bubble, we have may have achieved a pyrrhic victory. By presuming that science does not apply to us, we have left ourselves vulnerable to a number of criticisms, including that we are not a credible or serious discipline.

Why would some of our colleagues take a defensive (as opposed to a welcoming) stance, particularly at a moment in which our field is gaining credibility? I suggest that psychoanalysis has a long-held fantasy that we operate as elite and unique fighter pilots in the wars on human suffering. Although in some sense, we do offer something that others can’t, we are still held up to the standards of science, the public, and most importantly, to the patients we treat. Shouldn’t we be expected to explain what we do, using current nomenclature and cultural demands?

We risk a lot when psychoanalytic ideas become religious or when we act as if the gods of psychoanalysis explain everything and act enraged when others question our ideas. Owen Renik (2007) has described the risks to this way of thinking in our field. Psychoanalysis is a specialized field, and a lot of education and training go into becoming a psychoanalyst, or even a well-qualified psychoanalytic therapist. But psychoanalytic ideas are not the only game in town. We have a lot of competition. Other theories seem to be equally as meaningful to some and are likely not just a defensive reaction to knowledge of the unconscious. For example, existential therapy has many followers, and includes many painful realities we’d rather not think about. Additionally, the positive psychology movement advocates attention to character structure. One problematic assumption, that we may be paying for now, is that we tend toward imagining that no one else is capable of our insights or embrace our theories of the mind. I am often reminded of how faulty this assumption is when I talk with purportedly CBT colleagues who describe resistance and defenses in their patients!

However, it is also problematic to idealize science, or the fantasy that science can explain all of what we do. There are risks on either side of the argument. Whether we embrace empiricism or allow ourselves to be contained in an insular psychoanalytic universe that does not truly exist or does not match the expectations of the public, we are bound to disappoint some people, including ourselves.

A collapse in thinking has occurred in relation to recent psychodynamic research publications, but in my view, not quite in the way that McKinley describes. There may be a tendency to say to ourselves and others, “These articles and books make it so we don’t have to justify our approach, or reach out to the public. We can stop worrying because these authors are addressing everyone’s concerns.” But the reality is, no matter what kind of hero(s) we wish to rely on to disseminate the values of our work, we are still charged with the hard task of adjusting our reputation. Let’s face it, somewhere along the way, we have missed the mark and let people down. From what I can tell from the popular press (i.e., Merkin, 2010) we have a lot of disgruntled patients. What worries me most about the excitement over the recent Shedler article is that in fact, no hero can save us; we have to save ourselves. Though we are fortunate to have talented clinicians and researchers doing the heavy lifting in the press and within academia, we need to do our own public relations, in our offices and among ourselves. If people are so suspicious of us, shouldn’t we look inward for the reasons why?

Maybe we should take accountability for the ways that our approaches have not worked for some people. By assuming that we have all of the answers, we have failed to acknowledge that some of our non-analytic colleagues also possess some insightful ways to diminish human suffering. And at the risk of being even more provocative, what would it mean if we were to integrate some of these other helpful approaches into our practices? Could psychoanalytic clinicians imagine a world in which we embrace multiple methods to make our patients better?

Further, our own infighting has not helped our cause. Our arguing and jockeying for the position of the newest and most novel theorist can provide us with a great deal of satisfaction. This certainly helps to fill our practices. It also gives us an outlet for venting our own frustration regarding the ways that psychoanalysis has not helped us enough when we have been patients. On the other hand, while our debates may be meaningful to us, they do not make sense to many of those (within our field and without), who just want to know if we can alleviate suffering.

I blithely mentioned in a Division 39 board meeting a couple of years ago that what psychoanalysis needs is a good publicist. I think we may still need a publicist, but is it fair to put this burden on Shedler and others like him? If we really want to make the focus of psychotherapy research about empiricism, then we have won a battle or two. But if we want to win the war, we all have to do the work of repairing our reputations. And that means working out our own differences, managing our narcissism related to the fact that our colleagues see things differently from us, and coming up with a coherent message to the public about what we can offer.

I wonder sometimes how confident we actually are about what we provide for our patients. For example, some in our field are disappointed that their own analyses have not been very helpful (usually articulated euphemistically as, “the analysis was only partially successful”); how many people do you know who have had a second or third analysis? Many patients, including some of our colleagues, have not felt that analytic treatment results in meaningful behavioral changes. If those who believe in the power of analysis seek second and third treatments, as is increasingly common, perhaps something in our system of current analytic approaches is flawed. If this is true, then it makes the task of communicating among ourselves and to the public even more complicated.

If we don’t figure out how to collectively communicate and agree on at least some key points, our discipline will likely not survive, and science won’t be responsible for our demise. We will continue to have a part in our own downfall, and not even the Shedlers of the world will be able to save us. z

References

Hoffman, I. Z. (2009). Doublethinking our way to “scientific” legitimacy: The desiccation of human experience. Journal of the American Psychoanalytic Association, 57, 1043.

Lazar, S. G. (ed.) 2010. Psychotherapy is worth it. A comprehensive review of its cost-effectiveness. Washington DC: American Psychiatric Publishing.

Merkin, D. (2010). My life in therapy. New York Times, August 8.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2),98-109.

------. (2004). Review of Clinical and Observational Psychoanalytic Research: Roots of a Controversy: Edited by Sandler, J., Sandler, A., Davies, R. Madison CT. International Universiteis Press. Journal of the American Psychoanalytic Association, 52, 610-618.

Renik, O. (2007) Practical Psychoanalysis for Therapists and Patients. New York: Other Press.

Roth, A. & Fonagy, P. (2005). What Works for Whom?: A Critical Review of Psychotherapy Research (2nd Ed.) New York: Guilford.

Summers, R.F. & Barber, J.P. (2010). Psychodynamic therapy: A guide to evidence based practice. New York: Guilford.

[1] In this essay, I use the terms psychodynamic therapy and psychoanalytic therapy synonymously.