Does psychoanalysis have a valuable place in modern mental health services? NoBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1188 (Published 20 February 2012) Cite this as: BMJ 2012;344:e1188
All rapid responses
The statement by Salkovskis and Wolpert, that “ attempts to identify evidence for constructs such as the id, ego and superego and concepts such as the oedipal complex have sadly failed ,“ is an interesting opinion, but no more than that. It also serves to perpetuate a common misunderstanding about the language and terminology used by Freud.
Freud was badly served by the earlier English translations of his work, in the first half of the last century. They were a disappointment to those who had read Freud in the original German. Herman Hesse and Thomas Mann praised Freud’s original writings for their style and fluency.
The Standard Edition of Freud’s works was published about sixty years ago, and was an attempt to overcome previous errors in translation. The main translator was James Strachey.
Bruno Bettelheim was the son of an assimilated Jewish family in Vienna, and grew up in a similar environment to Freud, albeit fifty years later.
Bettelheim felt that Strachey had misrepresented Freud in a number of important respects.(1) Freud did not use the words id , ego and superego. Bettelheim explained that Strachey’s translation of “das Ich”, “das Es” and “das liber Ich” as id , ego and superego, did a great disservice to the essence and meaning of what Freud wrote.
Sixty years on and most people still associate id , ego and superego with Freud. They should not. His translator chose those words and it may not have been a wise choice.
1 Bruno Bettelheim. Freud and Man’s Soul. The Hogarth Press, 1983.
Competing interests: No competing interests
To the Editor BMJ
The interminable debate that pitches a particular psychological therapy against another, in this case psychoanalysis and psychoanalytical psychotherapies versus cognitive behavioural and behaviourist based interventions, continues to rumble on. In this case the psychoanalytical model was ably defended by Professors Fonagy and Lemma against the most extraordinary assertions of Professors Salkovkis and Wolpert.
To the substance of the debate, the cattle call by the behaviourists for scientific rigour in the evaluation of psychotherapeutic efficacy. This predictable line of attack on Freud, by the psychoanalytic knockers and nay sayers, usually begins by asserting that psychoanalytic theory was largely developed in relation to a culturally bound specific group of patients, namely the female bourgeoisie of fin de siècle Vienna. Those same critics tend to then reduce psychoanalysis to an historical artifice which is of little more than passing interest to the contemporary psychological cognoscenti. Sometimes, as Salkovkis and Wolpert do, these same critics even bemoan the fact that Freud had the holy grail of scientific psychology within his grasp if only he had not given up his neuropsychological investigations, after his disillusionment with his Project for a Scientific Psychology of 1895. Sadly, they conclude, Freud drifted into a sort of esoteric mysticism involving such concepts as dream analysis, free association and the twin demons of transference and counter-transference. Here typically, with a suitable degree of reverential head nodding and finger waving, scientific psychological practitioners leave the field, in a mournful and silent retreat.
Might we recall for a moment the words of the 12th century neo-Platonist Bernard of Chartres, “We are all like dwarfs standing on the shoulders of giants.” Freud’s contribution to psychology in the 20th century was immense, comparable in the philosophy of language for instance to the contributions of Russell, Wittgenstein and Ayer. No contemporary philosopher of language would seriously contend that the works of these thinkers represent an historical artifice that we should disregard. They would certainly also not contend that linguistic analysis begins and ends with Russell, Wittgenstein and Ayer. Yet this is the impression that Salkovkis and Wolpert continually attempt to make in their contribution to the debate. For instance they state: “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 1980’s.” Aside from not clarifying why there was an inevitability in this alleged drift away from psychoanalysis, the idea that the rich body of knowledge represented within psychoanalysis and its derivatives was somehow exhausted in the 1980’s is patently absurd. Whilst it is invidious to single out individual contributions one might direct the attention of Professors Salkovkis and Wolpert to developments in the fields of primitive psychological defensive structures (Steiner 1993), attachment research (Boston Change Process Study Group 2008), and the emergent field of neuro-psychoanalysis (Solms and Kaplan Solms 2000: Schore 2003).
It is not my intention to attack cognitive behavioural therapy, far from it. There is a place for this type of therapy with a wide range of presenting patients who may be assisted through work with skilled and talented practitioners. Rather I would suggest that practitioners of cognitive and cognitive behavioural therapies make an effort to keep up with the exciting and innovative developments occurring within the psychoanalytic psychotherapies at present.
