Dr. Richards says that psychoanalysis is in crisis. To support his argument, he notes that there are fewer analytic candidates and patients than there used to be, it has become more difficult to get insurance to cover the costs of psychoanalytic treatment, and the number of psycho-analytically-oriented professionals in the academy and hospitals has decreased. Perhaps most worrisome is the loss of public interest in and support of psychoanalysis. Dr. Richards discusses issues in science, art, and ideology as underlying these problems. I agree but have a bit of a different take on it. I believe that one of the main reasons, if not the main reason, that psychoanalysis is in trouble is its widespread and self-created isolation. Psychoanalysis has disconnected itself from science, other disciplines, and the public.
Psychoanalysis seems uninterested in developments in psychology and other sciences beyond the narrow confines of psychoanalytic treatment. For example, there is now a huge literature on unconscious processes (Weinberger & Stoycheva, 2020). For the most part, psychoanalytically oriented practitioners and theorists are not conversant with it. In fact, they tend to know almost nothing about it. If I use the terms implicit memory, implicit learning, automaticity, cognitive heuristics, the primacy of affect (or cognition), implicit motives, or attribution theory, it is my bet that most analysts know little to nothing about the work in these areas. Yet, there is a huge literature in each. Freud (1926) once said that psychoanalysis is the study of the unconscious. So how it is that the discipline that identifies itself with unconscious processes does not feel the need to know what others have said about it?
Another huge literature has devoted itself to trying to understand how the brain and mind work, something Freud abandoned early on because there was not enough known then. Computational neuroscience has done the most work here. There are three main approaches to this
question in computational neuroscience: massive modularity (Kurzban, 2011), connectionism (McClelland & Rumerhart, 1986,—PDP), and neural reuse (Anderson, 2014). One sees nary a mention of any of these in the psychoanalytic literature. It is as though scholarly work that is not directly about treating a patient is not of interest. As though understanding how the mind and brain work normatively is not relevant to treating people who also happen to have minds and brains. Psychoanalytic theory was once a theory of the human mind which could be applied to treatment (Brenner, 1974). No more.
Even research on psychotherapy tends to be unknown as does research on psychotropic medication. Nary a word in the psychoanalytic literature on these either. I have never understood why so many have believed that the only way to study the human mind is through case studies of psychoanalytic treatment. Yet that position has been argued as both the only scientific approach for psychoanalysis (e.g., Brenner, 1982) from those who profess a belief in science and as a non-scientific way of obtaining knowledge from those who abjure the application of science to psychoanalysis (e.g., Hoffman, 1998). Do psychoanalysts in the consulting room really have a monopoly on understanding the human condition? Is treatment really a microscope or telescope and there is no other way to do it? Are scientific approaches completely hopeless? These ways of dealing with the human condition seem oddly narrow.
Here are a couple of very cursory examples of what the scientific world is up to vis a vis the unconscious. Implicit memory research has shown that the brain structures underlying explicit, conscious, memory does not really begin to develop until about age three. But implicit, unconscious, memory is present from birth. That means that people still act as though they remember something that they deny any conscious recollection of. But repression is not a factor here. There is no infantile amnesia. This is just how the brain develops. Implicit learning research has shown that people tend to unconsciously infer causality when two events co-occur. Patients clearly act as though they believe certain things while denying any knowledge of those beliefs. (This can also partly underlie implicit bias.) But this is not necessarily defensive. Life history is critically important to understanding these beliefs, as psychoanalysis has long understood. But defensive functioning may be less implicated than heretofore believed. It is normative to develop these unconscious beliefs.
And they may or may not be adaptive depending upon what events co-occurred in the person's life. Attribution theory has shown that there is a normative bias for people to understand the actions of others as due to their personality or character whereas their own behaviors seem more explicable via the situation they found themselves in. Patients, being humans, often explain their behaviors as due to the situation. Analysts, being human, are prone to see these behaviors as attributable to character. The analyst may then see the patient as defensive and/or resistant. The patient may see the analyst as unempathic and unwilling to understand the circumstances they encountered. Either may be true or neither may be. Without being knowledgeable about normative attributional bias (called correspondence bias in the literature), misunderstandings and ruptures could occur. There are many more such possibilities and possible examples (cf. Weinberger & Stoycheva, 2020). But analysts are typically ignorant of this literature and so often cannot take account of these things.
