Does psychoanalysis have a valuable place in modern mental health services? YesBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1211 (Published 20 February 2012) Cite this as: BMJ 2012;344:e1211
All rapid responses
The recent debate1 regarding the value of psychoanalysis to modern mental health services should include consideration of the important contribution offered by group-analytic psychotherapy, or ‘group analysis’. Developed by Foulkes2 in the post WWII years, this form of treatment brings together two key disciplines: Freudian and post-Freudian psychoanalytic concepts, and, through the influence of eminent sociologist Elias3, an understanding of man’s inescapable identity as a social being.
In thinking about the individual patient as located within a social matrix, an enriched understanding and formulation of symptoms and strengths may be reached. Treatment offered in a carefully selected group setting not only makes use of the skills of the group analyst , or ‘conductor’, but also enables group members to reflect to each other useful insights and experiences in the here-and-now of the group sessions, which lead to ‘therapy of the group by the group.’
Group analysts work in many contexts in the NHS, in adult and child mental health services, and through an understanding of group behaviours and processes, can also offer valuable organisational consultancy in the NHS.
With regard to physical as well as emotional wellbeing, work such as Brown’s4 studies of psychosomatic illness highlights beneficial factors arising from group analytic treatment, including containment of painful emotions, improved communication, naming feelings and finding both the meaning of, and the ‘mentalisation’ of physical symptoms. Patients generally cope better with their illness as a result.
PostFoulkesian group analysis is very much alive : the ‘psyche and the social world ‘5 remain core preoccupations of its practitioners, and recent evidence from the Sheffield Systematic Review6 indicates this relatively cost-effective form of psychoanalytic treatment has much to offer the NHS.
1 Fonagy P, Lemma A. Does psychoanalysis have a place in modern mental health services?Yes. BMJ 2012;344:e1211(20th February.)
2 Foulkes SH. Therapeutic Group Analysis, London, Allen & Unwin,1964.
3 Elias N. The Civilising Process ,first British edn Oxford,Basil Blackwell,1978.
4 Brown D. ‘The psychosoma and the group’ in J Maratos(ed) Resonance and Reciprocity, selected papers by Dennis Brown, Routledge,2006.
5 Brown,D, Zinkin L (eds.) The Psyche and the Social World, Developments in Group-Analytic Theory Jessica Kingsley,2000.
6 Centre for Psychological Services Research, School of Health and Related Research,The University of Sheffield A Systematic Review of the Efficacy and Clinical Effectiveness of Group Analysis and Analytic/Dynamic Group Psychotherapy ,2009.
Competing interests: No competing interests
Dear Dr Godlee
In modern conflicts the killing of innocent civilians is euphemistically referred to as collateral damage. These victims are often either forgotten or dismissed as a price worth paying in achieving the aims of one power against another. Your edition of 25th February set up the Head to Head battle between psychoanalysis and cognitive behavioural therapy as one such winner-takes-all encounter. The impression given is that there is no common ground on which agreement can be reached or rapprochement made. Psychoanalysis must be killed and buried in order for others to triumph. Rather than playing the role of UN Peacekeeper the Editor chose to endorse the view that Paul Salkovskis and Lewis Wolpert had “outflanked” Peter Fonagy and Alessandra Lemma to win both the battle and the war.
So well done to them for winning their BMJ campaign medals but I’m afraid I have to report that that the unseen victim of this conflagration is access to child and adolescent psychotherapy for the very vulnerable children and young people we care for. I have had the misfortune to witness many of these psychoanalysis v CBT debates and never is the position of psychoanalytic child psychotherapy represented but yet we get hit by the shrapnel as it becomes ever more difficult to maintain our position as members of multidisciplinary child and adolescent mental health services (CAMHS) with particular skills and experience in treating the needs of the most damaged children and families seen within the NHS. I should add that there are also many clinicians, including Psychiatrists, who work psychoanalytically in adult services, often with the most severe and chronic needs, and are highly valued within those services and whose work is unfairly denigrated by the BMJ’s presentation of this issue.
