Whatever happened to symptom substitution?

Symptom substitution is at the core of Freudian psychology but according to a new article in Clinical Psychology Review there is virtually no evidence for its existence and the concept should be abandoned.

The idea is that if you treat a symptom, say a phobia of social situations, without addressing the underlying conflict, another symptom will just appear because the core problem is unchanged. It is based on the Freudian theory that all symptoms of mental illness are simply a reflection of an underlying unconscious conflict.

Freud was inspired by the first law of thermodynamics that says that energy cannot be created or destroyed just turned into another form. His psychology, and much Freudian-inspired psychodynamic psychotherapy that follows, applies a similar idea to emotions.

In this model, a conflict is caused by a forbidden unconscious impulse being held back by our conscious ego. Supposedly, we want to banish them from our conscious mind to maintain a positive self-image, so we repress them into our unconscious. But because they can’t just disappear they are expressed in other ways – i.e. as neurotic symptoms.

However, this model also plays an important symbolic role in the politics of mental health. It suggests that psychoanalysis is the only truly effective treatment, because it supposedly deals with the ‘root cause’, while drugs, behaviour therapy and CBT just alleviate symptoms and leave the patient open to further suffering.

Rather unusually for a Freudian idea, it leads to a directly testable hypothesis. Psychoanalytic treatment should lead to a better long-term prognosis, whereas we should see other other symptoms appear after treatment with other approaches.

Psychologist Warren Tryon decided to look at the medical literature to see whether other approaches were more likely to result in the appearance of other symptoms, and found no evidence from relevant empirical studies.

In fact, Tryon found only two cases studies that claimed to provide direct evidence for symptom substitution and one of them didn’t even fulfil the definition, it just reported that the same symptoms came back – therefore describing a relapse rather than a substitution.

Despite their being a lack of evidence so far, he does note that not many studies have directly addressed the issue, but proposes a direct test:

The following experimental design could identify genuine psychoanalytic symptoms. Form two groups of demographically matched patients displaying a hypothesized symptom. Provide psychoanalytic treatment to one group and symptomatic treatment to the other group. The hypothesized symptom can be considered to be a bone fide psychoanalytic symptom if patients receiving psychoanalytic therapy get better and symptom substitution occurs in patients receiving symptom oriented therapy. Helping these patients to get better by providing psychoanalytic therapy would provide additional supportive evidence and be ethically responsible. The literature review reported above indicates that the presence of bona fide psychoanalytic symptoms has yet to be demonstrated.

Link to ‘Whatever happened to symptom substitution?’ (thanks Karel!).
Link to PubMed entry for article.

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