BCPSG. (2008). Forms of relational meaning: issues in the relations between the implicit and reflective-verbal domains. Psychoanalytic Dialogues, 18 , 125-148.
Schore, A.N. (2003). Affect regulation and the repair of the self. New York: W.W. Norton.
Solms, M. And Kaplan-Solms,K. (2000). Clinical studies in neuro-psychoanalysis: in troduction to a depth neuropsychology. London: Karnac.
Steiner, J. (1993). Psychic Retreats: Pathological organizations in psychotic, neurotic and borderline patients. London and New York: Routledge.
Competing interests: No competing interests
I read the article and listened to the podcast of the debate chaired by Prof Sir Robin Murray at King's College.
In my opinion, the antipsychoanalytic point of view has been the victor since before the debate: poignant, offensive, it is an immediate eye catcher. It also has the depth of a bumper sticker. That's why it will stick. The other one, the nuanced, balanced, rational discourse in defence of psychoanalysis and psychoanalytic therapies doesn't have the same "limbic" effect. It probably won't stick.
Prof Salkovskis calls the juxtaposition of ideas a debate. Actually, it isn't. A debate rests on openness to dialogue, and there is no such interest on the part of Salkovskis and Wolpert. They start with the conclusion and appear refractory to either arguments or evidence.
Yet, there is a subtle revenge observable if one looks carefully to the picture of the debate. Actually, a double revenge.
Fongy and Lemma base their defence on evidence. Their discourse is rather stern. They put on display what their opponents fully deny to psychoanalysis: a scientific ground. On their part, Salkovskis and Wolpert are rather colourful. There is something delightfully personal, incoherent, and anecdotal in their accounts, especially Wolpert's. The two demonstrate a rather striking lack of scientific ground and discipline in their discourse: again, what they blame psychoanalysis for.
Finally, I am throughly fascinated by the spectacular show of the word 'perverse' in the argument of Salkovskis. Leaving aside a probably unconscious siding with the enemy in the choice of terms, I will focus at the perverse effect of Salkovskis & Wolpert's discourse. Their declared intention is to save modern mental health services (and the suffering people, I assume) from the perverse effect of an obsolete method. Yet, by their superficiality and disrespect to both scientific evidence and human suffering (I am thinking about disrespecting those who were actually helped by both psychoanalysis and psychodynamic therapies), the two professors help decomissioning psychotherapies which may save the lives of many.
Competing interests: I use and teach a psychodynamic form of psychotherapy for Borderline Personality Disorder.
With reference to the recent debate on the role of psychoanalysis in modern mental healthcare (1, 2), I should like to make some observations based largely on my experience of working on a young people’s psychiatric inpatient unit at Great Ormond Street Hospital over the past ten years. Psychoanalysis as defined by 3 –5 times weekly sessions, with a patient lying on a couch, is almost exclusively practised in the private sector and is usually highly valued by those who have direct experience of it. As a therapeutic technique it helps to provide insight and understanding into oneself and one’s relationships with others. Applied psychoanalysis can take many forms (3) and uses psychoanalytic insights in a range of NHS and other settings to the benefit of both clinicians and patients. On the Mildred Creak Unit (MCU) we operate a ‘therapeutic milieu’ (4), which draws on psychoanalytic understanding, including the understanding of unconscious processes in human relationships and a recognition of factors such as transference and countertransference in staff-patient dynamics. We help our patients develop their capacity to put feelings into words rather than, for example, expressing them through severe psychosomatic symptoms. We have a strong multidisciplinary team, which draws on psychoanalytic, systemic, cognitive-behavioural and psychiatric training and knowledge and we have excellent clinical outcomes with extremely unwell children and adolescents. Clinical experience tells us that this multidisciplinary approach is the essence of a good modern mental healthcare system –one that does not seek to exclude or sideline important understandings derived from many years of clinical practice but rather one that is inclusive, thoughtful and effective. A reductionist, one-size-fits-all approach is not what is needed in a modern mental health system. Applied psychoanalysis does have a place in such a system, and it is interesting to note that at the recent Maudsley debate, between the authors of the recent BMJ articles on the subject, the overwhelming majority (260 vs 44) agreed with this. A podcast of this debate will soon be available on the Institute of Psychiatry website.
1. Salkovskis, P and Wolpert, L. Psychoanalysis: does it have a valuable place in modern mental health services? BMJ 2012; 344:e1188.
2. Fonagy, P and Lemma, A. Psychoanalysis: does it have a valuable place in modern mental health services? BMJ 2012; 344:e1211.