Psychoanalytically-based child and adolescent psychotherapy is a core NHS profession with rigorously regulated standards and training, approved and funded by the Department of Health. Child psychotherapy is recognised as a core component of comprehensive CAMHS in the Children’s National Service Framework and is recommended in clinical guidance by the National Institute of Health and Clinical Excellence (NICE) on depression in children and young people (September 2005). Child and Adolescent Psychotherapists are the only profession whose training includes a four-year full-time post in a CAMHS service. This enables the trainees to develop skills in a multi-disciplinary setting from the outset.
Vocal critics of psychoanalysis such as Wolpert and Salkovskis use a number of outdated caricatures to establish an Aunt Sally version of psychoanalysis that is then very easy for them to knock down. In doing so I believe they demonstrate an ignorance of both the current practice of psychoanalytic and psychodynamic psychotherapy and the evidence of its contribution to modern mental health services. Compare this to the reasoned, inclusive and evidence-supported case made by Fonagy and Lemma. Amongst the tactics used by Wolpert and Salkovskis is to refer back to Freud as if his 100 year old writings were the manual for modern practice and as if there had been no development of theory, practice and evidence in the intervening period. How much more difficult to support would their case be in reference to Klein or Balint, Bowlby or Winnicott or indeed to the current work of Fonagy, Lemma and their contemporaries?
Wolpert and Salkovskis claim that there is no evidence base for the treatment which is blatantly untrue and I am concerned that the BMJ allowed this assertion to be published especially when your colleagues at the Harvard Medical School have recently concluded that,
“...there is now enough research evidence to claim that psychodynamic therapy is an evidence-based treatment with effect sizes similar to or superior to those reported for other psychotherapies…it is encouraging that the benefits of psychodynamic therapy not only endure after therapy ends, but increase with time. This suggests that insights gained during psychodynamic therapy may equip patients with psychological skills that grow stronger with use.” (Harvard Medical School, 2010)
This followed an article by Jonathan Shedler published in the American Psychologist, a leading peer-reviewed journal, that made the following point that shines a clear light on the story being peddled by Wolpert and Salkovskis.
“There is a belief in some quarters that psychodynamic concepts and treatments lack empirical support or that scientific evidence shows that other forms of treatment are more effective. The belief appears to have taken on a life of its own. Academicians repeat it to one another, as do health care administrators, as do health care policymakers. With each repetition, its apparent credibility grows. At some point, there seems little need to question or revisit it because “everyone” knows it to be so. The scientific evidence tells a different story: Considerable research supports the efficacy and effectiveness of psychodynamic therapy.”
Whilst there is less robust evidence for the effectiveness of psychoanalytic psychotherapy with children than with adults, perhaps understandably given the client group and the small size of the profession, there is nevertheless a substantial body of research as summarised in a recent review which “identified 34 separate studies that met criteria for inclusion, including nine randomised controlled trials.” (Midgley & Kennedy 2011)
At this point the critics will no doubt claim that this isn’t about “real” psychoanalysis but about some other kind of therapy that as Wolpert and Salkovskis say is “very far removed from the basic dogmas of psychoanalysis and show little or no evidence of their provenance.” I wonder where the critics have gained their understanding of psychoanalysis from; a Woody Allen film? Because what I am defending and what is supported by the Harvard Medical School, Shedler and Midgley & Kennedy is not this Aunt Sally version of psychoanalysis but the real version practised every day in adult and child and adolescent services in the treatment of real people in real distress. In these real services the majority of clinicians and managers recognise that what is needed is a range of interventions for a range of conditions and that some will work for some people and others will work for others. Real practice is about “and also” and not the reductive world of “either or”. But, as Fonagy and Lemma observe, what will be really missed if the psychoanalytic perspective is cut out of the NHS is its developmental perspective, the robustness of its practitioners in the face of severe disturbance and the understanding of emotions, behaviour and relationships that can inform and enrich the practice of the many different professionals who work with people with mental health difficulties across the range of public services.
The Head to Head article and your Editorial paint a false picture of psychoanalytic practice in the 21st Century which is particularly worrying given the increased role of the medical profession in commissioning CAMHS and adult mental health services. We value our relationships with GPs, Psychiatrists, Paediatricians and other doctors very highly and would worry if the BMJ were not concerned about the collateral damage caused to another NHS profession, and the patients we serve, by this article.
