Therapy wars: the revenge of Freud | Oliver Burkeman

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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?

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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 .)

Peter

Illustration: Peter Gamlen for the Guardian

But for those working challenging psychoanalysis with alternative approaches to therapy, even more troublesome was the sense that even the most sincere psychoanalyst is always engaged in a guessing-game, always prone to finding proof of his or her hunches, whether its there or not. The basic premise of psychoanalysis, after all, is that our lives are ruled by unconscious forces, which speak to us only indirectly: through symbols in dreamings, accidental slips of the tongue, or through what infuriates us about others, which is a clue to what we cant face in ourselves. But all this attains the whole thing unfalsifiable. Protest to your shrink that , no, you dont genuinely detest your parent, and that simply shows how desperate you must be to avoid acknowledging to yourself that you do.

This problem of self-fulfilling prophecies is a disaster for anyone hoping to figure out, in a scientific route, whats really going on in the mind and by the 1960 s, advances in scientific psychology had reached a point at which patience with psychoanalysis began to run out. Behaviourists such as BF Skinner had already shown that human behaviour could be predictably manipulated, much like that of pigeons or rats, by means of penalty and reward. The burgeoning cognitive revolution in psychology held that goings-on inside the mind could be measured and manipulated too. And since the 1940 s, there had been a pressing need to do so: thousands of soldiers returning from the second world war exhibited emotional disturbances that wept out for rapid, cost-effective treatment , not years of dialogue on the couch.

Before laying the groundwork for CBT, Albert Ellis had in fact originally trained as a psychoanalyst. But after practising for some years in New York in the 1940 s, he found his patients werent getting better and so, with a self-confidence that would come to define his career, he concluded that analysis, rather than his own abilities, must be to blame. Along with other like-minded therapists, he turned instead to the ancient doctrine of Stoicism, teaching clients that it was their beliefs about the world , not events themselves, that distressed them. Get passed over for a promotion might induce unhappiness, but depression came from the irrational propensity to generalise from that single setback to an image of oneself as an all-round failure. As I see it, Ellis told an interviewer decades later, psychoanalysis devotes clients a cop-out. They dont have to change their styles they get to talk about themselves for 10 years, blaming both parents and waiting for magic-bullet insights.

Thanks to the breezy , no-nonsense tone will be approved by CBTs proponents, its easy to miss how revolutionary its claims were. For traditional psychoanalysts and the individuals who practise newer psychodynamic techniques, largely derived from traditional psychoanalysis what happens in therapy is that apparently irrational symptoms, such as the endless repeat of self-defeating patterns in love or run, are revealed to be at least somewhat rational. Theyre responses that made sense in the context of the patients earliest experience.( If a parent abandoned you, years ago, its not so strange to live in constant dread that your spouse might do so too and thus to act in ways that screw up your matrimony as a result .) CBT flips that on its head. Emotions that might appear rational such as feeling depressed about what a catastrophe your life is stand exposed as the result of irrational reasoning. Sure, you lost your job; but it doesnt follow that everything will be awful forever.

Peter

Illustration: Peter Gamlen for the Guardian

If this second approach is right, change is clearly far simpler: you need only identify and correct various thought-glitches, rather than decoding the secret reasons for your agony. Symptoms such as sadness or nervousnes arent inevitably meaningful clues to long-buried fears; theyre interlopers to be banished. In analysis, the relationship between therapist and patient serves as a kind of petri dish, in which the patient re-enacts her habitual ways of associating with others, enabling them to be better understood. In CBT, youre just trying to get rid of a problem.

The sweary, freewheeling Ellis was destined to remain an foreigner, but the approach he pioneered soon attained respectability thanks to Aaron Beck, a sober-minded psychiatrist at the University of Pennsylvania.( Now 94, Beck has probably never called anything horseshit in their own lives .) In 1961, Beck devised a 21 -point questionnaire, known as the Beck Depression Inventory, to quantify clients suffering and showed that, in about half of all cases, a few months of CBT alleviated the worst symptoms. Objections from analysts were dismissed, with some justification, as the complaints of people trying to protect their lucrative turf. They saw themselves compared to 19 th-century “doctors ” bungling improvisers, threatened and offended by the notion that their mystical art could be reduced to a sequence of evidence-based steps.

