Вы находитесь на странице: 1из 4

Landman P. (2013) Tristesse Business; le Scandale du DSM 5. Editions Naccache L. (2006) Le Nouvel Inconscient.

Freud, Christophe Colomb


Milo. des Neurosciences. Odile Jacob.

Lehembre O. (2004) Qui sommes-nous? Que faisons-nous? Une Roudinesco E. (1982) Histoire de la Psychanalyse en France, vol. 1.
enquête du Syndicat des Psychiatres Français et de l’Association Le Seuil (réédition Fayard 1994).
Française de Psychiatrie. La Lettre de Psychiatrie Française, 31, 15–19.
Roudinesco E. (1986) Histoire de la Psychanalyse en France, vol. 2.
Ménéchal J. (2008) Psychanalyse et Politique. ERES. Le Seuil (réédition Fayard 1994).

THEMATIC The scientific standing of psychoanalysis


PAPER
Mark Solms

University of Cape Town, South


This paper summarises the core scientific
• We need to destroy frustrating objects
Africa;
email mark.solms@uct.ac.za claims of psychoanalysis and rebuts the
(things that get between us and satisfac-
prejudice that it is not ‘evidence-based’. I
tion of our needs). This is rage.
Conflicts of interest. None.
address the following questions. (A) How does
• We need to attach to caregivers (those
the emotional mind work, in health and
who look after us). Separation from
© The Author 2018. This is an
Open Access article, distributed
disease? (B) Therefore, what does
attachment figures is felt not as fear
under the terms of the Creative but as panic, and loss of them is felt as
Commons Attribution- psychoanalytic treatment aim to achieve?
NonCommercial-NoDerivatives (C) How effective is it?
despair. (The whole of ‘attachment the-
licence (http://creativecommons. ory’ relates to vicissitudes of this need.)
org/licenses/by-nc-nd/4.0/), which
permits non-commercial re-use, • We need to care for and nurture others,
distribution, and reproduction in especially our offspring. This is the
any medium, provided the ori-
ginal work is unaltered and is A. so-called ‘maternal instinct’, but it exists
properly cited. The written per- (to varying degrees) in both genders.
mission of Cambridge University As regards the workings of the emotional mind,
Press must be obtained for com- • We need to play. This is not as frivolous
our three core claims are the following.
mercial re-use or in order to cre- as it appears; play is the medium
ate a derivative work.
(1) The human infant is not a blank slate; like all through which social hierarchies are
other species, we are born with innate needs. formed (‘pecking order’) and in-group
These needs (‘demands upon the mind to and out-group boundaries maintained.
perform work’, as Freud called them, his The (upper brain-stem and limbic) anat-
‘id’) are felt and expressed as emotions. omy and chemistry of the basic emotions
The basic emotions trigger instinctual is well understood (see Panksepp, 1998
behaviours, which are innate action plans for a review).
that we perform in order to meet our (2) The main task of mental development is to learn
needs (e.g. cry, search, freeze, flee, attack). how to meet our needs in the world. We do not
Universal agreement about the number of learn for its own sake; we do so in order to
innate needs in the human brain has not establish optimal action plans to meet our
been achieved, but mainstream taxonomies needs in a given environment. (This is
(e.g. Panksepp, 1998) include the what Freud called ‘ego’ development.)
1
Here I am focusing on emo- following.1 This is necessary because innate action pro-
tional needs – which are felt as
separation distress, rage, etc. –
• We need to engage with the world – grammes have to be reconciled with actual
not bodily drives – which are felt since all our biological appetites (includ- experiences. Evolution predicts how we
as hunger, thirst, etc. – or sen- ing bodily needs) can only be met there. should behave in, say, dangerous situa-
sory affects – which are felt as
pain, disgust, etc. (See Panksepp, This is a foraging or seeking or ‘wanting’ tions, but it cannot predict all possible dan-
1998.) The way in which I use instinct. It is felt as interest, curiosity gers (e.g. electrical sockets); each
the term ‘action plans’ in this
article is synonymous with the and the like. (It coincides roughly but individual has to learn what to fear. This
use of the term ‘predictions’ in not completely with Freud’s concept of typically happens during critical periods
contemporary computational
neuroscience. ‘libido’.) in early childhood, when we are not best
• We need to find sexual partners. This is equipped to deal with the fact that innate
felt as lust. This instinct is sexually action plans often conflict with one another
dimorphic (on average) but male and (e.g. attachment v. rage, curiosity v. fear).
female inclinations exist in both genders. We therefore need to learn compromises,
• We need to escape dangerous situations. and we must find indirect ways of meeting
This is fear. our needs. This often involves substitute-

BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 1 FEBRUARY 2018 5


formation (e.g. kicking the cat). Humans psychoanalytic and psychopharmacological
also have a large (cortico-thalamic) capacity methods of treatment is that we believe feel-
for satisfying their needs in imaginary and ings mean something. Specifically, feelings
symbolic ways. It is crucial to recognise that represent unsatisfied needs. (Thus, a patient suf-
successful action programmes entail successful fering from panic is afraid of losing some-
emotion regulation, and vice versa. This is thing, a patient suffering from rage is
because our needs are felt as emotions; frustrated by something, etc.) This truism
thus, successful avoidance of attack reduces applies regardless of aetiological factors;
fear, successful reunion after separation even if one person is constitutionally more
reduces panic, etc., whereas unsuccessful fearful, say, than the next, their fear is still
attempts result in persistence of fear and meaningful. To be clear: emotional disorders
panic, etc. entail unsuccessful attempts to satisfy needs.
(3) Most of our action plans (i.e. ways of meeting (2) The main purpose of psychological treat-
our needs) are executed unconsciously. ment, then, is to help patients learn better
Consciousness (‘working memory’) is an (more effective) ways of meeting their needs.
extremely limited resource, so there is This, in turn, leads to better emotion regulation.
enormous pressure to consolidate and The psychopharmacological approach, by
automatise learned solutions to life’s pro- contrast, suppresses unwanted feelings. We
blems (for a review see Bargh & do not believe that drugs which suppress
Chartrand, 1999, who conclude that only feelings can cure emotional disorders.
5% of our goal-directed actions are con- Drugs are symptomatic treatments. To
scious). Innate action programmes are cure an emotional disorder, the patient’s
effected automatically from the outset, as failure to meet their underlying need(s)
are the programmes acquired in the first must be addressed, since this is what is
years of life, before the cortical (‘declara- causing their symptoms. However,
tive’) memory systems mature. Multiple symptom relief is sometimes necessary
unconscious (‘non-declarative’) memory before patients become amenable to psy-
systems exist, such as ‘procedural’ and chological treatment, since most forms of
‘emotional’ memory (which are mainly psychotherapy require collaborative work
encoded at the level of the basal ganglia). between patient and therapist. It is also
These operate according to different true that some types of psychopathology
rules. Not only successful action plans are auto- never become accessible to collaborative
matised. With this simple observation, we psychotherapy.
can do away with the unfortunate distinc- (3) Psychoanalytical therapy differs from other
tion between the ‘cognitive’ and ‘dynamic’ forms of psychotherapy in that it aims to
unconscious. Sometimes a child has to change deeply automatised action plans. This
make the best of a bad job in order to is necessary for the reasons outlined
focus on the problems which it can solve. above. Psychoanalytic technique therefore
Such illegitimately or prematurely automa- focuses on the following.
tised action programmes are called ‘the • Identifying the dominant emotions (which
repressed’. In order for automatised pro- are consciously felt but not necessarily
grammes to be revised and updated, they recognised as belonging to the self, etc.).
need to be ‘reconsolidated’ (Tronson & • These emotions reveal the meaning of
Taylor, 2007); that is, they need to enter con- the symptom. That is, they lead the
sciousness again, in order for the long-term way to the (ineffective) automatised pro-
traces to become labile once more. This is grammes that gave rise to the feelings.
difficult to achieve, not least because most • The pathogenic action programmes
procedural memories are ‘hard to learn cannot be remembered directly for the very
and hard to forget’ and some emotional reason that they are automatised (i.e.
memories – which can be acquired through unconscious). Therefore, the analyst
just a single exposure – appear to be indel- identifies them indirectly, by bringing to
ible, but also because the essential mechanism awareness the repetitive patterns of behav-
of repression entails resistance to reconsolidation iour derived from them.
of automatised solutions to our insoluble pro- • Reconsolidation is thus achieved through
blems. The theory of reconsolidation is reactivation of mainly subcortical long-
very important for understanding the term traces via their derivatives in the pre-
mechanism of psychoanalysis. sent situation (this is called ‘transference’
interpretation). Only cortical memories
B. can be ‘declared’.
• Such reconsolidation is nevertheless dif-
The clinical methods that psychoanalysts use flow
ficult to achieve, mainly owing to the ways
from the above claims.
in which non-declarative memory sys-
(1) Psychological patients suffer mainly from tems work, but also because repression
feelings. The essential difference between entails resistance to the reactivation of