Harvard Medical School, (2010). Merits of psychodynamic therapy. Harvard
Mental Health Letter. 27, 3,
Midgley, N & Kennedy E (2011) Psychodynamic psychotherapy for children and adolescents: a critical review of the evidence base, Journal of Child Psychotherapy, 37, 3, 232-260
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American
Psychologist, 65, 98-109.
Competing interests: No competing interests
TOE TO TOE
What is one to do when faced with the sight of one’s former mentors fighting in public? One can only assume that the argument is being put only to provoke thought and discussion. This would be a welcome move at a time when the NHS is so beleaguered by the threat of change, that it “doesn;t know what to do”. So are we to believe that what we are seeing is an encouragement to make the case for one side or the other, or do we fall foul to the twisty thought that this is all about resources, and a fight for survival? That we are in fact in danger of losing sight of things while looking for the things which make us feel more secure?
My dame has lost her shoe.
My master’s lost his fiddling stick,
And doesn’t know what to do!
Freudians among you may take some meaning from this association of mine to this important topic. Fiddling sticks and shoes are suspiciously suggestive of objects imbued with sexual meaning, and to a large extent, the fight within the NHS is about the problem of introducing a more masculine agenda (doing, orchestrating, making order, pushing forward, cutting back), on a system which has appealed to the public psyche based on its feminine qualities (providing, consulting, being receptive, making space, stretching out).
Many of us working in psychological treatments in the NHS, are used to integrating all of the above. That we are able to do it, is testament to the broad training we have gone through to get to where we are now. In my case, a degree in Biology, with classes from Lewis Wolpert, which were so mind opening that I still, some 40 years later, have the paper we were studying. Then there was, many years later, supervision in CBT with Paul Salkovskis which, though it did not lead me to my final destination, has made me forever a lover of CBT in its purity. And finally, there were Psychoanalytic conversations with Peter Fonagy. It is interesting that my experience of the complexity of the human mind is that I began with cells, and moved then from CBT, to Psychoanalysis. It did not strike me as non-progressive to be doing so. That I believe archaic vestiges are important seems only to lead us back to cells, and that which makes up the essence of what it is to be human.
So, do I believe that these giants in their respective fields, are really going “Head to Head”?
No – for the simple reason that we all know the “cupboard [is] bare”, and since none of us wants to “have none”, better we combine forces to give “Old Mother Hubbard” a helping hand. Perhaps relevant to our discussion, and at the very least entertaining are the origins of this verse which go back to 1805. In that version, the last line of the first verse is – “And so, the poor pecker had none”. One suggestion is that the rhyme referred to Cardinal Thomas Wolsey refusing Henry VIII’s divorce from Queen Catherine of Aragon.
Of course none of this is open to direct evidence, it’s meaning having gradually accreted over time, through cultural development. and complexity. And so it seems to me that it would be churlish to “throw the baby out with the bathwater”. We would, apart from anything else, lose that delicious experience of playing “this Little Piggy Went to Market”, on the warm little toes of our progeny. It is to be remembered, that while one “piggy stayed at home”, another “had roast beef”, and a third “ran all the way home”, a fourth piggy “had none”, and, was it the biggest? – “went to market”.
Competing interests: No competing interests
Your ‘Head to Head’ 1 was amusing slapstick, but failed to consider the middle ground inhabited by the majority of psychotherapists/counsellors and clients. (Who actually uses a couch these days?) My personal experience as both client and counsellor has shown me that early life events are very important, whereas CBT therapists focus rather on the here and now. However, even CBT students are advised that after the initial encounter between counsellor and client ‘This may or may not mean proceeding with this form of counselling or with this counsellor‘. 2 Also, attendance ‘several times a week’ 3 for psychotherapy is extremely rare: most practitioners offer weekly sessions for a limited period.
As Fonagy and Lemma argue, many types of psychotherapy are difficult but not impossible to research. 4 CBT is much easier since it is highly structured. But (anecdotally) people in deep depression can be thrust into deeper despair by ‘homework’ requirements. Even worse, CBT is now offered as a computer programme, to save the NHS money. 5 The answer to NHS funding problems is surely to make better use of community psychotherapy/counselling services, many of which are offered free of charge. This must be preferable to reliance on drugs, many of which have distressing side effects, leading to even more problems and expense.