Many more surveys followed, demonstrating the benefits of CBT in treating everything from depression to obsessive-compulsive disorder to post-traumatic stress. I went to the early seminars on cognitive therapy to fulfill myself that it was another approach that wouldnt run, David Burns, who went on to popularise CBT in his worldwide bestseller Feeling Good, told me in 2010. But I passed the techniques to my patients and people whod seemed hopeless and stuck for years began to recover.

Theres little doubt that CBT has helped millions, at least to some degree. This has been especially true in the UK since the economist Richard Layard, a vigorous CBT evangelist, became Tony Blairs happiness czar. By 2012, more than a million people had received free therapy as a result of the initiative Layard helped push through, working with the Oxford psychologist David Clark. Even if CBT wasnt especially effective, you might argue, that kind of reach would count for a lot. Yet its hard to shake the sense that something big is missing from its model of the agony mind. After all, we experience our own inner lives, and our relationships with others, as bewilderingly complex. Arguably the entire history of both religion and literature aim to grapple with what it all means; neuroscience daily discloses new subtleties in the workings of the brain. Could the answer to our woes genuinely be something as superficial-sounding as identifying automatic thoughts or modifying your self-talk or challenging your inner critic? Could therapy genuinely be so straightforward that you could receive it not from a human but from a book, or a computer?

A few years ago, after CBT had started to dominate taxpayer-funded therapy in Britain, a woman Ill call Rachel, from Oxfordshire, attempted therapy on the NHS for depression, following the birth of her first child. She was sent first to sit through a group PowerPoint presentation, promising five steps to improve your mood; then she received CBT from a therapist and, in between sessions, via computer. I dont believe anything has in the past made “i m feeling” as lonely and isolated as having a computer program ask me how I felt on a scale of one to five, and after Id clicked the sad emoticon on the screen telling me it was sorry to hear that in a prerecorded voice, Rachel recollected. Completing CBT worksheets under a human therapists guidance wasnt much better. With postnatal depression, she said, youve gone from a situation in which youve been working, earning your own fund, doing interesting things and abruptly youre at home on your own, mostly covered in sick, with no adult to talk to. What she required, she sees now, was real connect: that fundamental if hard-to-express sense of being held in the mind of another person, even if merely for a short period each week.

I may be mentally ill, Rachel said, but I do know that a computer does not feel bad for me.

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Jonathan Shedler remembers where he was when he first realised there might be something to the psychoanalytic idea of the mind as a realm far more complex, and peculiar, than most of us imagine. He was an undergraduate, at college in Massachusetts, when a psychology lecturer astonished him by construing a dreaming Shedler had associated about driving on bridges over lakes, and trying on hats in a store as an expression of the fear of pregnancy. The lecturer was exactly right: Shedler and his girlfriend, whose dreaming it was, were at that moment waiting to learn if she was pregnant, and desperately hoping she wasnt. But the lecturer knew none of this context; he was apparently simply an expert interpreter of the symbolism of dreamings. The impact could not have been greater, Shedler recollected, if his terms had been heralded by celestial trumpets. He decided that if there were people in the world who understood such things, I had to be one of them.

Yet academic psychology, the field Shedler next entered, meant having that kind of enthusiasm for the mysteries of the mind drummed out of you; researchers, he concluded, were committed to quantification and measurement, but not to the inner lives of real people. To become a psychoanalyst takes years of training, and its compulsory to undergo analysis yourself; studying the mind at university, by contrast, requires zero real-life experience.( Shedler is now that rarity, a trained therapist and researcher, who bridges both worlds .) You know that thing about how you need 10,000 hours of practise to develop an expertise? he asked. Well, the majority of members of the researchers constructing pronouncements[ about which therapies run] dont have 10 hours!

Shedlers subsequent research and writing has played a significant role in undermining the received wisdom that theres no hard proof for psychoanalysis. But its undeniable that the early psychoanalysts were sniffy about research: they were prone to viewing themselves as embattled practitioners of a subversive art that needed nurturing in specialist institutions which in practice meant forming cliquish private bodies, and rarely interacting with university experimenters. Research into cognitive approaches thus got a big head start and it was the 1990 s before empirical surveys of psychoanalytic techniques began hinting that the cognitive consensus might be flawed. In 2004, a meta-analysis concluded that short-term psychoanalytic approaches were at least as good as other roads for many ailments, leaving recipients better off than 92% of all patients prior to therapy. In 2006, a study tracking approximately 1,400 people suffering from depression, nervousnes and related conditions ruled in favour of short-term psychodynamic therapy, too. And a 2008 examine into borderline personality disorder concluded that merely 13% of psychodynamic patients still had the diagnosis five years after the end of treatment, compared with 87% of the others.

