Does Psychoanalysis Work?
On Psychoanalysis, 03
Efficacy of/in Psychotherapy
Soon after Freud founded the practice of psychotherapy, he was called into question regarding whether or not his procedures worked. Despite his skepticism of such a project, early analytic institutes in the 1920s began collecting systematic data on the efficacy of their treatment. However, this tradition did not last long and did not have much bearing on the psychotherapeutic community writ large.
It was not until Eysenck’s attempt to ‘debunk’ talk therapy in the 50s that research in the outcomes (that is, “Does it work?”) became a standard in the field. The attempt to quantify psychotherapy and to include it within the scientific framework has only exponentially increased since the 50s. One is hard-pressed to find a training institute, university, or mental health center that does not advertise their “evidence-based treatments” to soothe the skeptical.
Institutes in the 50s and 60s like the Menninger Foundation and the National Institute for Mental Health (NIMH) began funding increasingly larger projects to establish a scientific rationale for the practice and dissemination of psychotherapy. [1]
Is Psychoanalysis Efficacious?
This brings us to a question that has riddled the field of clinical psychotherapy for some time now. I won’t be spending much time on it, because, as I will claim later, it’s a stupid question. Or rather — it’s deeply misguided.
Insurance companies won’t pay or subsidize psychoanalytic treatment and most master’s level training institutes don’t recognize it in its fullness due to other modalities and techniques carrying with them more ‘efficacy’ and ‘evidence-based’ research. Let’s throw this cultural decision into doubt.
The question is: Is psychoanalysis effective? That is, does it work? Does it enact change? Of course, different theorists, studies, and institutes all have their own definitions of “effective”, “work”, and “change”. But let’s leave that aside for now and answer what most researchers and clinicians want to know: If psychoanalysis is practiced, can we expect positive results in our patients?
The affirmative to this answer has been cast in doubt. But this doubt is largely unfounded. To play the game according to their own rules, let me link a few studies which have shown psychoanalysis, psychodynamic, and psychoanalytic psychotherapy to be as effective or more effective than other forms of psychotherapy. With that accomplished (which takes only a few minutes on any academic journal search engine), we’ll move on to the more interesting question at hand:
C.F.J. Woll & F.D. Schönbrodt (2014); F. Leichsenring, S. Klein, & Simon Salzer (2014); T. Lindegaard, M. Berg, & G. Andersson (2020); C. Shepherd & N. Beail (2017); J. Shedler (2010); for a more conservative study, see S. de Maat et al. (2013); C. Steinert et al. (2017); Levy, Ehrenthal, Yeomans, & Caligor (2014).
As one can see, I only selected studies published after 2010 for updated research, and most of these are meta-analyses with various populations (depression, anxiety, personality disorders, etc.) and mediums (long-term, frequent, infrequent, teletherapy, etc.), and a hand-full being meta-analyses of randomized control trials. However, as the S. de Maat et al. (2013) study indicates, more RCT’s need to be completed to put the debate to rest — apparently. All of the studies I gathered (an impressively selective sample) were gathered from major institutions or recognized publications.
The Particularity of Psychoanalysis
In reality, none of this has bearing on the real question at hand: why psychoanalysis? The question that psychotherapeutic research seeks to answer — ‘Does this work and how?’ — is a deeply personal question that is re-examined with each patient.
Adam Phillips, in an interview with The Guardian, said
I think there is something compliant and servile about believing you have to meet the dominant criteria, and I don’t think psychoanalysts should have bought into the scientific model with such eagerness. I don’t think psychoanalysis is a science or should aspire to be one. I don’t think it should be a deliberately misleading mystification either, but I don’t think these kinds of empirical criteria are the only criteria of value. Nobody is going to do empirical research on Wallace Stevens.
What is Phillips getting at here? To reject the project of scientizing psychotherapy might get you expelled from a clinical training program today — and yet, it seems to be what is at stake in psychoanalysis. To inundate something, a practice, with knowledge and research, is to formalize it into a body of authorized practice.
In formalization, the body and mind of the patient and the analyst are objectified. How else can we measure something in quantitative terms? That which is constantly slipping, constantly re-creating itself, cannot by definition be defined — and therefore cannot be measured. Does this not mean that psychoanalysis cannot be helpful?
