Exciting, stimulating, surprising—that’s how we’d describe the 2018 Joseph Sandler Psychoanalytic Research Conference, hosted last May by USC’s Children’s Hospital of Los Angeles and the New Center for Psychoanalysis. The Sandler conference connects psychoanalysis to modern scientific research in treatment outcome, neuroscience, studies of therapeutic process, and models of therapeutic action. Clinicians attending the conference described how their knowledge of research findings helped and challenged them.
The conference title contains the phrase, “the Future of Psychoanalysis,” because at the turn of the twenty-first century, psychoanalysis was in danger on two fronts. First, psychoanalysis was slow to demonstrate through outcome studies that it was effective and could hold its own in comparison to other treatment methods. Thus, it could not defend itself and maintain market share in the face of the claims by other disciplines that their methods were more effective, less costly, and worthier because they were “evidence-based.”
Second, in contrast to its first 50 years of vibrant discovery, psychoanalysis had drifted into a period of fewer discoveries, fewer innovations, and unproductive competitions between schools of thought. Located outside of academia, psychoanalysis was not integrating the recent dazzling discoveries from neuroscience, cognitive science, and studies of interpersonal process, such as “now moments,” attunement, and interaction in the therapy process. Speaking of the decline of psychoanalysis in the past 50 years, Nobel laureate Eric Kandel wrote: “This decline is regrettable, since psychoanalysis still represents the most coherent and intellectually satisfying view of the mind. If psychoanalysis is to regain its intellectual power and influence, it will need more than the stimulus that comes from responding to its hostile critics. It will need to be engaged constructively by those who care for it and who care for a sophisticated and realistic
theory of human motivation” (Kandel, E. R., 2012). “Biology and the future of psychoanalysis: A new intellectual framework for psychiatry revisited.”
These two areas of concern—outcome research and connections with empirical studies of brain-mind and human interaction—were forcefully addressed at this conference.
The horse race is over: Psychodynamic treatment is as efficacious as other empirically supported treatments. The competition between psychodynamic therapies and cognitive behavioral therapies (CBT) has been dubbed “the horse race.” At this conference the horse race was declared over. (See Leichsenring below.) For depression, psychoanalytic treatment is at least as effective as other “empirically supported” treatments (CBT, SSRIs). There is no need to keep running the race with randomized controlled studies pitting one therapy against another. The questions have now evolved to: What works when and for whom? How can we tailor treatments to specific patients?
Emotions are central to our understanding of human nature and crucial to our work with patients. This contrasts with those who prefer to focus almost exclusively on thinking and see emotions as byproducts of thought.
Emotions are biologically-based, having evolved before consciousness and thought, and are the impetus to social behavior, civilization, and culture. (See Damasio below.)
Change through psychotherapies (through the reconsolidation of intrinsic memory) requires a level of emotional arousal during therapy that is not too little and not too much, i.e., enough emotion to activate memory reconsolidation but not so much that the patient becomes overwhelmed and disorganized. (See Lane below.)
Affective neuroscience has identified at least seven primary drives, each connected to specific emotional activations. (See Solms, who cites the late Jaak Panksepp.)
Emotions and their roles in nonverbal communication in intimate relationships, such as mother-infant and patient-psychotherapist, can be scientifically studied using audio-video recordings. (See Jimenez below.)
Psychoanalytic treatment can now be called a biologic treatment because biomarkers have been found that change with effective treatment. (See Peterson below.)
Spread the word! The survival and flourishing of psychoanalysis require that we inform decision makers and our academic colleagues of the efficacy, cost effectiveness, and scientific support for psychoanalytic treatments, which produce lasting changes in patients beyond remission of symptoms.
Researchers must teach their findings to the public in lay language, as Antonio Damasio has done with his best-selling books.
