Avoiding a collapse in thinking: Commentary on Jonathan Shedler’s “The Efficacy of Psychodynamic Psychotherapy”By Mark McKinley
It is a precarious time for the practice and fate of psychoanalysis. Pressures within and outside the field are demanding greater accountability and proven effectiveness for analytically informed psychotherapies. Implicit in such demands is a call for the systematic establishment of a knowledge base derived through scientific investigation in order to justify particular treatment decisions. The debate surrounding the role and utility of science in the practice of psychoanalysis began with its inception, though it seems to be reaching a fevered pitch in our contemporary climate of evidence-based medicine, managed care, and a general populace expecting scientifically verified treatments. Fierce disputes related to how the field should or should not respond to these demands exacerbate tensions that threaten to fracture the underlying integrity of psychoanalysis (Chiesa, 2010; Cooper, 2008).
At the heart of this division are questions regarding whether or not psychoanalysis can be subject to scientific inquiry (Popper, 1963; Grünbaum, 1984). If so, what type of science is best applied (Wallerstein, 2009)? Or is psychoanalysis completely outside the discourse of science and therefore best thought of as hermeneutic practice (Hoffman, 2009)? These pivotal questions set the stage for a hotly contested debate, with the identity of psychoanalysis and how best to practice it hanging in the balance. With so much at stake, intense anxieties are aroused and defended against through staunchly held positions or by blithely ignoring the issues. Taking any such position undermines the potential for a constructive debate and movement towards a more vibrant, relevant, and secure field. Fortunately, there exist some attempts to find middle ground; for example, Luyten, Blatt and Corveleyn (2006) as well as Wallerstein (2009) argue for a methodological pluralism that employs both quantitative and qualitative designs in psychoanalytic research. Notwithstanding such overtures, however, dogmatism still seems to prevail as the ultimate comforter in these troubled times.
In the context of a vulnerable field, Jonathan Shedler’s (2010) recent article, The Efficacy of Psychodynamic Psychotherapy, offers great hope and a way out of our mired philosophical disputes. Much to the applause of critics and proponents of psychoanalysis alike, Shedler exonerates psychoanalysis as a viable form of modern-day therapy as he reviewed recent empirical literature demonstrating the efficacy of psychodynamic psychotherapy. Shedler’s article stirred feelings of exuberance and a long overdue sense of vindication for practitioners who anecdotally saw the benefits of psychoanalysis for their own patients. Central to this redemptive feeling is the clear articulation of the value of psychoanalysis as determined by an objective measurement of its efficacy. Additionally, the article seemed to inspire renewed confidence that the efficacy of psychoanalysis could be adequately captured by research and, therefore, strengthened the belief in a systematic research program as the brightest avenue to restoring legitimacy back to a beleaguered tradition (Bornstein, 2001). Shedler’s call for more experimentally designed studies seems to have been answered with a new optimism that psychoanalysis can not only to compete with other empirically supported treatments, but can even out perform them.
Amidst this excitement, however, I am wondering if in following Shedler’s call, we are unwittingly entering into a Faustian bargain to restore the relevance of psychodynamic psychotherapy at the cost of compromising analytic thinking. The aim of the present paper is to caution against a collapse in thinking that seems unavoidable when determining the value of psychoanalysis through experimental or quasi-experimentally designed outcome studies. In an effort to explicate this inherent danger, I will briefly critique the methodological limitations of experimental or quasi-experimental designs and forewarn against the seemingly inevitable manualization of psychoanalysis. Beyond these methodological limitations, however, what is most pernicious is a shift in thinking that replaces a skeptical curiosity of the analytic attitude with a technological thinking based solely on instrumental rationality (Hoffman, 2009). Locating the value of psychoanalysis in terms of efficacy betrays Freud’s caution against therapeutic ambition (Freud, 1912) and threatens the integrity of the analytic enterprise. It is my contention that our efforts to restore the relevance of psychoanalysis strictly through positivistic science will subtly corrupt our analytic sensibilities and over time reduce the analytic experience to the mere algorithmic application of technical interventions.
Shedler’s (2010) much acclaimed and widely publicized article certainly marks a victory for psychoanalysis in the context of working within a healthcare system driven towards greater demands for treatment efficacy and accountability. However, Shedler’s call for more research employing experimental methodologies seems to herald a shift in course that puts analytic thinking in peril. The unrelenting march of such a reductionistic science “progresses” towards homogenizing the human experience by extracting abstract trends that become codified as normative and dismiss individual difference. Probabilistic generalizations are purchased at the price of leveling down the complexity of experience by only revealing that which is common across individuals. Admittedly, the aim of experimental studies is to yield nomothetic claims, but what about those individuals who do not trend with the statistical norm? What is dangerous in privileging outcome studies based solely on this methodology is we lose the ability to make intelligible that which is anomalous. This methodological limitation seems at odds with what is pertinent to practitioners who seek to understand the unique qualities, the idiosyncratic meanings, and the specific contexts of their patients’ lives. This type of research overlooks the complexities and aberrations that require an exploration of the ideographic variables of both patient and analyst as they mutually reveal and determine the meanings of the patient’s suffering.