3. Lemma, A and Patrick, M (eds.) Off the Couch. Contemporary Psychoanalytic Applications. Routledge, 2010.
4. Crouch, W. The therapeutic milieu and treatment of emotionally disturbed children: Clinical Application. Clinical Child Psychology and Psychiatry 1998; 3, 1, 115-129.
Competing interests: No competing interests
The debate on psychoanalysis (1, 2) is an example for current trend towards dehumanisation of medical profession. The very thought that psychoanalysis is irrelevant to modern mental health service is worrying. Psychoanalysis as a technique of intensive therapy may be time consuming, non-testable and expensive. However the principles of psychoanalysis are timeless, self evident and utilised by psychiatrist in their everyday interaction with their patients. It is hard to imagine seeing a patient without these principles even in ordinary follow up clinic. The scope of psychiatry will be diminished without these principles and is a discredit to declare psychoanalysis has no value in modern mental health service and is of historical value only.
The argument that lack of evidence and empirical grounding for the key construct and non-testability in a manner that is acceptable to current standards does not make psychoanalysis counterproductive and perverse in clinical practice- it only calls for different methods of testing its effectiveness and adapting to current needs.
The current health care delivery is economy driven, tick box exercise, and piece meal in its approach and this has made doctors into technicians resulting in treating part of body rather than whole individual. Proposing to make psychoanalysis irrelevant to modern mental health services is an addition to this process of dehumanising the medical professions. The recent ‘modern’ and ‘testable’ psychological treatments such as computer based Cognitive Behaviour Therapy (3) and telephone Cognitive Behaviour Therapy (4) are a few examples of such approaches. How can patients ventilate, get compassion, and empathy over telephone or with computers. Can anyone really experience emotional catharsis with a computer? We are not for from reading research proving empathy provided by computer is as good as or better than provided by therapist and adding this to ‘empirical evidence base’ to prove its success and provide rationale for economic viability of such treatments.
Thus, the principles of psychoanalysis have become even more relevant in the modern time and calls for introspection. The loser of making psychoanalysis a history will be modern mental health profession and its next generation not Sigmund Freud.
1. Paul Salkovskis and Lewis Wolpert Psychoanalysis: does it have a valuable place in modern mental health services BMJ 2012; 344:e1188
2. Peter Fonagy and Alessandra Lemma, Psychoanalysis: does it have a valuable place in modern mental health services BMJ 2012; 344:e1211.
3. Gerhards SA, de Graff LE, and Jacobs LE et, al Economic evaluation of online computerised cognitive behaviour therapy without support for depression in primary care: randomised trial, Br J Psychiatry 2010 Apr; 196(4):310-8
4. Turner C, Heyman I, Futh A and Lovell K. A pilot study of telephone cognitive –behaviour therapy for obsessive disorder in young people. Behave Cogn Psychother 2009 Jul: 37(4):469-74
Competing interests: No competing interests
It seems a sad sign of the times that so many doctors (74% in the online poll) should align themselves with 'no place for psychoanalysis'. There is increasing evidence from a variety of 'scientific' sources (just to take one example: we have been shown to be making decisions a split second before we 'think' we have made them) that the unconscious mind has even more influence than we previously believed.
So to eschew the work and understanding of the only practitioners who set out to train in accessing unconscious content in trounbled patients seems perverse.
I found the 'No' article highly polarising, emphasising outdated aspects of psychoanalytic thinking. Such tools as mentalisation and mindfulness techniques, therapeutic communities, & awareness of counter-transference in psychiatry all owe their origins to psychoanalytic thinking and carry it embedded in their practices.
Competing interests: No competing interests
Sometimes it is embarrassing to be a psychiatrist. Psychiatry has always strived like a younger sibling to establish its status as equivalent to physical medicine, borrowing its clothes to do so. But they don't fit. As non-psychiatrists, the strident tone of Salkovskis & Wolpert's argument against psychoanalysis (1) also bellies this anxiety. However anything but the most primitive psychiatric formulation reflects the messy reality that mental disorders are unique for each individual, their aetiology buried in a nexus of genes, early attachment experience, adverse events (inc. the biological) and the general rub of life with its pains & disappointments. Mental health is at its most fundamental level experienced through our relationships, both with others and ourselves. Psychoanalysis remains the source of our understanding here. We note with interest that whilst Fiona Godlee's editorial comes down on the side against (2), in the same issue of the BMJ two articles explicitly employ psychoanalytic explanatory models to understand the complex pathological reactions of both an individual and institutions to overwhelming, seemingly unmanageable realities: dissociative sensory loss in response to trauma & the constant restructuring of the NHS, respectively (3,4). Was this an unconscious slip or deliberate cheekiness on behalf of the BMJ?
