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A head-to-head debate between paul salkovskis and lewis wolpert, who argue that psychoanalysis has no place in modern mental health services, and peter fonagy and alessandra lemma, who suggest that it can provide a valuable contribution. The debate explores the historical significance of psychoanalysis, its effectiveness compared to evidence-based therapies, and its potential role in understanding mental health problems and providing effective interventions.
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18 BMJ | 25 FEBRUARY 2011 | VOLUME 344
Paul Salkovskis professor of clinical psychology and applied science, Department of Psychology, University of Bath, Bath BA2 7AY, UK P.M.Salkovskis@bath.ac.uk Lewis Wolpert emeritus professor of biology as applied to medicine, Department of Cell and Developmental Biology, University College London, London, UK Psychoanalysis is of historical value only and, at best, has no place in modern mental health services. Not only is there no evidence base for the treatment, but there is no empirical grounding for the key constructs underpinning it. In addition, we suggest that the theory and practice of psychoanalysis are inimical to modern mental health services and so are, at worst, counterproductive and perverse in that context. We do not doubt the historical significance of psychoanalysis, psychoanalytical theory, and its founding father, Sigmund Freud. The theoretical concept of the unconscious provided the foundations of current cognitive sciences. Modern evidence based and empirically grounded psychological therapies,^1 including cognitive behavioural therapy, were initially developed by clinicians who were trained in psychoanalytical approaches but found the approach wanting.^2 Even the small number of evidence based psychodynamic therapies are very far removed from the basic dogmas of psychoanalysis and show little or no evidence of their provenance; neither the analyst’s couch nor free association is in evidence. As regards evidence, they are often ineffective, even relative to being on a waiting list.^3 Clearly, true paradigm shifts have occurred in terms of the understanding of human psychology and of the ways in which people experiencing psychological problems and distress can be helped. Freud himself deserves credit for establishing psychoanalysis as a new paradigm over a century ago. There is, however, an inevitability in the subsequent shift away from psychoanalysis, which began 50 years ago and which was de facto completed in the 1980s. Paradigm shifts are a form of accelerated intellectual evolution, where the explanatory and heuristic power of a particular theory are supplanted by another that better explains and predicts the key phenomena under investigation. Sometimes a supplanted idea is kept alive in some form; there is something charming and at times amusing about the continued existence of a flat earth society or the psychoanalytical approach to literary criticism. However, we propose that it is no longer defensible to continue ideas whose time has come and gone and which have been succeeded by more Peter Fonagy Freud memorial professor and head of research, Department of Clinical, Educational and Health Psychology, University College, London WC1E 6BT p.fonagy@ucl.ac.uk Alessandra Lemma unit director, Psychological Therapies Development Unit, Tavistock and Portman NHS Foundation Trust, London Psychoanalysis is under greater attack than ever before. An unprecedented decom- missioning of psychoanalytical services has taken place across the United Kingdom’s NHS (for example, Forest House NHS Psychotherapy Clinic, London), justified by cost savings. What are the reasons for this attack and what can be said in psychoanalysis’s defence? It has been claimed, perhaps fairly, that psy- choanalysis and psychodynamic psychothera- pies have failed to promote a culture of systematic evaluation and that the outcomes are difficult to measure and demonstrate. Relative to the number of studies on the effectiveness of cognitive behav- ioural therapy, few adequate studies are available of psychodynamic therapy outcomes. A growing body of studies, however, reports that psychody- namic therapy is effective in the treatment of both mild and complex mental health problems. For example, a meta-analysis found substantial effect sizes in randomised controlled trials of long term psychodynamic psychotherapy, larger than those for short term therapies.^1 Positive correlations were also seen between outcome and duration or dos- age of therapy. Another meta-analysis found that psychotherapy in addition to antidepressants sig- nificantly reduced depressive symptoms compared with antidepressants alone.^2 A third meta-analysis found that short term psychodynamic psychother- apy may be more effective than other therapies for somatic disorders.^3 So evidence is on its way. Convergent support for psychoanalytical approaches comes from 20 studies of brain func- tion changes after a range of psychotherapeutic treatments, including psychodynamic ones, for several mental disorders.^4 Brain changes that have been shown include a substantial increase in 5-HT1A receptor density in patients with major depressive disorder after psychodynamic therapy—this was not the case in patients who received fluoxetine^5 —and normalisation of neu- ronal activity in patients with somatoform disor- ders.^6 Ultimately these investigations will enable us to better understand the therapeutic mecha- nisms of a range of approaches and provide badly needed improvements in our treatments of com- plex disorders.