Peter

Illustration: Peter Gamlen for the Guardian

These surveys havent always compared analytic therapies with cognitive ones; the comparison is often with treatment as usual, a phrase that covers a multitude of sins. But over and over again, as Shedler has argued, the starkest differences between the two emerge some time after therapy has finished. Ask how people are doing as soon as their treatment ends, and CBT seems convincing. Return months or years later, though, and the benefits have often faded, while the effects of psychoanalytic therapies remain, or have even increased suggesting that they may restructure the personality in a lasting route, rather than simply helping people manage their moods. In the NHS study conducted at the Tavistock clinic last year, chronically depressed patients receiving psychoanalytic therapy stood a 40% better opportunity of going to get partial remission, during every six-month period of the research, than those receiving other treatments.

Alongside this growing body of proof, intellectuals have begun to ask pointed questions about such studies that first fuelled CBTs ascendancy. In a provocative 2004 paper, the Atlanta-based psychologist Drew Westen and his colleagues showed how researchers motivated by the desire for an experiment with clearly interpretable outcomes had often excluded up to two-thirds of potential participants, typically because they had multiple psychological problems. The practise is understandable: when a patient has more than one problem, its harder to untangle the lines of cause and effect. But it may mean that the people who do get examined are extremely atypical. In real life, our psychological problems are intricately embedded in our personalities. The issue you bring to therapy( depression, tell) may not be the one that emerges after several sessions( for example, the need to come to terms with a sex orientation you fear your family wont accept ). Moreover, some studies have sometimes seemed to unfairly stack the deck, as when CBT has been compared with psychodynamic therapy delivered by graduate students whod received only a few days cursory trained in it, from other students.

But the most incendiary charge against cognitive approaches, from the torchbearers of psychoanalysis, is that they might actually make things worse: that finding ways to manage your depressed or anxious thoughts, for example, may simply postpone the point at which youre driven to take the plunge into self-understanding and lasting change. CBTs connoted promise is that theres a relatively simple, step-by-step route to gain mastery over agony. But perhaps theres more to be gained from recognise how little control over our lives, our emotions, and other people actions we really have? The promise of mastery is seductive not just for patients but therapists, too. Clients are anxious about being in therapy, and inexperienced therapists are anxious because they dont have a clue what to do, writes the US psychologist Louis Cozolino in a new book, Why Therapy Works. Therefore, it is comforting for both parties to have a task they can focus on.

Not astonishingly, leading proponents of CBT reject most of these criticisms, arguing that its been caricatured as superficial, and that some decrease in effectiveness is only to be expected, because its grown so much in popularity. Early surveys used small samples and pioneering therapists, enthused by the new approach; more recent surveys use bigger samples, and inevitably involve therapists with a wider range of talent levels. People who tell CBT is superficial have just missed the point, said Trudie Chalder, prof of cognitive behavioural psychotherapy at the Kings College Institute of Psychiatry, Psychology and Neuroscience in London, who highlights the fact that no single therapy is best for all maladies. Yes, youre targeting people notions, but youre not just targeting easily accessible notions. Its not just Oh, such person or persons looked at me peculiarly, so they must not like me; its notions like Im an unlovable person, which may derive from early experience. The past is very much taken into account.

Nonetheless, the dispute wont be settled by adjudicating between clashing surveys: it goes deeper than that. Experimenters may reach wildly different conclusions about which therapies have the best outcomes. But what should count as a successful outcome anyway? Studies measure relief of symptoms yet a crucial premise of psychoanalysis is that theres more to a meaningful life than being symptom-free. In principle, you might even aim a course of psychoanalysis sadder though wiser, more conscious of your previously unconscious reactions, and living in a more engaged route and still deem the experience a success. Freud famously declared that his objective was the transformation of neurotic suffering into common unhappiness. Carl Jung said humanity wants difficulties: they are necessary for health. Life is painful. Should we be thinking in terms of a remedy for painful emotions at all?