Then there is the popular belief in psychoanalytic circles that science does not apply to psychoanalysis. At all. The argument is that the psychoanalytic process is too complex and individualistic to be captured by science. Science is too reductionistic to capture the richness of psychoanalytic interactions. In fact, science is a negative as it relates to psychoanalysis (Hoffman, 1998; Stern, 1997). People who hold such views seem to have bought Popper's (1963) critique of the enterprise as being inherently unscientific and made it an asset. Now, understanding a bit about normative psychological processes is not only not relevant (see above), it could not possibly be of benefit and may even be harmful. Besides, Popper has been brilliantly responded to and, to my mind, refuted by Grunbaum (1984). Grunbaum showed, through what he called the “tally argument”, that psychoanalysis is very amenable to scientific scrutiny. But, he said, psychoanalysts do not tend to test and/or expand it in this way. There seems to be a lack of will to do so, with some small exceptions (e.g., Shevrin, Bond, Brakel, Hertel, & Williams 1996; Silverman & Weinberger, 1985).
Science is not the only area from which psychoanalysts have isolated
themselves. The psychoanalytically inclined tend to talk to one another and to no one else (Malcolm, 1981). Part of this is historical. Analysts created institutes that are inhabited by other analysts. One needs to undergo stringent and lengthy initiation to be admitted. And then there is little contact with the outside world beyond seeing the dwindling number of patients that are treated by the members of these institutes. There are debates, often bitter between institutes. How many sessions a week constitute true analysis? Should one focus on classical issues? On objects? On the self? On relational issues? On subjectivity? Who is really an analyst? How many angels can dance on the head of a pin? There is little effort to contact the outside world. There is little effort expended to communicate these ideas to the outside world. There is no effort to explain them in ways that an intelligent lay person would understand. Instead, discussion takes place within.
Talking to echo chambers tends not to move the interests of the parties involved. The world does not care about these esoterica. But the world does care about mental health and health care. The country and the world are having important and powerful debates about these things. Cognitive behavioral therapy (CBT), the American Psychological Association (APA), the American Psychiatric Association (also APA) and government agencies are big parts of this. Psychoanalysis is not. To the public, psychoanalysis appears elitist and uninterested. It can't be bothered talking to them. They wouldn't understand anyway.
Imagine yourself a member of the lay public. You are interested in psychotherapeutic treatment. So you Google it. Or, you look for books about it. You will find online psychotherapy that announces to you that you deserve to be happy (). You will discover many references to “evidence-based” psychotherapy which sounds meaningful but is a code word for CBT. Psychoanalytic treatment also has evidence but, with few
exceptions (e.g., Shedler, 2010), you will not see that discussed. Here is a list of evidence based therapies listed right up front in Google search (Bold in original):
* Applied Behavior Analysis.
* Behavior therapy.
* Cognitive behavioral therapy.
* Cognitive therapy.
* Family therapy.
* Dialectical behavior therapy.
* Interpersonal psychotherapy.
* Motivational Interviewing.
Psychoanalysis and psychodynamic therapy are conspicuously missing. Here is how cognitive behavior therapy is defined immediately in Google (bold in original):
“CBT is evidence-based. This means it's been clinically proven to work. CBT is continuously evolving by what is called “empirical evidence“ or ”evidence-based-practice“, and this form of psychotherapy constantly synchronises (sic) with the latest recommendations from the research suggesting what works best.”
If you go to the American Psychiatric Association website (assuming you have not been captured by the myriad of claims and sites before you see it and assuming you care about what professionals might say), you will see a superficial description of what psychotherapy is and what it can do (). Then you will see a listing of types of psychotherapy. First on that list is CBT. It also has the longest description. Fifth is psychoanalysis, which is described in one sentence (“Psychoanalysis is a more intensive form of psychodynamic therapy. Sessions are typically conducted three or more times a week.”). Psychodynamic psychotherapy (4th on the list)
has a bit more space and is above psychoanalysis. And this is one of the better sites for psychoanalysis. If you Google CBT, you will see only positive evaluations summarized. Only if you specifically ask for criticisms on Google, will you see anything negative and even that is mild (e.g., “Disadvantages of CBT. To benefit from CBT, you need to commit yourself to the process. … Some critics argue that because CBT only addresses current problems and focuses on specific issues, it does not address the possible underlying causes of mental health conditions, such as an unhappy childhood.”). In contrast, if you Google psychoanalysis, you will see a myriad of criticisms immediately, e.g., “The psychoanalytic approach offers no proper scientific evidence for the ideas it proposes. That is because Freud's theories do not follow the standard scientific protocol that is used in most scientific disciplines (i.e., physics, chemistry, etc.”.) You have to search to get anything positive; exactly the opposite of CBT.