Mark Solms (Cape Town, IPA chair of research and APsaA director of science) reprised his 2017 APsaA thoughtful and significant presidential lecture entitled “The Scientific Standing of Psychoanalysis” (Solms, M., 2018). [Solms’s lecture is more extensively reprised in this TAP, page 1.]
Solms asserted, “Everything we do in psychoanalysis is based on three claims:”
Like all other species we are born with innate needs. What they are is now the subject of research and supersede Freud’s original drive theories. Beyond body needs such as hunger, thirst, and elimination, at least seven different innate needs, their emotional manifestations, and underlying neural circuitry have been identified.
“We need to engage with the world.” To get our needs met there arises a foraging, seeking, or “wanting” instinct, which is felt as interest, curiosity, etc.
“We need to find sexual partners,” which is felt as lust.
“We need to escape dangerous situations,” which is felt as fear.
We need to destroy frustrating objects,” which is felt as rage.
“We need to attach to caregivers,” separation from whom is felt as panic, and loss of whom is felt as despair.
“We need to care for and nurture others, especially our offspring,” the so-called maternal instinct existing in both genders.
“We need to play.” Play is the medium through which social hierarchies are formed and in-group and out-group boundaries are maintained. This is felt as joy and delight.
Solms pointed out that these seven drive-affect systems could form the basis for a new nosology of psychopathologies.
Mental development is about learning to meet those needs. Feelings are the guide to what is working and what is not working in meeting those needs. (See Damasio below.)
Most action plans formed to meet needs are unconsciously executed. And when an action plan doesn’t lead to meeting a person’s needs, the individual likely doesn’t have access to why that plan exists, because the plan resides in non-declarative, unconscious memory systems. Transference phenomena in the therapeutic relationship makes these non-declarative memories labile again and open to reconsolidation where new information, primarily from the therapeutic relationship, can be added to modify and update the memories and action plan. Because declarative memory systems are almost indelible, this is a slow process; thus, we have “working through.” (See Lane below.)
Antonio Damasio (Los Angeles), USC professor of neuroscience, psychology, and philosophy and director of the Brain and Creativity Institute, gave the free public lecture of the conference entitled “The Nature of Feelings and Their Consequences” with intriguing ideas from his 2018 book The Strange Order of Things: Life, Feeling, and the Making of Cultures. Damasio described the role of emotion in the economy of living organisms from one-celled creatures up the phylogenetic tree to multicellular organisms, to complex organisms with nervous systems, then consciousness, and then the development of societies and cultures. This progression from one-celled organisms to cultural achievements is “the strange order of things.”
The core imperative for any living organism is homeostasis, which is not simply maintaining physiologic equilibrium but also a net acquisition of resources. This net gain is necessary to maintain the life of the organism and to propagate it into the future. Damasio proposes emotion is the biologic system that keeps track of whether an organism is succeeding or failing in its homeostatic imperative. Emotion stimulates necessary action. As organisms develop nervous systems, emotional activity becomes part of the nervous system. And when organisms develop consciousness, then emotions are experienced as conscious feelings. Feelings can then stimulate deliberation and motivate planning—at the level of the individual, the group, and society. Mark Solms urged us, “Get the book. You won’t be disappointed.”
Bradley Peterson (Los Angeles) in his talk “Can Neuroscience Contribute to Outcome Studies in Psychotherapy?” showed how brain function, structure, and metabolism can now be studied with functional magnetic resonance imaging (fMRI) to show the effects of psychological interventions. In an intriguingly novel study, “Less is more: Neural activity during brief and clearly visible exposure to phobic stimuli” (Siegel, P., et al., 2017). The study showed how exposure to phobic visual stimuli at an unconscious level, i.e., perceived but not “seen,” brought about a decline in subjects’ phobic response after the study. The unconscious exposure was shown to activate regulatory circuits in the mid-brain, whereas consciously registered exposure to the phobic stimulus led to more arousal in the amygdala.
