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Does psychoanalysis have a valuable place in modern mental health services? No

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e1188 (Published 20 February 2012) Cite this as: BMJ 2012;344:e1188
  1. Paul Salkovskis, professor of clinical psychology and applied science1,
  2. Lewis Wolpert, emeritus professor of biology as applied to medicine2
  1. 1Department of Psychology, University of Bath, Bath BA2 7AY, UK
  2. 2Department of Cell and Developmental Biology, University College London, London, UK
  1. P.M.Salkovskis{at}bath.ac.uk

Peter Fonagy and Alessandra Lemma say that the psychoanalytical approach can provide a useful and unique contribution to modern healthcare (doi:10.1136/bmj.e1211), but Paul Salkovskis and Lewis Wolpert argue that it may have no place there at all

Psychoanalysis is of historical value only and, at best, has no place in modern mental health services. Not only is there no evidence base for the treatment, but there is no empirical grounding for the key constructs underpinning it. In addition, we suggest that the theory and practice of psychoanalysis are inimical to modern mental health services and so are, at worst, counterproductive and perverse in that context.

We do not doubt the historical significance of psychoanalysis, psychoanalytic theory, and its founding father, Sigmund Freud. The theoretical concept of the unconscious provided the foundations of current cognitive sciences. Modern evidence based and empirically grounded psychological therapies,1 including cognitive behaviour therapy, were initially developed by clinicians who were trained in psychoanalytic approaches but found the approach wanting.2 Even the small number of evidence based psychodynamic therapies are very far removed from the basic dogmas of psychoanalysis and show little or no evidence of their provenance; neither the analyst’s couch nor free association is in evidence. As regards evidence, they are often ineffective, even relative to being on a waiting list.3

Clearly, true paradigm shifts have occurred in terms of the understanding of human psychology and of the ways in which people experiencing psychological problems and distress can be helped. Freud himself deserves credit for establishing psychoanalysis as a new paradigm over a century ago. There is, however, an inevitability in the subsequent shift away from psychoanalysis, which began 50 years ago and which was de facto completed in the 1980s. Paradigm shifts are a form of accelerated intellectual evolution, where the explanatory and heuristic power of a particular theory are supplanted by another that better explains and predicts the key phenomena under investigation. Sometimes a supplanted idea is kept alive in some form; there is something charming and at times amusing about the continued existence of a flat earth society or the psychoanalytic approach to literary criticism. However, we propose that it is no longer defensible to continue ideas whose time has come and gone and which have been succeeded by more appropriate ones in an area as important as healthcare. It would not be tolerated in cardiology or oncology; why should it be in mental health? In evolutionary terms, psychoanalysis can be regarded as a metaphorical appendix; vestigial and unfortunately of no continuing value.

Psychoanalysis rejected Freud’s original concept of psychoanalytic science.4 We suggest that psychoanalysis has become a pseudoscience because its claims are neither testable nor refutable. Attempts to identify evidence for constructs such as the id, ego, and superego and concepts such as the oedipal complex have sadly failed. Psychoanalysis has had its day, and more. It dominated psychological approaches for well over half a century, during which time it essentially stagnated, becoming conservative and authoritarian, depending on flawed wisdom of tribal leaders. As a movement, it greeted the development of the upstart behaviour therapy and later cognitive therapy by actively resisting, with passion and fury, the notion of outcome evaluation, and opposed what it regarded as the dangerous obscenity of symptom focused approaches. It still does.5

Psychoanalysis is quite different from psychiatry because it makes no attempt to diagnose a patient’s condition, and so does not recognise problems such as schizophrenia or others with a genetic cause. The patient does not have a defined illness and so no attempt is made to find a cure. This also means that the true psychoanalyst will resist medication for the patient. The treatment is also expensive because the patient typically attends sessions several times a week, usually over several years. The average duration of psychoanalytic treatment in the United States is estimated to be over five years.

Our opponents in this debate might choose to argue the usefulness of psychodynamic approaches, such as mentalisation and interpersonal therapy, given their associated research findings. They will find no argument from us. Neither, however, will they find a couch in the consulting rooms of those who practise such approaches—these methods are successors to psychoanalysis, rather than a continuation.

Is there value in some input from psychoanalysis in mental health? There are at least three reasons for a clear “no”. Firstly, historically: when psychoanalysis was the only significant force in psychotherapy, it failed to advance the care of people with mental health problems. Behaviour therapy and cognitive behaviour therapy were needed to do that. Secondly, theoretically: an approach that not only explicitly rejects but also opposes the use of treatments that deal with crippling symptoms such as anxiety and depression, obsessional rituals, and agoraphobic avoidance has no place in mental health services, which should by definition help service users to reduce distress and disability.6 Finally, empirically: the development of an accountable healthcare culture by the National Institute for Health and Clinical Excellence and other mechanisms has resulted in real improvements in mental healthcare; an approach that rejects outcome measurement has no place in the rapidly evolving and empirically grounded field of psychological understanding and interventions in mental health.

We can honour our traditions in mental health, but that does not mean that we should preserve traditions when we work with NHS service users to help them find pathways to recovery. We suggest that it would be perverse to provide any place in modern mental health services for psychoanalysis.

Notes

Cite this as: BMJ 2012;344:e1188

Footnotes

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years. PS is editor in chief of the journal Behavioural and Cognitive Psychotherapy, which is the official journal of the British Association for Behavioural and Cognitive Psychotherapies, a leading organisation for behavioural and cognitive psychotherapies in the UK.

  • Does psychoanalysis have a valuable place in modern mental health services? is the subject of a Maudsley debate at the Institute of Psychiatry, King’s College London on 7 March 2012 (www.iop.kcl.ac.uk/events/?id=1106).

  • Provenance and peer review: Commissioned, not externally peer reviewed.

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