1 Head to Head. BMJ 2012; 344: e1211 doi:10.1136/bmj.e1211
2 Trower P, Casey A, Dryden W. Cognitive Behavioural Counselling in Action. Sage Publications 1988, p. 10
3 Salkovskis P, Wolpert L. Does psychoanalysis have a valuable place in modern mental health services? No. BMJ 2012; 344:e1188.
4 Fonagy P, Lemma A. Does psychoanalysis have a valuable place in modern mental health services? Yes. BMJ 2012; 344:e1211.
5 Computers replace counsellors for depressed patients. Scotland on Sunday, 12 February 2012
Competing interests: No competing interests
The debate between Lemma, Fonagy and Wolpert and Salkovskis as to whether Psychoanalysis has a valuable place in modern medicine is an unhelpful debate at this critical time when the NHS is under considerable economic and organisational strain and its future development remains so uncertain. As Lemma and Fonagy point out, secondary care psychotherapy services that offer psychoanalytic/psychodynamic psychotherapy are seen as soft targets for managers with CIP savings to make, and are therefore vulnerable to, and being subject to cuts and closure.
The editor's view is that she puts her money on Salkovskis and Wolpert, although she fails to outline her arguments. However, in the same issue we are treated to two related articles that are relevant to the subject.
The first is by Ginn and Horder on the anatomy of the statistic "One in Four". It is clear that there is a vast ocean of unmet mental health need. This need encompasses psychological, economic, and societal problems that cannot be easily confined to a single approach or model of understanding or intervention.
IAPT (Improving Access to Psychological Therapy) has been the government's attempt to address psychological needs and help people back to work. IAPT services have offered a predominantly CBT approach to anxiety and depression but as the "We Need to Talk" report of 2010 highlights, people want choice and expert consultation, and IAPT provision should not be at the expense of existing services.
The second article is a book review by Iona Heath of "Intelligent Kindness: Reforming the Culture of Health Care" by Ballat and Campling. Heath gives the book her ringing endorsement and reviews how the book can offer insights "infused with a psychoanalytic perspective" on how organisations that support their staff in a kindly manner propagate their kindness in interactions with their patients. This is something we can all hope to be on the receiving end of when we are in need of health care, mental or physical, so that disasters such as occurred in Staffordshire can be avoided.
Walport and Salkovskis caricature psychoanalysis in modern medicine and come across as defensive, with a wish to throw away their heritage. Freud is so clearly part our cultural and societal inheritance that to deny his continuing contribution that is now embedded in our understanding of the human condition and psychology would be a denial of reality. This would result in a significant loss to modern medicine. As Fonagy and Lemma point out, psychoanalytically-informed approaches offer one form of understanding that not only can support staff but also can provide effective therapeutic interventions, often with the most difficult to treat patients.
When faced with real world situations in day-to-day clinical practice, clinicians rely on colleagues who offer a range of interventions from a broad base of theoretical understandings, including behavioural, cognitive behavioural, and psychodynamic approaches. As others have outlined in their responses, no one approach suits all, and engaging modality wars is to the detriment of our patients, and colleagues from “opposing camps”.
For my money we need integrated psychological therapy provision that values psychoanalytic and others’ contributions.
1. “One in four”: the anatomy of a statistic; Srephen Ginn and Jamie Horder BMJ 2012:344-1302
2. We Need to Talk Getting the right therapy at the right time: (we need to talk coalition): Mind 2010.
3. What goes around – Review of “Intelligent Kindness: Reforming the Culture of Healthcare”, Ballat and Campling: Iona Heath BMJ 2012;344-1171.
Competing interests: Academic Secrectary Faculty of Psychotherapy Royal College of Psychiatrists
As consultant Psychiatrists in Psychotherapy we support the case made for psychoanalytic work in the NHS made by Lemma and Fonagy and would like to add some further points.