Another study, “Evidence for neuroplastic compensation in the cerebral cortex of persons with depressive illness,” demonstrated how cortical thickening in depressed subjects increased after the appearance of depressive symptoms and decreased after ten weeks of treatment with the antidepressant duloxetine. Peterson interpreted this to mean the brain reacts adaptively to depression with thickening of the cortex. This thickening is reversible once it is no longer needed. (Bansal, R., Hellerstein, D. J., & Peterson, B. S., 2018).
Lane (see Lane below) also spoke of other biologic changes correlated with psychotherapeutic treatment:
Measures of arousal
MRI measurements of circuit activity and regional metabolic activity
Intracellular changes:
Epigenetic changes (e.g., methylation of certain alleles coding for endorphin receptors)
Lengthening of telomeres
Falk Leichsenring (Giessen, Germany), a major contributor to the growing evidence for the effectiveness of psychodynamic treatments, described an exceptional effort to thoroughly examine the growing set of studies of
psychodynamic therapy and see if there is equivalence with CBT. The 2017 article in The American Journal of Psychiatry, “Psychodynamic therapy: as efficacious as other empirically supported treatment? A meta-analysis,” shows there is equivalence for general symptoms and equivalence for psychosocial functioning. He noted the response rates are 50 percent for both CBT and psychodynamic therapy at equivalent dosages. (Steinert, Munder, Rabung, Hoyer, & Leichsenring, 2017) With the unequivocal support of data, he declared, “The horse race is over.”
Harriet Wolfe (San Francisco), former president of the American Psychoanalytic Association) discussing Leichsenring’s paper, touched on several subjects, including the rigor of the study. She emphasized that this study sought to account for and correct the bias introduced by the allegiances of the investigators conducting studies comparing the outcomes of different psychotherapy.
Marianne Leuzinger-Bohleber (Frankfurt a. m., Germany, IPA vice chair of research), presented results, for the first time, of a 15-year, multi-center study of structural change in 252 chronically depressed adults treated with long-term psychoanalytic and CBT treatments. This is the “LAC Depression Study” (Langzeittherapien Chronischer Depression) (Leuzinger-Bohleber, et al., 2018). After one year of treatment, symptom reduction was equivalent in both treatment arms. Also, after one year of treatment, positive “structural change” was observed in 24 percent of the CBT patients and 26 percent of the psychodynamic treatment patients. These chronically depressed patients achieved sustained improvement of symptoms and remission up to 61 percent after three years of treatment. Also, after three years of treatment, “structural change” increased to about 60 percent of patients in the psychodynamic group, significantly exceeding the 36 percent in the CBT patients. Further mediator and moderator analyses of the data will offer information about which chronically depressed patient may be best treated by which long-term treatment.
Richard Lane (Tucson), first author of the highly impactful and rigorously reviewed 2015 paper, “Memory reconsolidation, emotional arousal and the process of change in psychotherapy: New insights from brain science,” (Lane, et al.) presented the central hypothesis of the paper:
… that therapeutic change in a variety of modalities [of talk therapy] … results from the updating of prior emotional memories through a process of reconsolidation that incorporates new emotional experiences … That the essential ingredients of therapeutic change include: (1) reactivating old memories; (2) engaging in new emotional experiences that are incorporated into these reactivated memories by the process of reconsolidation; and (3) reinforcing the integrated memory structure by practicing a new way of behaving and experiencing the world in a variety of contexts.
Lane’s neuroscience perspective is highly compatible with psychoanalytic perspectives on psychic change. His assertion that an optimal level of arousal is necessary for memory reconsolidation resonates with Peterson’s findings in the “Less is more” paper. Lane notes, as do others, that older memories are hardest to influence, and that reconsolidation as a goal is favored over extinction as a goal. Lane’s ideas are further elaborated in his contribution to a February 2018 APsaA panel on “Reconstruction from Today’s Two-Person Perspective,” (Lane, R. D. 2018).