As general adult psychiatrists working on an acute ward for women (essentially a psychosis ward), we find clinical pictures often fail to conform to simple illness and treatment trajectories. We have found our weekly group for patients - supervised by a psychoanalyst - to prove popular with patients, who feel listened to, and richly informative for ourselves in terms of understanding them better, and thereby helping us manage them more effectively, thus more cost-effectively.
If we bring up the next generation of psychiatrists on a diet of only symptom checklists and cognitive therapy, we will fail both our patients and our medical colleagues who seek an expert opinion.
1. Salkovskis, P. & Wolpert, L. Psychoanalysis: does it have a valuable place in modern mental health services? No. BMJ 2012;344:e1188
2. Godlee, F. A modern approach to mental health. BMJ 2012; 344: e1322
3. Heath, I. What goes around. BMJ 2012; 344: e1171
4. Ingle, D. Medical classics: Tommy. BMJ 2012; 344:e1170
Competing interests: No competing interests
Psychoanalysis debate: Psychoanalysis in modern medicine
Having read Salkovskis & Wolpert’s polemic, in the recent psychoanalysis “head to head”1. it is my impression that, as per Mark Twain, reports of the death of psychoanalysis have been greatly exaggerated.
Indeed their slightly overwrought similes, likening psychoanalysis to the vestigial appendix, verges on the philippic. They also charge psychoanalysis with being a pseudoscience, whilst accepting the usefulness of psychodynamic approaches, this strikes me as wanting to have their cake and eat it. And their endeavour to redefine these psychodynamic approaches as “successors” to psychoanalysis smacks of an attempt to cleave the metaphorical progeny from its parent, which is generally recognised as having a deleterious effect on the development of such progeny. There is ample evidence that emotionally traumatic early life experiences have adverse effects not only on the development of psychopathology but also on general health.2. This insight is also reflected in the concept of the “social gradient of health” which is underpinned by a putative mechanism of causation i.e. the metabolic syndrome, and the allostatic load hypothesis arising out of the “causes of the causes” (social status, social affiliation, and early development).3.
This goes someway to providing an explanation for the concentration of poor mental health in disadvantaged populations as highlighted in the editor’s overview.4.This has implications for the necessity of more “upstream” interventions (whether early intervention/10 prevention) along with the maintenance of high quality services that promote significant in prevention.5.I agree that there are dangers in adopting a strict medical model; indeed I have heard it said that the understanding of psychoanalytic ideas, such as the patterns of attachment relationships, can enhance the effectiveness of clinical care.6. The overview also highlights the apparent expense of psychoanalysis. Then later draws attention to the upward revision of the oft quoted 1 in 4 estimate for the lifetime prevalence of mental health problems-to even 50%.4. Adopting such a life course approach, in the context of psychoanalysis, warrants a re-examination of the costs, since the economic argument in favour of interventions capable of addressing adverse experiences, and their consequences including health gradients, is one of future savings to the health system and society outweighing initial investments.7.
So for my money, psychoanalysis, rather than being outflanked, constitutes a valuable tool in the armamentarium that provides strength in depth for modern medicine’s management of chronic illnesses (mental &/or physical).
1.BMJ 2012;344:e1188 & 1211
2.Lanius RA, Vermetten E, Pain C. The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. Cambridge: Cambridge University Press; 2010
3.Marmot M, Wilkinson RG. Social Determinants of Health. 2nd Ed. Oxford: Oxford University Press; 2006
5.Hill A, Griffiths S, Gillam S. Public Health and Primary Care: Partners in Population Health. Oxford: Oxford University Press; 2007
6.Holmes J. Psychiatrist. Personal Communication 24 Jan 2012
7.Kuh K, Ben-Shlomo Y. A life course approach to chronic disease epidemiology. 2nd Ed. Oxford: Oxford University Press; 2004
Competing interests: No competing interests
It is ironic that the two proponents of evidence based medicine (1), who are fierce critics of what they see as a redundant psychoanalysis, fall back on the traditional twin cornerstones of a largely untested treatment model in mental health - reliance on diagnosis-led pharmacotherapy. They seem to have very little understanding of contemporary psychoanalysis and they are therefore criticising something they know little about. Psychoanalysts have studied and work with the inner world and many use this understanding to inform their work in different mental health settings. It is their inner world that causes those with mental health problem distress, frightening, disturbing and even torturing them. To say that this expertise has no place in modern medicine could be considered mindless.