It is important to distinguish in such a debate the difference between psychoanalysis, an intensive form of treatment 4-5x weekly using an analytic couch, and psychoanalytic therapy. The former is almost exclusively available in the private and voluntary sectors and not as Salkovskis and Wolpert suggest widely used in the NHS. By contrast, psychoanalytic psychotherapy, either individual and in groups, forms an important NHS treatment usually on a once weekly basis. It is misleading to confuse these two distinct treatments, although both derive from psychoanalysis.
In addition, psychoanalytic thinking provides a model to help understand the complexity and role of unconscious processes in understanding the often bewildering presentations of our patients in distress. No other psychological theory does this and our psychiatric colleagues in this Trust frequently ask us to help them understand and inform the management of many of our most complex and disturbed patients.
Furthermore, the value of understanding unconscious processes and how these can stir up informative feelings and responses (counter-transference) in clinicians has been widely acknowledged by doctors and lead to the widespread development of Balint Groups. These are psychoanalytically informed and are essential components of training for psychiatrists and GPs and continue to inform the work of trained GPs and psychiatrists across the country. The Royal College of Psychiatrists values these training experiences sufficiently highly as to make them mandatory requirements for trainee psychiatrists, many of whom also seek and value their experience of psychotherapy training cases to help them to become sophisticated and competent clinicians able to grapple with and understand the complex interpersonal dynamic created between doctor and patient.
Salkovskis and Wolpert make a number of unsubstantiated and rather wild claims in their article. We take exception to the notion that psychoanalytic therapists explicitly reject outcome evaluation; there is a growing body of evidence sufficient to persuade social insurance funded healthcare systems to pay for psychoanalytic psychotherapy in a number of European counties now and a major RCT looking at outcome in the treatment of treatment resistant depression is currently underway at the Tavistock Clinic. For example, full reviews of psychotherapy outcome research for the treatment of depression and other conditions illustrate the wider evidence available (Taylor, 2008: Shedler, 2010; 2011). Indeed outcome measures such as CORE and others are routinely used in NHS Psychotherapy services such as ours.
The claim that psychoanalysis makes no attempt to diagnose and does not recognise problems such as schizophrenia or the role of medication is simply untrue and shows a profound misunderstanding of psychoanalytic work. Psychoanalytic thinking has a great deal to contribute to diagnosis in its emphasis on careful history taking and use of counter-transference as a key tool to help distinguish for example between borderline and hysterical or psychotic pathology.
In addition, in cases of severe mental illness such as schizophrenia, complex and troubling interpersonal processes can contribute greatly to the patient’s difficulties. Again psychoanalytic ideas can help to understand and inform management of some of the illest psychiatric patients and their families, as recommended by NICE guidelines. Freud wrote extensively about the unconscious mechanisms behind psychotic processes and symptoms and acknowledged also the limitations of psychoanalytic treatment. Since then psychoanalytic ideas have continued to develop and contributed greatly to the growth of other forms of psychological treatment including family therapy and brief treatments. The importance of understanding unconscious processes in medical illness has also been well documented by psychoanalytic practitioners eg Stern (4), Shoenberg.(5)
We both work in services with very close links with psychiatric colleagues, and other services offering psychological treatments such as IAPT and have clear referral pathways and a stepwise approach to treatment. We receive many referrals from our colleagues in these services which work well, referrals coming to us when other treatments have proved inadequate or revealed the need for a more exploratory approach which patients are seeking. This is the same in many psychoanalytic psychotherapy NHS services across the land. Extreme, unsubstantiated and inaccurate arguments such as some of those outlined by Salkovski and Wolpert fail to recognise this clinical reality and we seriously question their inclusion in a reputable medical journal.
Drs Jo O’Reilly and Luigi Caparrotta
Consultant Psychiatrists and Psychoanalysts
Camden and Islington Foundation Trust
1. Taylor, D (2008) Psychoanalytic and Psychodynamic therapies for Depression; the evidence base. Advances In Psychiatric Treatment November 2008. Vol.14 Issue 6.
2. Shedler J. (2010), “The efficacy of Psychodynamic Psychotherapy”, American Psychologist, 65(2): 98-109
3. NICE Guidelines for Schizophrenia March 2009
4. Shedler J. (2011), “Science or Ideology?”, American Psychologist, 66(2): 152-54.
5. Stern, J (2009) Keeping the Gut In Mind . Psychoanalytic psychotherapy Vol 28 Issue 4
6. Shoenberg, P (2007) Psychosomatics: the uses of psychotherapy. Palgrave Macmillan
Competing interests: We are both psychoanalysts.
