APsaA is launching a major new research initiative to help meet the pressing need for more outcome studies focused on the symptomatic and structural effects of long-term psychoanalysis—versus not only CBT but also low-frequency and short-term psychoanalytic psychotherapies. Marianne Leuzinger-Bohleber has been appointed to design a randomized control trial that compares low-frequency and high-frequency psychoanalytic treatments. The study design will need to focus on just one particular psychopathology, to begin with, and will involve not only behavioral measures but also indexes of change in brain network dynamics (and other biomarkers) over the course of the treatments. The project was initiated by Harriet Wolfe and me, with seed-funding from APsaA, but the design of the study itself has been the responsibility of Leuzinger-Bohleber and her team. The pilot project will be funded jointly by APsaA and the IPA, an unusual arrangement which marks the importance of the investigation.
As background and support for this major initiative, I would like to share with APsaA’s membership an updated version of the article I published in 2018 in the International Edition of the British Journal of Psychiatry. The article is based on a paper I presented at APsaA’s 2017 National Meeting, when I became director of the Science Department.
My aim is to set out here what we psychoanalysts may consider to be the core scientific claims of our discipline. Such stock taking is necessary due to widespread misconceptions among the public and disagreements among ourselves regarding specialist details, which obscure a bigger picture upon which we can all agree. Agreement on our core claims, which enjoy strong empirical support, will enable us to better defend them against the prejudice that psychoanalysis is not “evidence-based.”
I shall address three questions: (1) How does the emotional mind work, in health and disease? (2) On this basis, what does psychoanalytic treatment aim to achieve? (3) How effective is it?
My arguments in relation to these questions will be:
Psychoanalysis rests upon three core claims about the emotional mind that were once considered controversial but are now widely accepted in neighboring disciplines.
The clinical methods psychoanalysts use to relieve mental suffering flow directly from these core claims and are consistent with current scientific understanding of how the brain changes.
It is therefore not surprising that psychoanalytic therapy achieves good outcomes—at least as good as, and in some important respects better than, other evidence-based treatments in psychiatry today.
Our three core claims about the emotional mind are the following: (1) The human infant is not a blank slate; like all other species, we are born with a set of innate needs. (2) The main task of mental development is to learn how to meet these needs in the world, which implies that mental disorder arises from failures to achieve this task. (3) Most of our methods of meeting our emotional needs are executed unconsciously, which requires us to return them to consciousness in order to change them.
These core claims could also be described as premises, but it is important to recognize they are scientific premises, because they are testable and falsifiable. As I proceed, I will elaborate these premises, adding details, but I want to differentiate between the core claims themselves and the specifying details. The details are empirical. Whether they are ultimately upheld or not does not affect the core claims. Detailed knowledge changes over time, but core claims are foundational. Everything we do in psychoanalysis is predicated upon these three claims. If they are disproven, the core scientific presuppositions upon which psychoanalysis (as we know it) rests will have been rejected. But as things stand currently, in 2019, they are eminently defensible, strongly—indeed increasingly—supported by accumulating and converging lines of evidence in neighboring fields. This continues to justify Eric Kandel’s assertion in 1999 that “Psychoanalysis still represents the most coherent and intellectually satisfying view of the mind.”
The articles by Mark Solms and Katie Lewis are part of a special section on The Science Behind Psychoanalytic Theory from our Special Section editor Michael Slevin. Because of space limitations, we were not able to include the third article in this section, Experimental Research Demonstrates Diverse Unconscious Brain Processes, by Marie G. Rudden. This article will appear in the next issue of TAP.
I turn now to each of the proposed three claims.
Claim 1. The human infant is not a blank slate; like all other species, we are born with a set of innate needs. These needs are regulated autonomically up to a point, beyond which they make “demands upon the mind to perform work” as Freud, in 1915, put it. Such mental demands constitute his id. They are ultimately felt as affects. That is why affect is so important in psychoanalysis. The affect broadcasting a need releases reflexive or instinctual behaviors, which are hard-wired predictions (action plans) we execute in order to meet our needs—e.g., we cry, search, freeze, flee, attack. Universal agreement about the number of innate needs in the human brain has not been achieved, but most mainstream taxonomies (e.g., Jaak Panksepp 1998) include at least a subset of the following emotional ones:
We need to engage with the world—since all our biological appetites (including bodily needs like hunger and thirst) can only be met there. This is a foraging or seeking instinct. It is felt as interest, curiosity and the like. (It coincides roughly but not completely with Freud’s concept of “libido” (see Solms, 2012.)