If you Google a diagnostic category, you get references to medication and CBT. Virtually nothing about psychoanalysis. If you watch TV and see ads about mental health and/or psychotherapy, you will see references to medication and CBT. You will see them touted as scientifically based. You will see nothing or next to nothing about psychoanalysis.
I teach an introductory psychology course. I had to search to find a textbook (Kowalski & Westen, 2010) that didn't declare psychoanalysis to be largely lacking in empirical support and I am under constant pressure to choose a more “current” text. I make a point of discussing both psychoanalytic theory and practice in my class. I also discuss psychodynamic treatment and theory. I give simple clinical examples. Late in the semester, I have class members do presentations for the class as part of their grade. Many choose to discuss psychopathology and treatment. Invariably, their presentations indicate that CBT and drugs are the way to go. Why? Because that is what they find when they look it up. If this is happening when people are explicitly presented with and are tested on psychodynamic concepts by someone who is motivated to present them fairly and positively, imagine what people without this exposure are thinking and feeling?
When you do not engage in a dialogue or debate, you give over the
narrative to those who do. Psychoanalysis has largely eschewed science. Some have been actively hostile to it. So the scientific narrative belongs to others and the term “evidence based” now means cognitive behavioral therapy (CBT). That is what the media and major professional organizations communicate to the public and that is what is therefore associated with respectable, useful treatment. When you do not explain what it is that you do, there either is no narrative or the narrative becomes the property of those who will explain it for you. Those others are the media, the insurance companies, the government, and proponents of alternative forms of treatment. When all you seem to do is argue with one another, the impression is that there are no real central principles to the enterprise.
The upshot of all of this is that psychoanalysis is seen as unscientific, not based on any evidence, anachronistic, self-involved, elitist, overly long, and overly expensive. Unless you are intrinsically motivated to investigate more deeply, that is the narrative. Why would it then surprise anyone that it is in crisis? Of course it is. Moreover, much of the problem is self-inflicted or due to neglect. And the field seems to take no responsibility for this. It is the fault of others and of society. We have done nothing wrong and we need not change anything. People and society should value what we do and if they don't, that is on them. If we had a patient who displayed these characteristics, we would diagnose a character disorder.
So what is the treatment? First, is insight. The field needs to realize that there is a serious problem. It needs to realize that much of its problems are self-inflicted. It needs to open up to areas that are not explicitly psychoanalytic. It would be nice to see some articles that do not solely reference papers from other psychoanalytic journals. Learn what other people are doing in their efforts to understand the mind and brain. Maybe some of it is valuable. Information is not exclusive to the consulting room. If some work does not pass the smell test, OK. But know what you are rejecting and why. What is wrong with it? Be able to discuss it intelligently. Don't simply declare it to be bad. Ignorance needs to go. Dismissal of non-psychoanalytic sources of knowledge needs to go.
Psychoanalysis needs to realize that even if some of its problems are
dues to external forces, that does not justify turning a blind eye to them. Righteous indignation changes nothing. Relationally, the field needs to open up communications with the outside community. Explain what they do in language that intelligent lay people can understand. Take back the evidence narrative. What we do has plenty of evidence behind it (cf. Shedler, 2010). Case studies are also evidence. Clinical experience matters. Explain why. Take on other approaches when they attack us. Don't give up the narrative. Talk to the media. They control the societal narrative. Get on and make the case. Just as it is important to learn from others, it is important to let others know what we have. Psychoanalysis, incomplete and insulated as it is, has the best overall understanding of any model of humans out there. Why keep it to ourselves?
Joel Weinberger, Ph.D.
Derner Institute, Adelphi University