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Does psychoanalysis have a valuable place in modern mental health services? Yes

BMJ 2012; 344 doi: (Published 20 February 2012) Cite this as: BMJ 2012;344:e1211

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Re: Does psychoanalysis have a valuable place in modern mental health services? Yes

Dear Ed

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.

29 February 2012
Josephine Kate O'Reilly
Consultant psychiatrist
Dr Luigi Caparrotta
Camden and Islington Foundation Trust
London, UK