The long read: Cheap and effective, CBT became the dominant sort of therapy, consigning Freud to psychologys dingy cellar. But new surveys have cast doubt on its domination and shown dramatic outcomes for psychoanalysis. Is it time to get back on the lounge?
Dr David Pollens is a psychoanalyst who considers his patients in a modest ground-floor office on the Upper East Side of Manhattan, a neighbourhood likely merely rivalled by the Upper West Side for the highest concentration of therapists anywhere on countries around the world. Pollens, who is in his early 60 s, with thinning silver hair, sits in a wooden armchair at the head of a lounge; his patients lie on the lounge, facing away from him, the better to explore their most embarrassing fears or fictions. Many of them come several times a week, sometimes for years, in keeping with analytic tradition. He has an impressive track record treating nervousnes, depression and other ailments in adults and children, through the medium of uncensored and largely unstructured talk.
To visit Pollens, as I did one darknes winters afternoon late last year, is to plunge immediately into the arcane Freudian language of resistance and neurosis, transference and counter-transference. He exudes a kind of warm neutrality; you could easily imagine telling him your most troubling secrets. Like other members of his tribe, Pollens considers himself as an excavator of the catacomb of the unconscious: of the sex drives that lurk beneath awareness; the hatred we feel for those we claim to love; and the other distasteful truths about ourselves we dont know, and often dont wish to know.
But theres a very well-known narrative when it comes to therapy and the relief of agony and it leaves Pollens and his fellow psychoanalysts decisively on the wrong side of history. For a start, Freud( this story goes) has been debunked. Young boys dont lust after their moms, or fear their fathers will castrate them; adolescent girls dont envy their brethren penis. No brain scan has in the past situated the ego, super-ego or id. The practise of charging clients steep fees to meditate their childhoods for years while characterising any objections to this process as resistance, demanding farther psychoanalysis seems to many like a swindle. Arguably no other notable figure in history was so fantastically wrong about nearly every important thing he had to say than Sigmund Freud, the philosopher Todd Dufresne declared a few years back, summing up the consensus and echoing the Nobel prize-winning scientist Peter Medawar, who in 1975 called psychoanalysis the most stupendous intellectual confidence trick of the 20 th century. It was, Medawar went on, a terminal product as well something akin to a dinosaur or a zeppelin in the history of ideas, a vast structure of radically unsound design and with no posterity.
A jumble of therapies emerged in Freuds wake, as therapists struggled to put their attempts on a sounder empirical footing. But from all these approaches including humanistic therapy, interpersonal therapy, transpersonal therapy, transactional analysis and so on its generally agreed that one emerged triumphant. Cognitive behavioural therapy, or CBT, is a down-to-earth technique focused not on the past but the current; not on mysterious inner drives, but on adjusting the unhelpful thought patterns that cause negative emotions. In contrast to the meandering dialogues of psychoanalysis, a typical CBT exercise might involve filling out a flowchart to identify the self-critical automatic thoughts that occur whenever you face a setback, like being criticised at work, or rejected after a date.
CBT has always had its critics, mainly on the left, because its cheapness and its focus on get people promptly back to productive work attains it suspiciously attractive to cost-cutting politicians. But even those opposed to it on ideological grounds have rarely questioned that CBT does the job. Since it first emerged in the 1960 s and 1970 s, so many studies have stacked up in its favour that, these days, the clinical jargon empirically supported therapies is usually simply a synonym for CBT: its the one thats based on facts. Attempt a therapy referral on the NHS today, and youre much more likely to end up , not in anything resembling psychoanalysis, but in a short series of highly structured meetings with a CBT practitioner, or perhaps learning methods to interrupt your catastrophising guessing via a PowerPoint presentation, or online.
