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BookREVIEW: The Problem with Psychoanalytic Psychotherapy

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Kirsty Hall, Nicola Godwin and Iain Snell
London: Karnac Books 2010
pp 96, £12.99 (paperback)

Review by Brigitta Mowat

This book is timely as it adds grist to the current counselling and psychotherapy regulation debate. It is part of a series of publications that aims to investigate theoretical and practical problems inherent in the three main branches of psychotherapy: psychoanalytic, humanistic and cognitive-behavioural therapies.

In Chapter One the authors highlight some of Freud’s main concepts such as the topographical and structural map of the mind, the Oedipus Complex and love-transference. Freud’s paper ‘The Question of Lay Analysis’, written in defence of Theodor Reik, who practiced as a non-medical psychoanalyst, outlines Freudian psychoanalysis. The success of Reik’s trial opened the way to viewing psychoanalysis as a psychological treatment and introduced a whole range of regulatory problems as practitioners, in Europe at least, no longer needed to be registered doctors.

Another problem (amongst the many highlighted) was that psychoanalysis was seen by some as a form of confession: Foucault criticised therapies for using the confessional format believing it could be used as a way of imposing power and control over people’s sexual lives (p.6).

The use of Interpretation and taking words at face value exemplify another set of serious problems for followers and dissenters of psychoanalysis. Psychoanalysis is a ‘talking cure’. Freud’s advice is to read between the lines ie listen to the repressed content. The authors point out that: “such a practice is notably absent from manualised therapies and from the ever-expanding guidelines produced by NICE and others” (pp16-17).

Chapters Two, Three, and Four are a fast-track course on the movements that grew out of Freudian Psychoanalysis: Analytic Psychology, British Object Relations, Ego-Psychology and the Lacanian School. For example, Klein followed Freud but shifted the focus to early infant development; Bion expanded on this and drew parallels to working with adults who lacked sufficient containment in infancy. An inherent problem with all Object Relations, the authors argue, is that these theories responded to a pre- and post-war Britain and need to be adapted to the cultural values and problems of today. Here they could have mentioned that adaptations do exist – see for example Val Richards who updated Winnicott’s theory. With regard to Kleinian theory, the authors raise the point that Klein’s focus on young children led to an overemphasis on searching for clients’ problems in early life at the expense of attending to more current issues.

Then there is the big question of whether, since it lacks rigorous research components, psychoanalysis is scientific? Bowlby fares well in the scientific community as he introduced the tools and concepts of empirical research. By contrast, Jung’s theories ‘have a more humanistic and spiritual quality’ (p.21). Jung’s therapeutic focus is on unifying rather than seeing human nature as being divided: his detailed observations are descriptive thus not strictly scientific. The philosopher Paul Feyerabend argues that there is a tendency to overvalue science: science is not as rational and progressive as previous generations of philosophers have claimed.

Paradoxically for Freud, but more so for his American followers, lay analysts posed another serious problem, namely that psychoanalysis lost its scientific face. For this reason, The American Psychoanalytic Society (APA) maintained a closed shop policy which caused a rapid decline in psychoanalysis. Only in 1988, after three decades of highly charged battles and a court case, did APA allow non-medics to train in psychoanalysis. The exclusion of lay analysts was not to maintain psychoanalysis as a natural science – this was never the real reason – but a way to protect incomes. The authors note that: “Advances in medical science and the use of drugs to treat mental illness, added fuel to the debate about the scientific validity of Freud’s thinking” (p.41).

The US analyst Robert Wallerstein called ‘for systematic psychoanalytic research that would require cooperation with other scientific disciplines’ (p.42). The authors question the validity of empirical research in mental health that relies on proscribed language, the main argument being that mental health problems are often rooted in a disorder of language and thinking. Because it uses language to uncover the unconscious ‘in the interest of the widest possible expression’ (p.48) this is one of the reasons why Lacanian psychoanalysis is not suited to empirical research.

Freudian thinking was not only challenged by scientists and creators of health policies but also came under attack by Feminists – including Nancy Chodorow, Virginia Golder, Adrienne Harris and Judith Butler – from within and without the psychoanalytic movement. One outcome of these debates was that Gender Studies became a subject in its own right.

In Chapter Five the authors explore the pros and cons of manualising psychoanalytic therapy. On the pro side Roth and Fonagy (2005) argue that psychotherapeutic interventions that relieve mental suffering, regardless of theoretical orientation, need to be tested by means of replication – thus paving the way towards reaching a kind of scientific truth. Roth and Fonagy believe that therapy could ultimately become manualised. The general message of those who subscribe to Freud’s advice – to read between the lines and listen to the repressed – are hard to win over. As clinical experience in the last hundred years has shown, it can take years to undo  resistance against unbearable truths.

The authors make the point that there is a widespread perception that science can do everything. Evidenced-based psychotherapies such as CBT and interpersonal therapy are the chosen favourites in the NHS. They point out that: “… current treatments are moving in the direction of increasing manualisation, and self-administered computerised CBT programmes” (p.56). However evidence has shown that short-term CBT only works for 50% of people.

The conclusions are full of meaty arguments weighing up the advantages and disadvantages of psychoanalysis. History has shown that Freud has come under fire since the beginning of 1900 and this is not set to change. While CBT produces quicker results in the short term and is therefore more financially viable, the scientific verification of Freudian metapsychology would be a difficult task to undertake. Darian Leader (p.70) says that researchers today tend to focus on surface behaviour, dubious biochemistry and shallow psychology. “Nowhere in the statistics and charts was the actual reported speech of patients themselves, as if listening no longer mattered (Leader, 2008, p.5).

Are Randomized Control Trials (RCT) in the field of psychoanalysis useful? Are they the method that could for example test the hypothesis: should transference-love be encouraged or discouraged in clinical practice?

This is a well-researched book and brings to light a wide spectrum of inherent problems that require serious reflection. I would recommend this book to every counselling and psychotherapy student/practitioner as well as to all the people involved in writing health policies.

Brigitta Mowat is married and has two grown-up children. She is a UKCP registered integrative psychotherapist in private practice and lecturer on the MA/PgD programme in Contemporary Therapeutic Counselling at the University of Hertfordshire.