Furthermore, a strict reliance on data revealed through experimental outcome studies threatens to collapse our thinking about clinical phenomena. A limit to any methodology is that it can only illuminate particular aspects of the phenomenon under investigation, depending on the specific question and measurements used to frame the study. German philosopher Martin Heidegger (1953) aptly described this limitation when he wrote, “Because physics, indeed already as pure theory, sets up nature to exhibit itself as a coherence of forces calculable in advance, it orders its experiments precisely for the purpose of asking whether and how nature reports itself when set up in this way” (p.326). Accordingly, what is captured in outcome studies only represents how the phenomenon revealed itself from the lens through which it was investigated. As such, by problematizing clinical phenomena strictly in an instrumental fashion (i.e., measuring outcomes), our thinking becomes entrapped to see all clinical phenomena only in terms of means-ends relationships. Taking outcome studies to their logical conclusions eventuates in rigid instrumental rationality as the means to prescribed ends are perpetually squeezed by the vise grip of science into further refinements for greater effectiveness and efficiency.
This constriction is bound to reverberate in the therapeutic endeavor. Adopting this type of thinking restricts our mindset to a calculative approach towards psychotherapy, dispensing with an “evenly-suspended attention” in favor of executing tactically derived interventions. Our capacity to hold complexity, contradiction, and uncertainty are eroded by this instrumentality. Moreover, the focus on instrumental thinking and developing technological interventions is likely to lead to standardized treatments. It seems just a matter of time before researchers elucidate more expedient routes to maximally develop psychological capacities and formalize such protocols in manualized treatments. Automation replaces thinking as we become master technicians skilled in executing prescribed interventions in a routinized way. The inherent messiness and ambiguity of psychotherapy are denied as measurements, rather than meanings, are privileged. The invitation to use creativity and play in coming to understand the other is supplanted as the potential space for exploring sameness and difference and ultimately coming to terms with one’s own unique psychology is truncated under the procedural weight of manualized interventions.
Embedded within a more technologically oriented, instrumental rationality is also a subtle shifting of responsibility for therapeutic change from patient to therapist. The underlying presumption in outcome studies is that the catalyst of change originates in the actions—the thinking and interventions—implemented by the therapist. In this conceptual framework, therapeutic change rests on the correct timing and application of an intervention, which disburdens the patient of the responsibility and agency to make the change he or she seeks. Freud warned against such presumptions with his principle of therapeutic ambition. In his paper, Recommendations to Physicians Practicing Psycho-Analysis, Freud (1912) wrote:
Under present-day conditions the feeling that is most dangerous to a psycho-analyst is the therapeutic ambition to achieve by this novel and much disputed method something that will produce a convincing effect upon other people. This will not only put him into a state of mind which is unfavorable for his work, but will make him helpless against certain resistances of the patient, whose recovery, as we know, primarily depends on the interplay of forces in him (p.115).
As was then and is still today, the pressure to evidence a “convincing effect” threatens to undermine the analytic sensibility as justifications predicated on knowledge claims subvert the capacity for open-minded inquiry. Thompson (2004) wrote, “One cannot genuinely inquire while professing to know what will be discovered. Thus it is impossible to hear what is said when the answers to one’s queries are predetermined in light of theory that has been elevated to the status of omniscience” (p. 116). Therapeutic ambition blinds the practitioner with the illusion of knowing what is best for the patient and being able to single-handedly facilitate change. To caution against such hubris, Freud (1912) further advised, “A surgeon of earlier times took as his motto the words, ‘I dressed his wounds, God cured him.’ The analyst should be content with something similar” (p.115).
Pressures to know conclusively and act efficiently in our contemporary society make it difficult to hold the awesome complexity and ambiguity of our everyday existence. In the rush to serve a public eager for quick fixes and policy-makers demanding measurable results, perhaps we too quickly forfeit the greatest strength of psychoanalysis--our capacity to think, to hold contradictory positions, and explore with an open-mind what is possible. Constructively engaging in this debate requires the capacity to hold tensions between competing ideas and epistemologies, and to examine the implications of our actions as a field. By blindly following Shedler’s call for more experimental studies, we run the risk of further pigeonholing the value of psychoanalysis purely in terms of efficacy. Moreover, we concede to a corrosive mindset predicated on a rigid instrumental rationality that transforms an art into a technologically-driven engineering project. What is at stake is the loss of subjectivity for both patient and therapist and the genuine opportunity for human contact. The fear is that by adapting to market pressures, we become master technicians and become in the words of Max Weber (1976), “specialists without spirit, sensualists without heart” (p.182). As it is, what is most valuable and unique about psychoanalysis is the type of thinking employed by its practitioners, and that quality of thinking needs to be safeguarded from dangers within and outside the field. z
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