The evidence that diagnosis 'works' either in the conceptual sense, that everyone agrees what different labels are defining / describing, or in the applied sense, that everyone performs diagnosis accurately and consistently with a given patient population, is often less than impressive (2). If Professors Wolpert and Salkovscis are arguing there are simple algorithms from diagnosis to disposal in mental health, the so-called 'cookie cutter' approach to patient care, they are no friends to modern evidence based practice.
Equally, the evidence that we can safely assume medication treatment adds value is also increasingly being called into question (3, 4, 5). Attacking psychoanalysts for taking these and other open empirical questions seriously is akin to promoting bad science. Modern dynamic practitioners, as Fonagy and Lemma have demonstrated, are made of more than just straw (6).
The mistake made by Professors Wolpert and Salkovscis is to rely uncritically on evidence from randomised trials showing that their preferred treatments do indeed work to support a belief that they will probably therefore work for all. How do they know which works for whom - given they work in different ways? Evidence from published trials also shows that psychoanalysis works, sometimes more effectively than CBT and medication with certain patients (7). It is fair enough to point out we don't fully understand why; nor do they. But to attack clinicians, whether psychoanalytic or otherwise, for applying best judgement to a limited evidence base reveals, again, a poor understanding of the limits of causal inference, and the nature of what constitutes modern evidence based practice, where uncertainties and trade-offs tend to prevail (8).
No one who supports evidence-based practice disputes offering equal access to appropriate medication and effectively- delivered CBT, both individually and in combination for different mental health conditions. But the arguments that Wolpert and Salkovskis use to dismiss psychoanalysis as an equally valid treatment option, where indicated, alongside others on the NHS, are long outdated. What patients prefer, when options are explained, is likely to have an impact on differential outcome (9, 10). It seems reasonable to assume this is something to do with specific appeal of how a treatment works. It may be possible, using evidence-based assessment, to improve the match between patient and clinician, and thus improve outcome (11, 12, 13). To test these assumptions, on a range of NICE-approved therapies, we need supporting evidence from practice based studies, in addition to further testing the effectiveness of RCT-based therapies in routine practice settings (14, 15).
Wolpert and Salkovskis would not only seek to deny us opportunity to build this kind of evidence base, by eradicating viable competitor therapies from the NHS, but also to offer choice to patients. Not unlimited choice; choice of the NICE-approved therapy options, albeit with uncertainty attached. It is as if, like a tired couple of examiners, faced with gathering piles of unmarked A-level essays, one examiner agrees with another: 'Don't worry about content. If it weighs enough, give it A-D or C-B. The rest, just fail'.
1. Salkovskis, P. & Wolpert, L., BMJ 2012 344
2. Mitchell, A. et al, Lancet 2009 374, 609-619
3. Kirsch, I. et al, Public Lib Science Medicine, 2008 5, 260-268
4. DeRubeis, R.J., Siegle, G.J., & Hollon, S.D., Nat Rev Neurosci 2008 9 788-796
5. Hollon, S.D., Jarrett, R.B., Nierenberg, A.A., et al, J Clin Psychiatry 2005 66 455-468
6. Fonagy, P. & Lemma, A., BMJ 2012 344
7. Shedler, J: Am Psychol 2010 65(2) 98-109
8. Cartwright, N. and Munro, E., Jour Evaluation in Clin Practice 2010 16 260-266
9. Van, HL. Dekker, J. Koelen J. et al., Psychother Res 2009 19 205-212
10. Swift, J. & Callahan, J. Jour Clin Psychol 2009 65(4) 368-381
11. Crits-Christophe, P. et al, Jour Consulting and Clin Psychol 2011 79(3) 267-278
12. DeRubeis, R.J. & Feeley, M. Cognitive Ther & Res 1990 14(5) 469-482
13. Feeley, M., DeRubeis, R.J., & Gelfand, L.A., Jour Consulting and Clin Psychol 1999 67(4) 578
14. Barkham M. & Parry, G., Psychol & Psychother: Theory, Res & Practice, 2008 81 399-417
15. Clarke, J. & Barkham, M., Clin Psychol Forum 2009 202 7-13
Competing interests: Chair of the Association of Psychoanalytical Psychotherapy in the NHS and Chair of the NHS Liaison Committee, British Psychoanalytical Society.
