A quick fix for the soul or slow milking of the cash cow

An article in The Guardian by psychoanalyst Darian Leader argues that new psychological therapies are driven by a capitalist approach to mental well-being and that they commoditise the soul.

This article is the latest salvo aimed at bashing cognitive-behavioural therapy (CBT), an evidence-based psychological treatment which has inspired the ire of psychoanalysts for recently being heavily funded by the UK government.

CBT is a psychological therapy that typically looks at the link between thoughts, feelings and behaviour and is usually time-limited to 12 or 16 sessions. It is evidence-based with meta-analyses and randomized controlled trials showing it to be effective for various conditions and it is subject to improvement and testing by cognitive science.

Not only that, but the research has been almost entirely funded independent of industry or special interest groups, meaning some of the major conflicts of that pervade mental health are absent (although some remain relevant).

Leader’s article repeats several common accusations which, when not plain wrong, are just a bit bizarre.

Chief among these are the fact that CBT does not go ‘deep enough’ and doesn’t address the root problem, and this is apparently related to a ‘quick fix’ capitalist view of human nature (a criticism often made by UK psychologist Oliver James).

There are two parts to the ‘doesn’t go deep enough’ criticism. The first is that psychoanalysis says that symptoms are not the problem, they’re just the expression of an underlying conflict, so if you treat the symptom another will appear in its place unless you’ve dealt with the unconscious turmoil. Virtually the only verifiable aspect of this is the idea of ‘symptom substitution’ which is both testable and entirely without evidence, as we discussed previously.

Leader refers to the fact that something could be empirically testable as the ‘new rhetoric of “science”‘ (yes, those are really scare quotes around the word science), but that aside, psychoanalysis certainly does go ‘deeper’ than CBT. This is because it continues for years on end.

Owing to the fact that public health organisations are reluctant to fund poorly validated treatments, there are few psychoanalysts who work in the health public system, so a typical session from the many hundreds of you will need can set you back about £60-100 pounds a hour in the UK.

I only mention this because it strikes me that a psychoanalyst is the last person who should be accusing anyone of mental capitalism, let alone focusing his criticism on a therapy that’s widely available on the public health system.

The rest of the article is full of curious straw men, saying that CBT aims to ‘correct’ people’s thinking (it doesn’t, it trains people to test themselves for how useful their assumptions and beliefs are), that it is unconcerned with early experiences (it isn’t and considers that many of our assumptions come from earlier life and childhood), and that symptoms are just seen as meaningless aberrations of the mind (if this was the case, why would CBT even try to tackle them?).

A further irony is that when actually tested with “science” – sorry, science – psychoanalytically-inspired therapies of the briefer kind actually do quite well for the limited evidence that exists. This seems to be particularly the case for people diagnosed with ‘personality disorder’ – a vague and controversial category but one which suggests the person has pervasive problems with sustaining relationships.

Interestingly, transference is one of the genuinely important, testable and innovative ideas to come out psychoanalysis, and it specifically describes how experiences of past relationships affect how we interpret social interactions.

Unfortunately, psychoanalysis has always had something a little homeopathic about it, suggesting that it treats people ‘holistically’ and so empirical studies and “science” are irrelevant. Oddly, Freud was quite convinced of the opposite – that he was doing science, despite virtually avoiding anything scientific during the development of his now famous therapy.

It comes down to the fact that if you want any particular therapy funded by the government or your health insurance company you need to do studies to show it’s effective.

Now let me give my statement of ‘full disclosure’ – I’m trained in CBT and have used it regularly. I don’t think it’s perfect or a cure all, but it is a very useful and effective way of working with distressed people, despite its drawbacks.

I think a lot of psychoanalysis is bunk but I also think other parts, like transference, are wonderful and innovative. Psychoanalytically-inspired therapies seem also to be powerful and effective on the basis of the little rigorous evidence that exists.

What’s odd is that rather than being pleased that a psychological therapy is being widely promoted and throwing their ideas into the mix, some psychoanalysts seem to have gone on the attack and retreated into the the “we’re above science” position, while this actually seems a perfect opportunity to take the chance to test the evidence for psychoanalytic treatments while the funders are listening.

I’m constantly struck by the irony that for a practice that focuses on resolving conflicts, psychoanalysis has a long tradition of infighting. This latest episode seems to be the most recent manifestation of this recurrent pattern. Troubled infancy perhaps?

UPDATE: With uncanny timing, today’s New England Journal of Medicine has published a meta-analysis on the effectiveness of long-term (1 year+) psychodynamic psychotherapy in complex mental disorders, finding it a useful and effective treatment. It’s not a huge sample of studies (11 RCTs and 12 observational studies) but clearly suggests the benefit of this type of psychological treatment (thanks Ben!).

Link to oddly acerbic ‘A quick fix for the soul’ article.

2 Comments

  1. fangster2008
    Posted October 2, 2008 at 11:59 am | Permalink

    Hi there – love the blog and thought I’d post for the first time. I’m a psychiatrist trained in long-term and brief psychodynamic psychotherapy, CBT, IPT and have a great interest in CAT (as it’s a neat hybrid of a few of its predecessors). I’d suggest it’s very much a horses-for-courses issue – some patients, for example those with straightforward anxiety disorders, will do beautifully with an SSRI and CBT; similarly, I’ve a good track record with OCD with a mixture of CBT and response prevention therapy. However with chronic depression and personality disorders, a predominantly psychodynamic psychotherapeutic approach is warranted, although cognitive techniques can be very helpful to manage comorbid anxiety, or to initiate some immediate containment of poorly regulated affect and to manage their emotional response to interpersonal conflict.
    For the most seriously traumatised patients – particularly those with very complicated abuse histories where so much damage has been done, and so much panelbeating is required – it’s very difficult to get anywhere without a longer-term dynamic approach.
    So as a practitioner of most of these therapies, I’m gratified to see some evidence of one of the cornerstones of my psychotherapeutic practice. However it’s a mistake to conflate psychodynamic psychotherapy with psychoanalysis; strict interpretations of psychotherapeutic technique tend to be dogmatic and reductionistic. Like the CBT practitioner who believes that a short-term cognitive approach is the solution to most mental health problems, so too the psychoanalyst who slavishly adheres to a psychoanalytic model where it’s probably clinically inappropriate is a dogmatic reductionist who puts the needs of their own belief system over and above the needs of their patient. This is a potential trap for the psychoanalyst, the behaviourist, and the CBT practitioner alike.

  2. Posted October 7, 2008 at 8:24 pm | Permalink

    Hi there,
    I think you hit the nail on the head and said exactly what I was trying to say but not quite so eloquently. Indeed, it is dogma which is the difficulty and all new developments should be welcomed and tested.


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