18 BMJ | 25 FEBRUARY 2011 | VOLUME 344
HEA D TO HEA D
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 p rovide badly
needed improvements in our treatments of com-
plex disorders.
Psychoanalysis:
does it have a
valuable place
in modern
mental health
services?
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
has no place there at all
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