In the same way that invoking Schrödinger’s cat has Stephen Hawking reaching for his gun, my hackles rise when I continue to see in 2012 the so-called psychotherapy ‘culture wars’ (see Norcross & Lambert, 2011) played out in this kind of head-to-head debate.
The brief answer to the question ‘Psychoanalysis: does it have a valuable place in modern mental health services’ is an unequivocal yes. While I am persuaded by the data and rationale marshalled by Fonagy and Lemma, I believe psychoanalysis and its derivatives should be maintained within the talking therapies available to NHS patients for other reasons.
A more persuasive argument, in my view, makes the case that it is the most skilled and effective therapists from each and every therapeutic modality that should be maintained within the NHS, over and above specious arguments concerning one modality versus another. This case can be made on the basis of policy – patients’ right to choose the therapy they believe will most help and suit their way of being, but equally on the basis of evidence, which I review briefly below.
In the 35 years since Smith and Glass (1977) published the first meta-analysis looking at the absolute efficacy of psychotherapy we have learned a great deal about what matters in the talking therapies. First, the absolute efficacy of psychotherapy has been established. Across a large number of meta-analyses the effect size of psychotherapy versus control/no treatment is somewhere between .75 and .85. Wampold (2001) makes the case that a defensible effect size for psychotherapy is .80. This means that about 79 percent of patients who receive talking therapy are better off than those people left to fend for themselves. Lemma, Target and Fonagy (2011) in their review of evidence-based practice and psychodynamic psychotherapy highlight the epidemiological metric Number Needed to Treat (NNT – the average number of patients that need to be treated with the intervention under scrutiny for one to benefit when compared to the control group). They make the point, as does Wampold elsewhere (2007), that the NNT for psychotherapy is lower (and therefore by inference better) when compared to even the most effective treatments for medical conditions such as aspirin in the treatment of heart attack.
Second, with reference to the relative efficacy of different therapy modalities, the one thing we can agree on is that there is no more hotly contested question in psychotherapy. In his clear and thorough literature review, Cooper (2008) summarises and critiques the evidence for both ‘empirically supported treatments’ and the ‘common factors’ (i.e., all therapies are equal) positions. He concurs with colleagues in the USA, notably Castonguay and Beutler (2006) and more recently Norcross (2011) arguing that we need to “start from the premise that both common factors and orientation-specific factors are likely to have the potential to contribute to psychological change…[This position] would explain, for instance, why most therapies tend to be about as effective as each other for some forms of psychological distress, but why other forms of psychological distress (in particular, anxiety disorders) may be more responsive to some practices than others. It would also explain why…that both common factors and the use of specific techniques and practices are associated with positive therapeutic outcomes.” (Cooper, 2008: 55).
While acknowledging the weight of evidence to support specific approaches to specific disorders (see Roth and Fonagy, 2005), the therapeutic alliance is closely associated with outcome regardless of therapeutic modality (Horvath and Bedi, 2002; Horvath and Symonds, 1997). Indeed, the therapeutic alliance accounts for more variance in outcome that modality (Kim, Wampold and Bolt, 2006). Although, as Norcross and Lambert (2011) wryly remind us, the variance in outcome accounted for by client factors dwarfs that explained by treatment method or relationship. Nevertheless, recent research suggests that it is particularly the therapist’s ability to form a sound alliance (over and above the client’s) that is closely associated with outcome, and there are substantial between-therapist differences in that capacity (Baldwin, Wampold and Imel, 2007; Zuroff, Kelly, Leybman, Blatt and Wampold, 2010). Considered together, this suggests we should move towards a position where the therapist becomes the independent variable of interest in relation to outcome over and above the therapeutic modality.
Bruce Wampold in debate with Steve Hollon made precisely this case at the 2008 New Savoy Partnership Psychological Therapies in the NHS Conference. You can hear the debate (labelled ‘Closing debate, Thursday’) at http://www.newsavoypartnership.org/2008conference.htm.
