The State of Psychoanalytic Psychotherapy

Shedler’s (2010) article ‘The Efficacy of Psychodynamic Psychotherapy’ dropped like a bombshell on the psychotherapy research world. He conducted a meta-analysis of the various meta-analyses on the efficacy of psychodynamic (psychoanalytic) psychotherapy. In the psychology world, proving the effectiveness of a psychotherapy treatment is important to placate the insurance companies and academic research psychologists (i.e the Big Other). Shedler’s review yielded impressive results. Not only was psychodynamic psychotherapy proven to have large effect sizes (larger than cognitive-behavioral therapy, currently the most popular form of psychotherapy in the States), but patients were shown to continue to make gains even after the termination of treatment. This was welcome news to psychoanalytic clinicians, as it verified the utility of our method. I am very proud of the results, as I have seen great improvements in my personal work with patients, which has only confirmed my beliefs.

However, what I wanted to address in this post is the way in which Shedler defined the unique ingredients that comprise psychodynamic treatment. To be fair, Shedler noted that these seven factors are based on research studies on practicing psychodynamic clinicians. So any criticisms I direct towards Shedler merely represent the field’s current approach to psychodynamic treatment and theory. Recall in Seminar XI that Lacan listed the four fundamentals of psychoanalysis: the unconscious, repetition, transference, and drive. Let me list the seven factors that Shedler listed, which I plan to critique from a Freudo-Lacanian perspective:

1) Focus on affect and emotional expression
2) Exploration of attempts to avoid distressing thoughts and feelings – defense/resistance
3) Identification of recurring themes and patterns – repetition compulsion
4) Discussion of past experience
5) Focus on interpersonal relations
6) Focus on the therapy relationship – transference
7) Exploration of fantasy life

First, let me begin with the ‘focus on affect and emotional expression’. Affects are important, to be sure. Unlike cognitive-behavioral therapy that emphasizes the ways in which our thinking determines our emotions and behaviors, psychodynamic theory supposedly prioritizes emotions over thinking, according to Shedler. Fink (2007), a prominent Lacanian, discusses how many psychodynamic clinicians are on the search for affects in treatment, what he terms ‘affect hunting’. Fink argued that emotions are by no means the royal road to the unconscious; instead repression and anxiety are signals to the clinician that the unconscious is emerging (or being defended against). Lacan refused to acknowledge any division between affect and thinking, claiming that over-intellectualization was simply “an excuse(s) for sloppy thinking” (Ecrits, p. 171). It is probable that psychodynamic clinicians have prioritized affect in an attempt to distinguish our technique from cognitive-behavioral clinicians. However, the patient can use anything as a defense: thinking, behavior (recall Freud who said repeating was a way to defend against remembering), and emotions. Emotions can be used as a defense against thinking, just as thinking can be used as a defense against feeling. Neither affects nor emotions should be prioritized by psychodynamic clinicians.

Second, Shedler is right to point the importance of defenses and resistance in psychodynamic treatment. I have no qualms with this point. Next, he identifies the importance of repetition and patterns. Shedler also included the importance of past experience, which is certainly important (particularly childhood sexual and interpersonal experience (age 1-3 – preoedipal stages (oral-anal) and 3-5 oedipal stage). Shedler also discussed the importance of interpersonal relationships. This calls to mind Fairbairn’s description of the libido as object-seeking rather than libido as pleasure-seeking (Freud). The importance of factors 3-5 (repetition, development, and interpersonal relations) makes the therapeutic relationship (and the transference) central for dynamic clinicians. Other therapists tend to downplay the transference, viewing it as an obstacle to a successful treatment. Finally, Shedler noted that psychodynamic clinicians emphasize the centrality of fantasy life and the patient’s free associations in treatment. Recall that Freud said the fundamental rule of analysis is for the patient to say whatever is on her mind without censoring the material. Of course, this is not a simple task, as it promotes all sorts of defenses and resistance (factor 2).

Now, that I have discussed what Shedler included on his list let me describe some of the factors he omitted that I view as crucial to psychoanalytic work. He failed to include two of Lacan’s four fundamentals: the unconscious and drive. First, apparently psychodynamic clinician do not stress the importance of Freud’s dual-drive theory: the libidinal drive and the death drive (externally in the form of aggression, internally in the form of masochism and self-destruction). In my work, I find aggression to be absolutely crucial, and the various ways the patient communicates this aggression. Patients often view aggression as too dangerous to communicate to others, and they might re-direct it inwardly (leading to depression and self-rebuke). Freud (1917) highlights this dynamic in the context of grief and loss in his famous paper on ‘Mourning and Melancholia’. Although I focus on aggression, I find that sexuality and libidinal wishes are generally more distressing for patients. Despite all the advances our society has made in our acceptance of sexuality, we are still so uncomfortable speaking freely about our sexuality. This is evident given in our culture’s fascination with aggression and violence but our Puritanical rules against showing sexuality on TV. In fact, my supervisor told me that the he has found that novice therapists of our generation are more repressed and defended against sexuality in comparison to therapists of older generations. I encountered this resistance when I was a TA for a two-semester course this year on psychoanalytic theory. The students were particular uncomfortable with Freud’s theory of infantile sexuality.