We need to find sexual partners. This is felt as lust. This instinct is sexually dimorphic (on average) but male and female inclinations exist in both genders. (Like all other biological appetites, lust is channelled through seeking.)
We need to escape dangerous situations. This is fear.
We need to destroy frustrating objects (things that get between us and satisfaction of our needs). This is rage.
We need to attach to caregivers (those who look after us). Separation from attachment figures is felt not as fear but as panic, and loss of them is felt as despair. (The whole of attachment theory relates to this need, and the next one.)
We need to care for and nurture others, especially our offspring. This is the so-called maternal instinct, but it exists (to varying degrees) in both genders.
We need to play. This is not as frivolous as it appears; play is the medium through which social hierarchies are formed (“pecking order”), in-group and out-group boundaries are maintained, and territory is won and defended.
Claim 2. The main task of mental development is to learn how to meet our needs in the world. We do not learn for its own sake; we do so in order to establish optimal predictions as to how we may meet our needs in a given environment. This is what Freud called “ego” development. Learning is necessary because even innate predictions have to be reconciled with lived experience. Evolution predicts how we should behave in, say, dangerous situations in general, but it cannot predict all possible dangers (e.g., electrical sockets); each individual has to learn what to fear and how best to
respond to the variety of actual dangers. The most crucial lessons are learned during critical periods, mainly in early childhood, when we are, unfortunately, not best equipped to deal with the fact that our innate predictions often conflict with one another (e.g., attachment vs. rage, curiosity vs. fear). We therefore need to learn compromises, and we must find indirect ways of meeting our needs. This often involves substitute-formation. Humans also have a large capacity for delaying gratification and for satisfying their needs in imaginary and symbolic ways.
It is crucial to recognize that successful predictions entail successful emotion regulation, and vice versa. This is because our needs are felt. Thus, successful avoidance of attack reduces fear, and successful reunion after separation reduces panic, etc., whereas unsuccessful attempts at avoidance or reunion result in persistence of the fear or panic, etc.
Claim 3. Most of our predictions are executed unconsciously. Consciousness (short-term “working memory”) is an extremely limited resource, so there is enormous pressure to consolidate learned solutions to life’s problems into long-term memory, and ultimately to automatize them (for review see John Bargh and Tanya Chartrand, 1999, who conclude only 5 percent of goal-directed actions are conscious). Innate predictions are effected automatically from the outset, as are those acquired in the first two years of life, before the preconscious (“declarative”) memory systems mature (cf. infantile amnesia). Multiple unconscious (“non-declarative”) memory systems exist, such as “procedural” and “emotional” memory, which operate according to different rules. These stereotyped systems (cf. the repetition compulsion) bypass thinking (i.e., the secondary process) and define the system unconscious.
The following fact is of utmost importance. Not only successful predictions are automatized. With this simple observation, we overcome the unfortunate distinction between the “cognitive” and “Freudian” unconscious (Solms, 2017). Sometimes a child has to make the best of a bad job in order to focus on the problem that it can solve. Such illegitimately or prematurely automatized predictions (i.e., wishes as opposed to realistic solutions) are called “the repressed.” In order for predictions to be updated in light of experience, they need to be “reconsolidated”; that is, they need to enter consciousness again, in order for the long-term traces to become labile once more (Karim Nader et al. 2000, Susan Sara 2000, Natalie Tronson & Jane Taylor 2007). This is sometimes difficult to achieve, however; not least because procedural memories are hard to learn and hard to forget and some emotional memories—which can be acquired through just a single exposure—appear to be indelible; but also because the essential mechanism of repression entails resistance to reconsolidation despite prediction errors. The theory of reconsolidation is very important for understanding the mechanism of psychoanalysis. This leads to my second argument, concerning our treatment.