That we seem collectively resistant to assimilating and accommodating this ever growing body of evidence into our approach to the talking therapies within the NHS says much about our apparent distaste for the message. What is the point of doing science if we only pick and chose that evidence which substantiates our preconceived world-view?
Baldwin, S.A., Wampold, B.E., & Imel, Z.E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75, 842–852.
Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change that work: Integrating relationship, treatment, client, and therapist factors. New York: Oxford University Press.
Cooper, M. (2008). Essential Research Findings in Counselling and Psychotherapy. London: Sage.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 37–70). New York: Oxford University Press.
Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139–149.
Kim, D.-M., Wampold, B. E., and Bolt, D. M. (2006). Therapist effects in psychotherapy: A random-effects modeling of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data. Psychotherapy Research, 16, 161–172.
Lemma, A., Target, M. and Fonagy, P. (2011). Brief Dynamic Interpersonal Therapy. Oxford: Oxford University Press.
Norcross, J. C. & Lambert, M. J. (2011). Evidence-based therapy relationships. In J. C. Norcross (Ed.), Psychotherapy Relationships that Work: Evidence-Based Responsiveness (pp. 3-21). New York, Oxford University Press.
Roth, A. and Fonagy, P. (2005). What Works for Whom: A Critical Review of Psychotherapy Research. 2nd ed. New York: Guilford Press.
Smith, M. L. & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32, 752-760.
Wampold, B. E. (2001). The Great Psychotherapy Debate: Models, Methods and Findings. Mahwah, NJ: Erlbaum.
Wampold, B. E. (2007). Psychotherapy: The humanistic (and effective) treatment. American Psychologist, 62, 857-873.
Zuroff, D.C., Kelly, A.C., Leybman, M.J., Blatt, S.J., & Wampold, B.E. (2010). Between-therapist and within-therapist differences in the quality of the therapeutic relationship: Effects on maladjustment and self-critical perfectionism. Journal of Clinical Psychology, 66, 681-697.
Competing interests: No competing interests
If Fonagy and Lemma wanted to make a credible, evidence-based case that the psychoanalytic approach has a place in modern healthcare, they should have considered more carefully what that they were presenting as evidence.
For instance, they cited the Leichsenring and Rabung meta-analysis (1), which is derivative of an earlier meta-analysis in JAMA (2). Ten of the 11 seriously flawed studies in the British Journal of Psychiatry article were previously included in the JAMA meta-analysis. The Leichsenring and Rabung JAMA paper was marred by serious problems, including an idiosyncratic calculation of effect sizes by which an ES = 6.9 was reported for a set of studies, none of which individually had an effect size of more than 2 (3).
One of the studies in the BJP meta-analysis warrants particular scrutiny (4). It involves a comparison of an unvalidated psychotherapy without any treatment manual to 23 times as many sessions of long-term psychodynamic psychotherapy (LTPP), 9.8 sessions in the control group versus 232 sessions of LTPP, and LTPP patients were more likely to receive medication or hospitalized than the patients in the control condition. Nonetheless, differences were not obtained at a number of time points for a number of outcome measures, but Leichsenring and Rabung nonetheless managed to generate a positive effect size for LTPP by comparing outcomes for LTPP and the control group obtained at different time points. Just consider the cost-effectiveness issues for psychodynamic therapy that are raised by this finding.
A recent carefully conducted and transparently reported meta-analysis (5) covered the same literature as Leichsenring and Rabung. The conclusion:
The recovery rate of various mental disorders was equal after LTPP or various control treatments, including treatments without a specialized psychotherapy component. Similarly, no statistically significant differences were found for the domains target problems, general psychiatric problems, personality pathology, social functioning, overall effectiveness or quality of life.
Fonagy and Lemma also cite a meta-analysis by Jakobsen (6) that was conducted on five trials, all of them uniformly rated as having high risk of bias. Four of the trials evaluated interpersonal psychotherapy for depression, an approach that proponents have taken pains to indicate is not psychodynamic (7). For the fifth trial (8), the only assessment-of-bias-risk items that could be confidently rated positive was that there was adequate blinding; whether there were adequate sequence generation, allocation concealment, intention to treat analysis, or comparability of dropouts could not be established, and there was a lack of comparability of dropouts between intervention and comparison groups.