Second, I was shocked that psychodynamic clinician do not highlight the centrality of the analysis of the unconscious (at least according to Shedler’s list). For me, this is what makes psychodynamic psychotherapy unique. Behavioral and cognitive-behavioral psychologists restrict their investigations to the patient’s conscious actions and thoughts, totally ignoring the unconscious determinants that drive behavior and thinking. Emphasizing the unconscious and repression is indispensable to treatment, and it helps explain the ways in which patients defend against encountering their unconscious mind. Without a focus on the unconscious one cannot claim to be doing psychoanalytic work. This is why free association is such an indispensable technique because it allows for the patient’s unconscious to emerge in session.

Third, Shedler failed to include intrapsychic conflict. In my work, I continue to point out how the patient resolves (or fails to resolve) antagonistic desires, wishes, and fears. The patient’s negotiations of these conflicts result in symptoms or compromise formations (Brenner). Conflicts are understood to be the primary cause of psychopathology in most psychoanalytic schools; hence an analysis of conflict is indispensable for psychoanalytic technique.

Fourth, Lacanians would object to the fact that the centrality of language is not included on Shedler’s list. Psychoanalysis is, after all, a talking cure. It is very interesting that the mere arrangement of signifiers in a certain order can alleviate a patient’s symptoms (depression, anxiety, guilt, etc). Freud’s early work (especially Psychopathology of Everyday Life, 1901) stressed the importance of slips of the tongue, pen, and bungled actions. Following Lacan, psychoanalytic clinicians should listen to the patient’s speech and stop focusing on the patient’s intention, which is often used defensively by the patient to evade slips-of-the-tongue (or to avoid acknowledging the ego is the master of its own house). More succinctly, what matters is what the patient said (symbolic) not what she intended (imaginary).

Lastly, Shedler doesn’t explicitly state the importance of the therapist’s interpretation. Psychoanalytic clinicians provide both a relationship and insight (through interpretation) to our patients. I would argue that the therapist’s interpretive capacity is our unique function. Friends and lovers can provide empathy, love, and acceptance, but only the therapist is in a unique position (due to the structure of psychoanalytic work) to provide insight and interpretation of the transference and unconscious conflicts to the patient.

5 thoughts on “The State of Psychoanalytic Psychotherapy

  1. Great post, Jeremy! I’ve been tackling Lacan’s first seminar, so I appreciate these technical points.

    Your criticism of the affect-centred approach echoes Lacan’s remarks on Margaret Little and Melanie Klein in the first seminar, how they couldn’t see beyond the imaginary dimension of the transference. I think it’s important to revisit those remarks in the context of this post, because I suspect the Shedler paper (I haven’t read it yet!) still approaches the question of efficacy in a quantitative way. Lacan didn’t doubt the power of affect-centred approaches to improve the patient’s feelings, albeit temporarily, as is evident in Little’s case. The reliance on reciprocal projection, on the imaginary plane, from the ego to the alter ego, and the focus on the patient’s feelings hic et nunc, may lead the therapist to miss the role played by the symbolic transference which, for Lacan, is the real source of analytic efficacy. But, as was the case with Klein, even if she did not appreciate the symbolic dimension, she nevertheless mobilised its power in her treatment of Little Dick, despite her not knowing that she was doing it. So, it seems that one doesn’t necessarily need to know the theory to be able to implement it in practice.

    So, of course, there are patients who report improvement having undertaken therapies that use such an approach, and they probably make up the numbers in Shedler’s results. But more often than not, it’s a happy coincidence, and relying on that chance is not very helpful. So theory is important, and being able to explain the source of the efficacy is as crucial as showing that a particular method is effective. I agree that one can’t fully appreciate what goes on in the consulting room without the right concepts, and the four concepts are indeed fundamental. Lacan makes this point very well with his discussion of famous cases, such as Little’s and Klein’s, and my favourite, Kris’s. If Kris had the concept of the object and knew to interpret “within” the transference than interpret the transference itself, he probably wouldn’t have thwarted the professor’s desire and led him to that famous acting out, about the fresh brains.

    So… we need theory!

  2. Yes, I definitely had Seminar I in mind. I’m actually right now writing journal article on transference and countertransference with Lacanian interventions on the various debates in the analytic literature. I’ll send it to you once I complete my first draft.

    The imaginary transference obviously restricts the analytic encounter to the ego-ego discourse. Lacan made this point in Seminar I, “In every analysis of the intersubjective relation, what is essential is not what is there, what is seen. What structures it is what is not there” (p. 224).

    Have I recommended you read Michael Miller’s (2011) Lacanian Psychotherapy? I believe Fink was his supervisor and the books is really quite good, especially his detailed case histories. Probably the most user-friendly book I’ve seen on Lacanian technique.

    Klein, despite all her failings, also stressed the importance of the drives and the unconscious. Even if she is often hung up on the love-hate (imaginary) aspects of the transference, she also recognized the importance of getting around defenses to the unconscious material. Segal (1950) says this quite well in her paper “Some Aspects of the Analysis of a Schizophrenic”, “I thought it worthwhile in the analysis of a schizophrenic to attempt that which Freud has shown to be the only way of attacking the roots of a mental illness; that is, not to strengthen the defence mechanisms of the patient but to bring them into the transference and analyze them” (p. 278). After the Lacanians, I side with the Kleinians.

    We need theory? I couldn’t agree more.

  3. To be fair, much of the field has rejected Freud’s drive theory. Instead, the major motivational (drive) force is the desire for relationships/attachment (which is why I mentioned Fairbairn’s idea that libido is object-seeking). This is particularly trendy in the object-relations and relational/interpersonal psychoanalytic schools.

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