Peter Fonagy and Alessandra Lemma say that the psychoanalytical approach can provide a useful and unique contribution to modern healthcare, but Paul Salkovskis and Lewis Wolpert argue that it
BMJ | 25 FEBRUARY 2011 | VOLUME 344 19
appropriate ones in an area as important as healthcare. It would not be tolerated in cardiology or oncology; why should it be in mental health? In evolutionary terms, psychoanalysis can be regarded as a metaphorical appendix; vestigial and unfortunately of no continuing value. Psychoanalysis rejected Freud’s original concept of psychoanalytical science.^4 We suggest that psychoanalysis has become a pseudoscience because its claims are neither testable nor refutable. Attempts to identify evidence for constructs such as the id, ego, and superego and concepts such as the oedipal complex have sadly failed. Psychoanalysis has had its day, and more. It dominated psychological approaches for well over half a century, during which time it essentially stagnated, becoming conservative and authoritarian, depending on flawed wisdom of tribal leaders. As a movement, it greeted the development of the upstart behaviour therapy and later cognitive therapy by actively resisting, with passion and fury, the notion of outcome evaluation, and opposed what it regarded as the dangerous obscenity of symptom focused approaches. It still does.^5 Psychoanalysis is quite different from psychiatry because it makes no attempt to diagnose a patient’s condition, and so does not recognise problems such as schizophrenia or others with a genetic cause. The patient does not have a defined illness and so no attempt is made to find a cure. This also means that the true psychoanalyst will resist medication for the patient. The treatment is also expensive because the patient typically attends sessions several times a week, usually over several years. The average duration of psychoanalytical treatment in the US is estimated to be over five years. Our opponents in this debate might choose to argue the usefulness of psychodynamic approaches, such as mentalisation and interpersonal therapy, given their associated research findings. They will find no argument from us. Neither, however, will they find a couch in the consulting rooms of those who practise such approaches—these methods are successors to psychoanalysis, rather than a continuation. Is there value in some input from psychoanalysis in mental health? There are at least three reasons for a clear “no.” Firstly, historically: when psychoanalysis was the only significant force in psychotherapy, it failed to advance the care of people with mental health problems. Behaviour therapy and cognitive behaviour therapy were needed to do that. Secondly, theoretically: an approach that not only explicitly rejects but also opposes the use of treatments that deal with crippling symptoms such as anxiety and depression, obsessional rituals, and agoraphobic avoidance has no place in mental health services, which should by definition help service users to reduce distress and disability.^6 Finally, empirically: the development of an accountable healthcare culture by the National Institute for Health and Clinical Excellence and other mechanisms has resulted in real improvements in mental healthcare; an approach that rejects outcome measurement has no place in the rapidly evolving and empirically grounded field of psychological understanding and interventions in mental health. We can honour our traditions in mental health, but that does not mean that we should preserve traditions when we work with NHS service users to help them find pathways to recovery. We suggest that it would be perverse to provide any place in modern mental health services for psychoanalysis. Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure. pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years. PS is editor in chief of the journal Behavioural and Cognitive Psychotherapy , which is the official journal of the British Association for Behavioural and Cognitive Psychotherapies, a leading organisation for behavioural and cognitive psychotherapies in the UK. Does psychoanalysis have a valuable place in modern mental health services? is the subject of a Maudsley debate at the Institute of Psychiatry, King’s College London on 7 March 2012 (www.iop.kcl.ac.uk/events/?id=1106). Provenance and peer review: Commissioned, not externally peer reviewed. References are in the version on bmj.com. Cite this as: BMJ 2012;344:e The psychoanalytical approach makes three valuable and unique contributions to a modern healthcare economy. Firstly, in their applied form, psychoanalytical ideas can support mental health staff to provide high quality services despite the interpersonal pressures to which they are inevi- tably exposed when working with disturbed and disturbing patients. Psychoanalytical under- standing helps us to respond in humane ways when anxiety and stress threaten our ability to contemplate behaviour in terms of underlying mental states. The framework psychoanalysis provides for understanding why things go wrong in therapeutic relationships draws on a well devel- oped theory of interactional process.^7 There are few viable alternative models for how a disturbed individual or community can affect the thinking and behaviour of those engaged with them. Secondly, there are increasingly strong indica- tions that adult mental health problems are devel- opmental in nature; three quarters can be traced back to mental health difficulties in childhood, and 50% arise before age 14 years.^8 The psycho- analytical model is unique in proposing a develop- mental theory (of attachment relationships) that is now firmly supported by evidence.^9 It therefore allows us to understand the relation between early experience, genetic inheritance, and adult psychopathology. This developmental frame- work emphasises early intervention and has been critical in shaping positive mental health policy, including the UK government’s “No Health With- out Mental Health” strategy.^10 Acknowledging the developmental, relational foundations of mental health also has implications for prevention. Thirdly, psychoanalytical ideas continue to provide the foundations for a wide range of applied interventions. Research and clinical observation show that other modalities— particu- larly cognitive behavioural therapy—have made use of theoretical and clinical features of the psy- choanalytical approach and incorporated these into their techniques. This may well enhance the overall effectiveness of these modalities; for example, some evidence suggests that the good outcomes achieved by other therapies correlate with the extent to which those therapies use psy- chodynamic techniques.^11 Research clearly shows that there is no one size fits all approach to the treatment of mental health problems; irrespective of brand, psycho- therapy only substantially helps around 50% of referred patients who complete treatment^12 and medication fares no better.^13 Rationally designed services should therefore provide a range of approaches for which some evidence of effectiveness exists, and should continue to broaden the research base to ensure monitoring and improvement of the effectiveness of these services. More comprehensively, perhaps, than any other theory of the mind, psychoanalysis points to key psychological phenomena and proc- esses (such as the limitations of consciousness, defences, resistance to treatment, transference and countertransference). These have to be inte- grated into our understanding of clinical work if adequate and effective psychological treatment is to be offered. If psychoanalysis is thrown out, these aspects of the mind will have to be redis- covered—just like Graeco-Roman culture was rediscovered after the dark ages. Competing interests: none declared. Provenance and peer review: Commissioned, not externally peer reviewed. References are in the version on bmj.com. Cite this as: BMJ 2012;344:e