6 BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 1 FEBRUARY 2018


insoluble problems. For these reasons, psychoanalysis it was 1.38. Leuzinger-
psychoanalytic treatment takes time – i. Bohleber et al (2018) will shortly report
e. numerous and frequent sessions – to even greater effect sizes for psychoanalysis
facilitate ‘working through’. in depression. The consistent trend toward
Mental healthcare funders need to learn larger effect sizes at follow-up suggests that
how learning works. For a more detailed psychoanalytic therapy sets in motion pro-
account of the mechanism of psychoana- cesses of change that continue after therapy
lytic therapy, see Solms (2017). has ended (whereas the effects of other
forms of psychotherapy, such as CBT,
C. tend to decay).
(3) The therapeutic techniques that predict
Psychoanalytic therapy achieves good outcomes –
the best treatment outcomes, regardless of
at least as good as, and in some respects better
the form of psychotherapy, make good sense
than, other evidence-based treatments in psych-
in relation to the psychodynamic mechanisms out-
iatry today.
lined above. These techniques include (Blagys
(1) Psychotherapy in general is a highly effective & Hilsenroth, 2000):
form of treatment. Meta-analyses of psycho- • unstructured, open-ended dialogue
therapy outcome studies typically reveal between patient and therapist
effect sizes of between 0.73 and 0.85. An • identifying recurring themes in the
effect size of 0.8 is considered large in psy- patient’s experience
chiatric research, 0.5 is considered moder- • linking the patient’s feelings and percep-
ate, and 0.2 is considered small. To put tions to past experiences
the efficacy of psychotherapy into perspec- • drawing attention to feelings regarded
tive, recent antidepressant medications by the patient as unacceptable
achieve effect sizes of between 0.24 and • pointing out ways in which the patient
0.31 (Kirsch et al, 2008; Turner et al, avoids such feelings
2008). The changes brought about by psy- • focusing on the here-and-now therapy
chotherapy, no less than drug therapy, are relationship
of course visualisable with brain imaging. • drawing connections between the ther-
(2) Psychoanalytic psychotherapy is equally effective apy relationship and other relationships.
as other forms of evidence-based psycho- It is highly instructive to note that these
therapy (e.g. cognitive–behavioural therapy techniques lead to the best treatment out-
(CBT)). This is now unequivocally estab- comes regardless of the type of psychother-
lished (Steinert et al, 2017). Moreover, apy the clinician espouses. In other words,
there is evidence to suggest that the effects these same techniques (or at least a subset
of psychoanalytic therapy last longer – and of them; see Hayes et al, 1996) predict opti-
even increase – after the end of the treat- mal treatment outcomes in CBT too, even
ment. Shedler’s (2010) authoritative review if the therapist believes they are doing
of all randomised controlled trials to date something else.
reported effect sizes of between 0.78 and (4) It is therefore perhaps not surprising that
1.46, even for diluted and truncated forms psychotherapists, irrespective of their sta-
of psychoanalytic therapy. An especially ted orientation, tend to choose psychoana-
methodologically rigorous meta-analysis lytic psychotherapy for themselves!
(Abbass et al, 2006) yielded an overall effect (Norcross, 2005)
of 0.97 for general symptom improvement
with psychoanalytic therapy. The effect I am aware that the claims I have summarised
increased to 1.51 when the patients were here do not do justice to the full complexity and
assessed at follow-up. A more recent variety of views in psychoanalysis, both as a theory
meta-analysis by Abbass et al (2014) yielded and a therapy. I am saying only that these are our
an overall effect size of 0.71, and the finding core claims, which underpin all the details, includ-
of maintained and increased effects at ing those upon which we are yet to reach agree-
follow-up was reconfirmed. This was for ment. These claims are eminently defensible in
short-term psychoanalytic treatment. the light of current scientific evidence, and they
According to the meta-analysis of de Maat make simple good sense.
et al (2009), which was less methodologically
rigorous than the Abbass studies, longer- References
term psychoanalytic psychotherapy yields Abbass A. A., Hancock J. T., Henderson J., et al (2006) Short-term
an effect size of 0.78 at termination and psychodynamic psychotherapies for common mental disorders.
0.94 at follow-up, and psychoanalysis Cochrane Database Syst Rev, 4, CD004687.
proper achieves a mean effect of 0.87, and Abbass A. A., Kisely S. R., Town J. M., et al (2014) Short-term
1.18 at follow-up. This is the overall finding; psychodynamic psychotherapies for common mental disorders
the effect size for symptom improvement (as (update). Cochrane Database Syst Rev, 7, CD004687.
opposed to personality change) was 1.03 for Bargh J. & Chartrand T. (1999) The unbearable automaticity of
long-term psychoanalytic therapy, and for being. Am Psychol, 54, 462–479.

BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 1 FEBRUARY 2018 7


Blagys M. D. & Hilsenroth M. J. (2000) Distinctive activities of Norcross J. C. (2005) The psychotherapist’s own psychotherapy:
short-term psychodynamic-interpersonal psychotherapy: a review of the educating and developing psychologists. Am Psychol, 60, 840–850.
comparative psychotherapy process literature. Clin Psychol, 7, 167–188.
Panksepp J. (1998) Affective Neuroscience. Oxford University Press.
de Maat S., de Jonghe F., Schoevers R., et al (2009) The effectiveness
Shedler J. (2010) The efficacy of psychodynamic psychotherapy. Am
of long-term psychoanalytic therapy: a systematic review of empirical
Psychol, 65, 98–109.
studies. Harv Rev Psychiatry, 17, 11–23.
Solms M. (2017) What is ‘the unconscious’ and where is it located in
Hayes A. M., Castonguay L. G. & Goldfried M. R. (1996) Effectiveness
the brain? A neuropsychoanalytic perspective. Ann NY Acad Sci.,
of targeting the vulnerability factors of depression in cognitive
1406: 90–97.
therapy. J Consult Clin Psychol, 64, 623–627.
Steinert C., Munder T., Rabung S., Hoyer J. & Leichsenring F. (2017).
Kirsch I., Deacon B. J., Huedo-Medina T. B., et al (2008) Initial
Psychodynamic Therapy: As Efficacious as Other Empirically
severity and antidepressant benefits: a meta-analysis of data
Supported Treatments? A Meta-Analysis Testing Equivalence of
submitted to the food and drug administration. PLoS Med, 5, e45.
Outcomes. Am J Psychiatr, doi: 10.1176/appi.ajp.2017.17010057
Leuzinger-Bohleber M., Hautzinger M., Fiedler G., Keller W., Bahrke Tronson N. C. & Taylor J. R. (2007) Molecular mechanisms of
U., Kallenbach L., Kaufhold J., Ernst M., Negele A., Schött M., memory reconsolidation. Nat Rev Neurosci, 8, 262–275.
Küchenhoff H., Günther F., Rüger B. & Beutel M. (2018) Outcome of
psychoanalytic and cognitive-behavioral therapy with chronic Turner E., Matthews A., Linardatos E., et al (2008) Selective
depressed patients. A controlled trial with preferential and publication of antidepressant trials and its influence on apparent
randomized allocation. Br J Psychiatry, submitted. efficacy. N Engl J Med, 358, 252–260.