Fonagy and Lemma open their article with a declaration that "psychoanalysis is under greater attack ever before." Perhaps they will interpret my critical scrutiny of the "evidence" they present as further signs of that attack. My perspective, however, is that promoters of psychoanalysis have advanced claims of being evidence-based that threaten the entire evidence-based psychotherapy movement because of their continued insistence that we accept as evidence flawed meta-analyses of flawed studies.
Overall, the literature cited by Fonagy and Lemma raises issues about whether the psychoanalytic approach has a place in modern healthcare, unless we are willing to put aside evidence as the basis for making such decisions.
1.Leichsenring F, Rabung S. Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis. Br J Psychiatry 2011;199:15-22.
2.Leichsenring F, Rabung S. The effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA 2008; 300: 1551– 64.
3.Bhar SS, Thombs BD, Pignotti M, Bassel M, Jewett L, Coyne JC, et al. Is Longer-Term Psychodynamic Psychotherapy More Effective than Shorter-Term Therapies? Review and Critique of the Evidence. Psychotherapy and Psychosomatics;79(4):208-16.
4.Knekt P, Lindfors O, Harkanen T, Valikoski M, Virtala E, Laaksonen MA, et al. Randomized trial on the effectiveness of long- and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during 3-year follow-up. Psychological Medicine 2008;38(5):689-703.
5.Smit, Y., Huibers, M.J.H., Ioannidis, J.P.A., van Dyck, R., van Tilburg, W. & Arntz, A., The effectiveness of long-term psychoanalytic psychotherapy -a meta-analysis of randomized controlled trials, Clinical Psychology Review Clin Psychol Rev. 2012;32(2):81-92.
6.Jakobsen JC, Hansen JL, Simonsen E, Gluud C. The effect of adding psychodynamic therapy to antidepressants in patients with major depressive disorder. A systematic review of randomized clinical trials with meta-analyses and trial sequential analyses. J Affect Disord2011, published online 16 Apr.
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Competing interests: No competing interests
Without skills and knowledge of psychoanalysis being available to ALL mental health practitioners , a suffering soul is entitled to ask:
"Who, out there, can share the burden, terror and the liberation of my dreams?
Who is familiar with and yet unafraid of their power?
Who can bear to be with me?"
Competing interests: No competing interests
Salkovskis and Wolpert are negative about the value of psychoanalysis to practice (1). In attempting to understand recent scandals of abuse and neglect among health providers in England, I suggest not a Cognitive Behaviour Therapy manual but the psychoanalytic insights of Isabel Menzies Lyth (2).
Presciently, for this was 50 years ago, she described how ill-understood mental defences amongst hospital nursing staff can be destructive and dehumansing . If I find myself attending a series of meetings at work characterised by endless forward thinking but no real decisions, I will consult neither Salkovkis nor Wolpert but Larry Hirschorn (3), who with great clarity shows how social defences and other unconscious mechanisms described by psychoanalysis affect organisational behaviour. Using concepts such as transference and counter-transference, the psychoanalyst Michael Balint helped doctors understand how their reactions and feelings in a consultation can provide important information to help the patient and to help themselves perform optimally.
Fortunately thousands of doctors have been through ‘Balint groups’; would that it were all. Or perhaps Salkovkis and Wolpert might skip forward in the same issue of the BMJ and read Iona Heath’s excellent review of Intelligent Kindness, which she described as “suffused with fascinating psychoanalytical insight”. Interestingly, her article is entitled ‘What goes around ...’.
1.Fonagy, P, Lemma, A, Salkovskis, P, Wolpert, L. Psychoanalysis: does it have a valuable place in modern mental health services? BMJ 2012;344e1188
2. Menzies, IEP. The functioning of social systems as a defence against anxiety: a report on a study of the nursing service of a general hospital Human Relations 1959;13:95-121
3. Hirchhorn, L. The workplace within: psychodynamics of organisational life 1990 The MIT Press Cambridge Massachusetts, London, England
4. Heath, I. What goes around BMJ, 2012;344e1171
Competing interests: No competing interests