Of course not. It is helpful in the way that Wallace Stevens is helpful. Phillips, in the same interview, again drives home the spirit of psychoanalysis:
There are plenty of other treatments in the culture and something else may work for you, it may be aromatherapy, but this is what psychoanalysis is like, give it a go. But that’s all. To make too much of a case for it beforehand is to make a false promise. Some people find it wonderful. Some people find it absolutely pointless. Some people find it exploitative. It’s only for the people who are moved by it, amused by it, interested by it, comforted by it. People who find it fraudulent, diminishing and absurd shouldn’t do it. That’s fine.
So psychoanalysis is for those who are ‘moved by it’, ‘interested by it’. Just as one person might prefer Sylvia Plath to Wallace Stevens. Phillips is telling us a deeper truth about living: there is a limit to knowledge and to formalism. And it is only once we reach that limit that we begin to truly live. Psychoanalysis, then, is about truly living. It’s about love, death, history, wishes, longings, and fantasies as they emerge spontaneously between two people.
There is something wonderful about listening to music you like, reading poetry that amuses you, having coffee with someone who interests you. Knowledge, if anything, bogs this down. Makes it boring. Makes it replicable. As Robert Solomon observes in his About Love: love is a thing that has been practiced a million times over and will be practiced for millions of times to come. All the lines you say have been said, the dates have been had, the sex has been enjoyed. But there is something constitutive and necessary about the truly uniquely subjective experience of the way you’re saying those lines, having those dates, and enjoying that sex.
Knowledge and Average Joe
Desire is what sustains psychoanalysis, both the treatment and the ‘cure’. It is not knowledge. Freud realized early on that insight is not enough to sustain deep change.
To formalize psychoanalysis is to transform the analyst into a mass-producer of Knowledge, the analysand being the consumer of emotional well-being and relational enlightenment. We have all been in situations wherein our expectations were shattered, and as a consequence, the experience was much more delightful. This is what is at stake in life and in analysis. This is not at stake in a scientific psychotherapy. There is nothing wrong with formalizing a science of human behavior — psychology is this effort, and psychotherapy is its praxis. But psychoanalysis is not this.
Phillips seems to be saying that it is closer to poetry. And what is a poem but an experience, an impact, that perhaps moves us to look at ourselves and the world and other people differently. A piece of music, sculpture, literature, painting, film, or philosophy often have similar effects.
Objective discourse — the speech of science and of psychology — often overrides personal discourse — the truthful and honest speech of the self. How often do we jump to diagnoses, personality tests, and categories to stabilize our identity and our experience? Is being unique that painful? (Sometimes I wonder whether Nietzsche’s melodramatic prose got in the way of his insights into the terror of uniqueness.)
Psychoanalysis is about becoming who you want to be. It’s about deepening one’s engagement with oneself and becoming more interesting to and for oneself.
In an interview with Verso (analysts seem to do their best work talking to others…), Lacan rejects the notion that there is some ‘average’, shared reality that all human subjects adhere to and exist within.
… let’s get rid of this average Joe, who does not exist. He is a statistical fiction. There are individuals, and that is all. When I hear people talking about the guy in the street, studies of public opinion, mass phenomena, and so on, I think of all the patients that I’ve seen on the couch in forty years of listening. None of them in any measure resembled the others, none of them had the same phobias and anxieties, the same way of talking, the same fear of not understanding. Who is the average Joe: me, you, my concierge, the president of the Republic?
Concluding Thoughts: The Case Study
There is a place for research in psychotherapy. But the method most suited to its practical means is the case study. Studying a detailed report or transcription with the analyst’s or therapist’s thoughts is immensely useful for learning the psychotherapeutic process and way of being/thinking. Looking at whether or not CBT is effective for this or that disorder for this or that allotted time-frame is patently useless to the clinician.
When confronted with the subjectivity of another human being, face to face with their demand to be recognized, abstracting oneself to the register of ‘statistical fictions’ won’t get you anywhere. On the other hand, studying the logic of a case and the development of a therapeutic encounter can enrich one’s own clinical processing.
This is an installment of a series in which I attempt to elucidate as clearly as possible the findings and theories of the field of psychoanalysis in my own words and understanding.
[1] Most of this history is from Strupp and Howard (1992), “A brief history of psychotherapy research”, in Freedheim et al., History of Psychotherapy: A Century of Change.