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Theres something deep appealing about the idea that therapy shouldnt be approached as a matter of science that our individual lives are too distinctive to be submitted to the relentless generalisation by which science must be pursued. That sentiment may help explain the commercial success of The Examined Life, Stephen Groszs 2013 collection of narratives from the analysts couch, which expended weeks on UK bestseller lists and has been translated into more than 30 speeches. Its chapters consist not of experimental findings or clinical diagnoses, but of stories, many of which involve a jolt of insight as the patient abruptly gets a sense of the depths he or she contains. Theres the man who lies compulsively, in a bid for secret intimacy with those he can persuade to join him in deceit, just like his mother hid evidence of his bedwetting; and the woman who ultimately realises how effortfully shes been denying the evidence presented by her husbands infidelity when she notices how neatly someone has stacked the dishwasher.

Each life is unique, and your role, as an analyst, is to find the unique narrative of the patient, Grosz told me. There are so many things that merely come out through slips of the tongue, through someone confiding a fiction, or employing a certain word. The analysts job is to stay watchfully receptive to it all and then, from such ingredients, help people stimulate meaning of their lives.

Peter

Illustration: Peter Gamlen for the Guardian

Surprisingly, perhaps, recent support for this seemingly unscientific perspective has emerged from the most empirical corner of its further consideration of the mind: neuroscience. Many neuroscience experiments have indicated that the brain processes info much faster than conscious awareness can keep track of it, so that countless mental operations operate, in the neuroscientist David Eaglemans phrase, under the hood unseen by the conscious mind in the driving-seat. For that reason, as Louis Cozolino writes in Why Therapy Works, by the time we become consciously aware of its own experience, it has already been processed many times, activated memories, and initiated complex patterns of behaviour.

Depending on how you construe the evidence, it would seem we can do countless complex things from performing mental arithmetic, to hitting a autoes brakes to avoid a crash, to making a choice of matrimony partner before becoming aware that weve done them. This doesnt mesh well with a basic assumption of CBT that, with train, we can learn to catch most of our unhelpful mental reactions in the act. Rather, it seems to confirm the psychoanalytic intuition that the unconscious is huge, and largely in control; and that we live, unavoidably, through lenses created in the past, which we can only hope to modify partially, slowly and with great effort.

Perhaps the only undeniable truth to emerge from disputes among therapists is that we still dont have much of a clue how minds run. When it comes to easing mental agony, its like weve got a hammer, a insure, a nail-gun and a loo brush, and this box that doesnt always work properly, so we just maintain hitting the box with each of these tools to find what works, said Jules Evans, policy director for the Centre for the History of Emotions at Queen Mary, University of London.

This may be why many intellectuals have been drawn to what has become known as the dodo-bird verdict: the idea, supported by some studies, that the specific kind of therapy attains little change.( The name comes from the Dodos pronouncement in Alice in Wonderland: Everybody has won, and all must have prizes .) What seems to matter much more is the presence of a compassionate, dedicated therapist, and a patient committed to change; if one therapy is better than all others for all or even most problems, it has yet to be discovered. David Pollens, in his Upper East Side consulting room, said he had some compassion for that verdict, despite his passion for psychoanalysis. There was a wonderful British analyst, Michael Balint, who was very involved in medical train, and he had a question he liked to pose[ to doctors ], Pollens said. It was: What do you think is the most powerful drug you prescribe? And people would try to answer that, and then eventually hed tell: the relationship.

Yet even this conclusion that we simply dont know which therapies work best might be seen as a point in favour of Freud and his successors. Psychoanalysis, after all, represents simply this awed meeknes about how little we can ever comprehend about the workings of our intellects.( The one question nobody can ever answer, writes the Jungian analyst James Hollis, is of what are you unconscious ?) Freud the man scaled heights of arrogance. But his legacy is a reminder that we shouldnt inevitably expect life to be all that happy , nor to assume we can ever genuinely know whats going on inside indeed, that were often deep emotionally invested in preserving our ignorance of unsettling truths.

What happens in therapy, Pollens said, is that people come in asking for help, and then the very next thing they do is they try to stop you helping them. His smile hinted at the element of sillines in the situation and in the whole therapeutic endeavour, perhaps. How do we help a person when theyve “ve told you”, in one way or another, Dont help me? Thats what analytic treatment is about.

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