Lo! How the mighty have fallen, one might say. This essay considers Freud’s legacy as he turns 150, describing the state of British psychoanalysis. The authors, one of whom is a British psychiatrist, remind us of the fury and “seriousness with which disputes over psychoanalysis were being conducted in the 1980s” (typified by the controversy over Jeffrey Masson so ably described by New Yorker writer Janet Malcolm back then), and how far toward the edifice passing with a whimper, instead of a bang, we have come in the two decades since.

The British government and, I might add from my perspective, U.S. managed care companies, are gangbusters over cognitive therapy instead these days, insofar as they have any truck with ‘the talking cure’ at all anymore. The article describes cognitive therapy and how it is different from psychoanalytically-based therapy. The article seems to contrast the two first and foremost on the basis of technique — focusing on Freudian analysis’ reliance on free association and the transference. “…The process is classically driven by (these) two mechanisms, and these are essentially all there is to the technique…” I think there are more extensive, and more accessible, ways of capturing what is unique about psychoanalytic therapy. For example, that it is insight-based, that exploration of one’s past is considered important to that insight, that the therapist is attentive to what is avoided and not said by the patient as well as what is being discussed, that there is an emphasis on how the patient functions interpersonally, and that the internal life of wishes, fantasies and dreams is considered important. All of these are largely absent from cognitive therapy.

I also think the essayists are misleading about transference. They describe it as “what takes place between you and the analyst as you become embroiled in an intimate relationship that is unlike any other you might have outside the consulting room”. It is not different; it is simultaneously the same and different! The beauty of analysis of the transference is that the patient will create a relationship with the therapist that cannot escape replicating the rigid and problematic patterns with which they interact with everyone else in their social spheres. All that is different is that the therapist is a trained observer with respect to this process, so that s/he can understand it, comment upon it, and facilitate the patients’ reshaping it, all while staying somewhat above the fray and preventing the relationship from being disrupted. It would not work if it were “unlike any other” relationship the patient has!

Quite rightly, the authors point out that one has to consider not only technique but the theory on which it is based. The true lynchpin of psychoanalysis, the understanding of the human being that it informs, and the therapeutic impact of the insight patients develop through psychoanalytically-based therapy, has been the notion of the unconscious` — that some of the forces which shape how we think, feel and behave are not obvious to us, remain undiscovered and out of our control, and that that is the basis of our distress. The notion of the unconscious has little empirical backing and is different from the subconscious processes that cognitive science posit and the neurophysiological underpinnings of mental function that biological psychiatry and neuroscience suggest.

In contrast to the baroque complexities of psychoanalysis, cognitive therapy is built on the idea that distress is an outcome of dysfunctional and correctable thoughts that patients have aboout themselves. The article has a good description of what a patient can expect to find in a cognitive therapy. The empirical evidence for cognitive therapy’s efficacy is reviewed.

Much is made of the notion that, in psychoanalytic treatment, instead of “tell[ing] you what it is that you’ve got,… [or] explain[ing] how you will get over it,… you embark on a personal exploration during which you find that you don’t only suffer from the symptoms you thought you did, but also a range of other conflicts underlying them.” Arguably, from this perspective, patients do not get ‘better’ in psychoanalysis. Much is made of Freud’s famous (perhaps his most famous) statement that “much will be gained if we succeed in transforming your hysterical misery into common unhappiness.” Certainly, shouldn’t the result-driven governments or insurance companies funding mental health treatment abhor such an empirically unproven, costly and unproductive practice!

In a word, the problem lies in the lack of precision, refinement or specificity about what getting better means. Quite simply, cognitive therapy was developed to deal with depression and anxiety. Along with medications, it is an effective and cost-effective treatment for limited subtypes of the human misery we are dealing with in the mental health field, the bread-and-butter disorders of the field. You may not need to understand yourself better to improve from these and similar conditions and, indeed, understanding yourself better may not help.

But that is a far cry from dismissing psychoanalysis for the “near-uselessness of its insights,” as Janet Malcolm is quoted as saying. Whether empirically proven or not, psychoanalysis works because its practitioners are skillful at spinning a web of belief and enlisting their patients into adhering to a coherent and believable story about why they feel and act the way they do. This exists in an entirely different sphere than that in which you can measure the ‘truth’, or the empirical validity, of what one comes to understand. It is more akin to faith than scientific knowledge; treatment is more akin to going to church to reaffirm and extend one’s belief than going to the doctor’s office. Argue as you might about the damage that faith may bring; there are spheres in which it is important, and in which nothing else works. Paradoxically, perhaps, this is the case for some of our least sick patients, the so-called “walking wounded”; and also some of our sickest, the so-called personality-disordered or character-disordered patients. In contrast to someone undergoing a depressed episode, these are people who have chronic and pervasive maladaptive ways of being in the world and interacting with others throughout the bulk of their adult lives. In these cases, getting ‘better’ may mean not so much repairing anything as it does entering into a new, more comforting and perhaps more empowering storyline about oneself and one’s relationships. Doesn’t it make sense that there might be a distinction between conditions in which relief comes from changing what we cannot bear and others in which it is a matter of bearing what we cannot change? And that different techniques might facilitate those two kinds of solution? As the authors conclude:

Let us not throw the baby out with the bathwater. CBT, medication-based treatment, etc., have largely supplanted open-ended exploratory and revelatory therapy not because they are better or more suitable for all but because they suit a society which has gone overboard with quick fixes, with linear and concrete understanding instead of nuanced analysis, with the romance of the evidence-based, and ultimately with cost-consciousness. This is a society that has excised most of the meaning out of people’s lives already. At least, in my profession, I can draw the line somewhere, and continue to attempt to help patients find meaning in their suffering and value in their lives.