My second argument is the clinical methods psychoanalysts use to relieve mental suffering flow from the above core claims, which are consistent with current understanding of how the brain changes. The argument unfolds over three steps:
Psychological patients suffer mainly from feelings. The essential difference between psychoanalytic and psychopharmacological methods of treatment is that we believe feelings mean something. Specifically, feelings represent unsatisfied needs. (Thus, a patient suffering from panic is afraid of losing something, a patient suffering from rage is frustrated by something.) This truism applies regardless of etiological factors; even if one person is constitutionally more fearful than the next, or cognitively less capable of updating predictions, their fear still means something. To be clear: Emotional disorders entail unsuccessful attempts to satisfy needs. That is, psychological symptoms (unlike physiological ones) involve intentionality.
The main purpose of psychological treatment, then, is to help patients learn better ways of meeting their needs. This, in turn, leads to better emotion regulation. The psychopharmacological approach, by contrast, suppresses unwanted feelings. We do not believe drugs that treat feelings directly can cure emotional disorder; drugs are symptomatic (not causal) treatments. To cure an emotional disorder, the patient’s failure to meet underlying needs must be addressed, since this is what is causing the symptoms. However, symptomatic relief is sometimes necessary before patients become accessible to psychological treatment, since most forms of psychotherapy require collaborative work between patient and therapist (see below). It is also true some types of psychopathology never become accessible to psychotherapy. We must also concede that patients just want to feel better; they do not want to work for it.
Psychoanalytical therapy differs from other forms of psychotherapy in that it aims to change deeply automatized predictions, which—to the extent they are consolidated into non-declarative memory—cannot be reconsolidated in working memory. Non-declarative (i.e., unconscious) predictions are permanently unconscious. Psychoanalytic technique therefore focuses on:
Identifying the dominant emotions (which are consciously felt but not always recognized as arising from specific needs and predictions).
My third argument is that psychoanalytic therapy achieves good outcomes—at least as good as, and in some respects better than, other evidence-based treatments in psychiatry today. This argument unfolds over four stages:
Psychotherapy in general is a highly effective form of treatment. Meta-analyses of psychotherapy outcome studies typically reveal effect sizes of between 0.73 and 0.85. (An effect size of 1.0 means the average treated patient is one standard deviation healthier than the average untreated patient.) An effect size of 0.8 is considered a large effect in psychiatric research, 0.5 is considered moderate, and 0.2 is considered small. To put the efficacy of psychotherapy into perspective, recent antidepressant medications achieve effect sizes of between 0.24 (tricyclics) and 0.31 (SSRIs). The changes brought about by psychotherapy, no less than drug therapy, are visualizable with brain imaging (see Mario Beau-regard, 2014).
Psychoanalytic psychotherapy is equally effective as other forms of psychotherapy (e.g., CBT). This has recently been demonstrated conclusively by comparative meta-analysis (Christiana Steinert et al., 2017). However, there is evidence to suggest the effects last longer—and even increase—after the end of the treatment. Jonathan Shedler’s authoritative review of all randomized control trials to date reported effect sizes of between 0.78 and 1.46, even for diluted and truncated forms of psychoanalytic therapy. An especially methodologically rigorous meta-analysis (Allan Abbass et al, 2006) yielded an overall effect size of 0.97 for general symptom improvement with psychoanalytic therapy. The effect size increased to 1.51 when the patients were assessed at follow-up. A more recent meta-analysis by Abbass et al yielded an overall effect size of 0.71 and the finding of maintained and increased effects at follow-up was reconfirmed.
This was for short-term psychoanalytic treatment. According to the meta-analysis of Saskia de Maat et al. , which was less methodologically rigorous than the Abbass studies, longer-term psychoanalytic psychotherapy yields an effect size of 0.78 at termination and 0.94 at follow-up, and psychoanalysis proper achieves a mean effect size of 0.87 and 1.18 at follow-up. This is the overall effect; the effect size she found for symptom improvement (as opposed to personality change) at termination was 1.03 for long-term therapy, and for psychoanalysis it was 1.38. Marianne Leuzinger-Bohleber et al.’s subsequent study (in press) shows even bigger effect sizes: between 1.62 and 1.89 after three years of treatment. These are enormous effects. (Follow-up data are, of course, not yet available from this ongoing study.) The consistent trend toward larger effect sizes at follow-up—where the effects of other forms of psychotherapy, like CBT, tend to decay—suggests psychoanalytic therapy sets in motion processes of change that continue even after therapy has ended (cf. working through, discussed above).