John Clarkin (New York), the co-developer with Otto Kernberg of Transference Focused Psychotherapy (TFP) for borderline personality disorder (BPD), spoke about “Comparative Outcome Studies of Psychotherapy,” which affirmed the effectiveness of TFP in two randomized clinical trials. (Other effective treatments for BPD patients include Mentalization-based Therapy (MBT) and Dialectic Behavior Therapy [DBT].) TFP enhances and amplifies the BPD patient’s representations of self and others. TFP, as a “manualized” treatment, is not a cookbook but rather a set of principles to be adapted to each clinical situation. It has been shown to decrease activity in the amygdala and increases activity in the cingulate cortex, which increases reflective functioning. TFP does this through a clearly structured treatment program that motivates change and, above all, explicates the self/other representations of the patient as they manifest in the spontaneous treatment relationship. (Clarkin, J. F., Cain, N. M., & Lenzenweger, M. F., 2018).
Juan Pablo Jimenez (Santiago di Chile), gave a talk entitled “An Innovative, Scientific, Clinically-Sensitive Approach to Psychoanalytic Process-Outcome Research.” Quotes from his slides:
Outcome studies, while important in justifying the value of psychoanalytic treatment to society, say nothing about the mechanisms of therapeutic change and do not illuminate psychoanalytic practice.
Process-Outcome Research:
can teach about the mechanisms of therapeutic change;
can enrich an “evidence-based therapeutic practice” beyond “brands,” and contribute to answer the questions of “what works for whom” and under what circumstances;
is the path to link theory-driven “top-down” research, guided by psychoanalytic concepts, and “bottom-up” research that does justice to real psychoanalytic practices.
Since Freud, a central theoretical and practical concept in psychoanalysis
Psychoanalytic candidates must demonstrate “psychoanalytic process” in their treatment reports to achieve graduation
Clinical inquiry: Each analytic process is unique, ideographic, and therefore different and incomparable to any other, or to any other analytic dyad (Foehl, 2010)
Empirical Research: Psychoanalytic process eludes definition, and, despite a good deal of psychoanalytic research, we cannot identify substantial progress in empirically validating the concept of psychoanalytic process
We propose to change strategy and focus on a detailed observation and description of the analyst-patient interaction using modern technologies such as videotaping (Schachter, 2017).
Jimenez took his cues from research on mother-infant interaction using video recordings to study adult-adult dyads—with analysis focusing on observing processes—through gaze, vocalization, facial behavior, silences, etc. He showed a video from a therapy session. It lasted only a few minutes, but when viewed in very short segments with a focus on the moment to moment interactions of the two people, it yielded a fascinating and extensive set of observational data. Studying observable interactions can contribute to development of theories on psychoanalytic process and can be used in clinical training and supervision. (Jimenez, J. P. 2006, 2008).
Simone Hauck (Porto Alegre, Brazil) discussed Jimenez’s presentation, emphasizing the role of facial expressions in communication. With this in mind, she raised the question of how on-the-couch therapy differs from face-to-face therapy.
Linda Goodman, Joshua Pretsky, and Morris Eagle (Los Angeles), three faculty at the New Center for Psychoanalysis (NCP), presented a panel on “Critical Thinking and Research in Psychoanalytic Education.” They described their efforts to stimulate critical thinking and introduce psychotherapy research into the culture of the NCP. Pretsky generously shared the bibliography he uses in teaching research to USC psychiatry residents, NCP psychoanalytic psychotherapy trainees, and analytic candidates at NCP.
The authors thank Harriet Wolfe, former president of APsaA, for her encouragement and comments.
Considering that psychoanalysis developed in a hermeneutic tradition, how can critical thinking and research (hypothesis formation and testing) be brought into psychoanalytic discourse and education to supplant the role of authority in the discovery of new truths, formulations, and attitudes?
The camaraderie and enthusiasm of the participants at this conference was infectious and uplifting.