THEMATIC Psychodynamic psychotherapy training


PAPER
in South East Asia: a distance learning
pilot program
César A. Alfonso,1 Limas Sutanto,2 Hazli Zakaria,3 Rasmon Kalayasiri,4
Petrin Redayani Lukman,5 Sylvia Detri Elvira5 and
Aida Syarinaz Ahmad Adlan6
1
Associate Professor of Populous countries in the Asia–Pacific region have Asian psychiatrists have a keen interest in improving
Psychiatry, Columbia University
Medical Center, New York, USA; adequate psychiatric residency curricula but inad- psychodynamic psychotherapy education. Liaisons
email caa2105@cumc.columbia. equate psychotherapy clinical supervision, and with the Royal College of Psychiatrists in Thailand,
edu
2
the paucity of training programs reflects how the Malaysian Psychiatric Association and the
Universitas Brawijaya, Malang,
East Java, Indonesia underserved psychiatry is in this zone (Ruiz & University of Indonesia gave rise to our multi-
3
Universiti Kebangsaan Malaysia Bhugra, 2008; Tasman et al, 2009). Cognitive national, collaborative, pedagogic endeavour
Medical Centre, Kuala Lumpur, behavioural therapy is systematically taught in (Alfonso et al, 2018). The WPA pilot program was
Malaysia
4
most of Asia but other modalities such as support- designed to take place over 5 years, targeting three
Chulalongkorn University,
Bangkok, Thailand ive, interpersonal, dialectic behavioural, group, countries (see Table 1). It was designed to be
5
Universitas Indonesia, Jakarta, marital, family and psychodynamic psychothera- self-sustaining – with the aim of improving the psy-
Indonesia pies are not well supervised. It is challenging to chotherapy skills of those enrolled in study activities
6
Universiti Malaya, Kuala Lumpur, bridge these gaps given the demands of high and teaching psychiatrists how to supervise – so that,
Malaysia
volume services and few formally trained supervi- after completion, psychiatrists could work effectively
Conflicts of interest. None. sors. Initiatives have been implemented to improve as psychotherapy supervisors.
psychotherapy training in Asia (Alfonso et al, 2018).
© The Authors 2018. This is an The most widely recognised among these in- Phase 1: full-day workshops to improve
Open Access article, distributed
under the terms of the Creative itiatives is the China American Psychoanalytic clinical skills
Commons Attribution- Alliance program, which is largely conducted Full-day psychodynamic psychotherapy workshops
NonCommercial-NoDerivatives
licence (http://creativecommons. through videoconferencing (Fishkin et al, 2011). took place at meetings sponsored by the national
org/licenses/by-nc-nd/4.0/), which This article describes an abridged program psychiatric societies in Jakarta, Surabaya, Kuala
permits non-commercial re-use,
distribution, and reproduction in designed to provide advanced psychotherapy Lumpur and Bangkok between 2013 and 2014.
any medium, provided the ori- training in underserved areas with limited peda- The hosting psychiatric society selected local psy-
ginal work is unaltered and is
properly cited. The written per-
gogical resources. Although the program was chiatrists to run workshop modules according
mission of Cambridge University piloted in Asia, our hope is that it could be adapted to the experts’ areas of interest (see Table 2).
Press must be obtained for com-
mercial re-use or in order to cre-
or replicated in other areas with similar needs. Clinical correlations and applicability of psycho-
ate a derivative work. The World Psychiatric Association (WPA) dynamic thinking in a variety of settings were
Psychotherapy, Education in Psychiatry, and emphasised. Attendance ranged from 35 to 50 peo-
Psychoanalysis in Psychiatry Sections identified that ple; a manageable number for the maintenance of

8 BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 1 FEBRUARY 2018