I am well aware the claims I have summarized here do not do justice to the full complexity and variety of views in psychoanalysis, both as a theory and a therapy. I am saying only that these are our core claims, which underpin all the details, including those upon which we are yet to reach agreement. If we can agree on just these few claims, underpinning the arguments presented in this article, we are much better placed to explain our point of view to neighboring disciplines and to the public. I believe these claims and arguments are eminently defensible, in light of available scientific evidence, and that they make simple good sense.
There is further need for more studies. The new research initiative sponsored by APsaA and the IPA, directed by Leuzinger-Bohleber, will be a powerful contribution. It will help provide empirical support to questions about the importance of high vs. low frequency of sessions, as well as correlating biomarkers with treatment outcomes. A major disadvantage we suffer in comparison with psychopharmacological and CBT researchers is an almost total lack of financial support for psychoanalytic outcome studies from commercial and statutory sources. If we are going to overcome the prejudice that feeds this lack of support—namely the self-fulfilling (and false, see Shedler, 2015) claim that psychoanalysis is not evidence-based—then we will have to fund such studies ourselves, at least to begin with.
The author would like to thank Jonathan Shedler for his generous help with this article.
Editor’s Note:
For more information about the references in this article, please contact the author at .
These emotions reveal the meaning of the symptom. That is, they lead the way to the particular automatized predictions that gave rise to the symptom.
The pathogenic predictions cannot be remembered directly for the very reason that they are automatized (i.e., non-declarative). Therefore, the analyst identifies them indirectly, by bringing to awareness the repetitive patterns of behavior derived from them.
Reconsolidation is thus achieved through reactivation of non-declarative traces via their derivatives in the present (this is called “transference” interpretation). Automatized predictions cannot be retrieved into working memory, but patients can be made aware of the here-and-now enactments of those predictions. This is the essence of psychoanalytical cure.
Such reconsolidation is nevertheless difficult to achieve, mainly due to the ways in which non-declarative memory systems work (they are hard to learn, hard to forget and in some respects “indelible”) but also because repression entails intense resistance to the reactivation of insoluble problems. For all these reasons, psychoanalytic treatment takes time—and frequent sessions—to facilitate working through. Working through entails numerous repetitions of transference interpretations in relation to ongoing derivatives of repressed predictions, while new (and crucially, better) predictions are slowly consolidated. (Funders of psychological treatments need to learn how learning works.)
It is important to recognize these findings concern symptom improvement only. Psychoanalytic treatments are not directed primarily at symptomatic relief but rather at what might be called personality change. Not surprisingly, therefore, psychoanalytic treatments achieve much better results than other treatments on this outcome measure. In Leuzinger et al.’s ongoing study, for example, almost twice as many patients receiving psychoanalytic treatment vs CBT reached their criteria for structural change after three years (60 percent vs 36 percent).
The therapeutic techniques that predict best treatment outcomes make good sense in relation to the psychodynamic mechanisms outlined above. These techniques are (Matthew Blagys and Mark Hilsenroth, 2000):
unstructured, open-ended dialogue between patient and therapist
identifying recurring themes in the patient’s experience
linking the patient’s feelings and perceptions to past experiences
drawing attention to feelings regarded by the patient as unacceptable
pointing out ways in which the patient avoids feelings
focusing on the here-and-now therapy relationship
drawing connections between the therapy relationship and other relationships.
It is highly instructive to note these techniques lead to the best treatment outcomes, regardless of the “brand” of therapy the clinician espouses. In other words, these same techniques (or at least a subset of them; see Hayes et al. 1996) predict optimal treatment outcomes in CBT too, even if the therapist believes they are doing something else.
Therefore perhaps it is not surprising that psychotherapists, irrespective of their stated theoretical orientation, tend to choose psychoanalytic psychotherapy for themselves. (John Norcross, 2005)