Yet rumblings of disagreement from the vanquished psychoanalytic old guard have never quite gone away. At their core is a fundamental discrepancy about human nature about why we suffer, and how, if ever, we can hope to find peace of mind. CBT represents a very concrete view of painful emotions: that theyre principally something to be eliminated, or failing that, made tolerable. A condition such as depression, then, is a bit like a cancerous tumor: sure, it might be useful to figure out where it came from but its far more important to get rid of it. CBT doesnt precisely claim that happiness is easy, but it does imply that its relatively simple: your distress is caused by your irrational beliefs, and its within your power to confiscate hold of those notions and change them.
Psychoanalysts contend that things are much more complicated. For one thing, psychological pain needs first not to be eliminated, but understood. From this perspective, depression is less like a tumor and more like a knife pain in your abdomen: its telling you something, and you need to find out what.( No responsible GP would just pump you with painkillers and send you home .) And happiness if such a thing is even achievable is a much murkier matter. We dont genuinely know our own intellects, and we often have powerful motives for keeping things that route. We find life through the lens of our earliest relationships, though we usually dont realise it; we want contradictory things; and change is slacken and hard. Our conscious intellects are tiny iceberg-tips on the dark ocean of the unconscious and you cant truly explore that ocean by means of CBTs simple, standardised, science-tested steps.
This viewpoint has much romantic appeal. But the analysts debates fell on deaf ears so long as experiment after experiment seemed to confirm the superiority of CBT which helps explain the shocked response to a study, published last May, that seemed to show CBT get less and less effective, as a treatment for depression, over time.
Examining ratings of earlier experimental trials, two researchers from Norway concluded that its effect sizing a technical measure of its usefulness had fallen by half since 1977.( In the unlikely event that this trend were to persist, it could be entirely useless in a few decades .) Had CBT somehow benefited from a kind of placebo effect all along, effective merely so long as people believed it was a miracle cure?
That puzzle was still being digested when researchers at Londons Tavistock clinic published outcomes in October from the first rigorous NHS study of long-term psychoanalysis as a treatment for chronic depression. For the most severely depressed, it concluded, 18 months of analysis worked far better and with much longer-lasting impacts than treatment as usual on the NHS, which included some CBT. Two years after the various therapies aimed, 44% of analysis patients no longer fulfilled the criteria used for major depression, compared to one-tenth of the others. Around the same period, the Swedish press reported a finding from government auditors there: that a multimillion pound scheme to reorient mental healthcare towards CBT had proved completely ineffective in satisfying its goals.
Such findings, it turns out, arent isolated and in their midst, a freshly emboldened band of psychoanalytic therapists are pressing the case that CBTs pre-eminence has been largely built on sand. Indeed, they argue that teaching people to guess themselves to wellness might sometimes make things worse. Every thoughtful person knows that self-understanding isnt something you get from the drive-thru, said Jonathan Shedler, a psychologist at the University of Colorado medical school, who is one of CBTs most unsparing critics. His default bearing is one of wry good humour, but exasperation ruffled his demeanour whenever our dialogue dwelt too long on CBTs claims of supremacy. Novelists and poets seemed to have understood this truth for thousands of years. Its only in the last few decades that people have said, Oh , no, in 16 sessions we can change lifelong patterns! If Shedler and others are right, it is possible to period for psychologists and therapists to re-evaluate much of what they thought they knew about therapy: about what works, what doesnt, and whether CBT has really consigned the cliche of the chin-stroking shrink and with it, Freuds picture of the human mind to history. The impact of such a re-evaluation could be profound; eventually, it might even change how millions of people around the world are treated for psychological problems.
How does that stimulate you feel?
Freud was full of horseshit ! the therapist Albert Ellis, arguably the progenitor of CBT, liked to say. Its hard to deny he had a point. One big part of the problem for psychoanalysis has been the evidence that its founder was something of a charlatan, prone to distorting his findings, or worse.( In one especially eye-popping case, which merely came to light in the 1990 s, Freud told a patient, the American psychiatrist Horace Frink, that his suffering stemmed from an inability to recognise that he was homosexual and hinted that the solution lay in making a large fiscal contribution to Freuds run .)