BMJ letter to the editor 29th February 2012
In the head-to-head debate on Psychoanalysis (BMJ 25th of February) all four contributors were guilty of either propping up or tilting at straw men (perhaps encouraged by a provocative choice of title by the BMJ) since the use of the Psychoanalytic Couch in the current NHS is as relevant as the use of Skinner Boxes would be. Indeed the “No” article even constructed some extremely fallacious straw men of it’s own such as Psychoanalysis’ alleged rejection of and opposition to other treatments. Laudable as it is for the BMJ to encourage contributions from other professions and interest groups (three clinical psychologists and a service user) I do think it is important to counterbalance this from a medical psychiatric perspective.
All the authors (and of course NICE) seem to have missed the point that truly reliable evidence in psychiatry in general and psychotherapy in particular is extremely limited. I think there are good reasons for this and for the difficulty in treating psychiatric illness to do with the indirect nature of psychiatric illness presentation resulting from unknown disease processes, the complexity of the brain and the further complexity of the developmental and social environment in which mental illness develops and is treated. Furthermore, with the deluge of often dubious and flawed research "evidence" it is increasingly impossible to separate the evidential wheat from the chaff. The scandals of the suppression of negative pharmaceutical antidepressant research studies and the almost universal biases in CBT research with inadequate control groups conducted by those with vested interests are only two of many examples indicating the poor quality of the evidence base.
The health services in general and psychiatry in particular are increasingly in danger of losing their humanity and humility, and in particular the "craft" associated with health care, by attempting to substitute this with a false managerial "certainty" to appease the anxieties of politicians and others. I choose the word "craft" carefully in order to distance myself from the real "pseudoscience" espoused by all four authors and much of the current NHS NICE guideline obsessed policy. In my view doctors as a profession are often confronted by their own impotence in the face of the complexity of illness and as a result the good ones show humility about "the usual muddle of clinical practice… In situations where uncertainty is a daily companion, anxieties high and needs are pressing" (Britton 2003). None of the current models of psychotherapy are particularly good at treating illness, and indeed when research directly compares one model with another there is very little difference between different models, most of the variance being accounted for by the quality of the treatment alliance or patient factors (Mollon 2010). A recent review of the Placebo Effect makes interesting reading for those too certain of the apparent efficacy of specific psychological treatments (McQueen and St. John Smith 2012). It is essential that we keep an open mind and do not reach for certainty when there is none.
I also believe that it is important to maintain a perspective of humility about the reductionist models which underpin current psychological and psychiatric theories of such complex interconnected systems as the mind and the brain. It may well be that a true paradigm shift needs to occur in the psychological sciences, and that complexity theory and chaos theory will be required to underpin further developments in understanding. Interestingly it is recognised that psychoanalytic models incorporate features of complexity theory to some degree (Rustin 2010), this perhaps providing a scientific explanation for their possible practical usefulness. Complexity theory may also underpin "Craft", the skills and knowledge acquired over many years of practice in which complex patterns of information become recognisable, and relevant can be extracted from irrelevant information (Sennett 2003). Indeed the traditional “craft workshop” apprenticeship model was used for many years in the medical firm structure.
I fear that the current pressures in the NHS to throw out both the psychoanalytic and the craft babies with the bathwater will have profound consequences for both the humanity and the effectiveness of mental health services. I am also concerned that the dubious way in which this debate has been promoted by the BMJ at this difficult time for Psychotherapy Services in the NHS has not been at all helpful in encouraging a thoughtful approach to these serious issues.
Dr. Bill Lang, D. Phil., MRCPsych.
Consultant Psychiatrist in Psychotherapy and Psychoanalyst, Heatherwood Hospital Ascot.
BMA membership number 6841480
Britton, R. (2003) Sex, Death and the Superego; Experiences in Psychoanalysis. page x. Karnac, London
McQueen, D. and St. John Smith, P., (2011) Placebo effects: a new paradigm and relevance to Psychiatry. International Psychiatry 9, pages 1,2.
Mollon, P. (2009) The NICE guidelines are misleading, unscientific and potentially impede good psychological care and help., Psychodynamic Practice 15, pp 9-24
Rustin, M (2010) The Psychoanalytic Relevance of complexity theory. Bulletin of the British psychoanalytical Society Pages 14-17
Sennett, R., (2008). The Craftsman. Allen Lane, London.
Competing interests: No competing interests