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The scientific standing of psychoanalysis

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Abstract

This paper summarises the core scientific claims of psychoanalysis and rebuts the prejudice that it is not ‘evidence-based’. I address the following questions. (A) How does the emotional mind work, in health and disease? (B) Therefore, what does psychoanalytic treatment aim to achieve? (C) How effective is it?
Landman P. (2013) Tristesse Business; le Scandale du DSM 5. Editions
Milo.
Lehembre O. (2004) Qui sommes-nous? Que faisons-nous? Une
enquête du Syndicat des Psychiatres Français et de lAssociation
Française de Psychiatrie. La Lettre de Psychiatrie Française, 31, 1519.
Ménéchal J. (2008) Psychanalyse et Politique. ERES.
Naccache L. (2006) Le Nouvel Inconscient. Freud, Christophe Colomb
des Neurosciences. Odile Jacob.
Roudinesco E. (1982) Histoire de la Psychanalyse en France,vol. 1.
Le Seuil (réédition Fayard 1994).
Roudinesco E. (1986) Histoire de la Psychanalyse en France,vol. 2.
Le Seuil (réédition Fayard 1994).
THEMATIC
PAPER The scientic standing of psychoanalysis
Mark Solms
University of Cape Town, South
Africa;
email mark.solms@uct.ac.za
Conicts of interest. None.
© The Author 2018. This is an
Open Access article, distributed
under the terms of the Creative
Commons Attribution-
NonCommercial-NoDerivatives
licence (http://creativecommons.
org/licenses/by-nc-nd/4.0/), which
permits non-commercial re-use,
distribution, and reproduction in
any medium, provided the ori-
ginal work is unaltered and is
properly cited. The written per-
mission of Cambridge University
Press must be obtained for com-
mercial re-use or in order to cre-
ate a derivative work.
This paper summarises the core scientic
claims of psychoanalysis and rebuts the
prejudice that it is not evidence-based.I
address the following questions. (A) How does
the emotional mind work, in health and
disease? (B) Therefore, what does
psychoanalytic treatment aim to achieve?
(C) How effective is it?
A.
As regards the workings of the emotional mind,
our three core claims are the following.
(1) The human infant is not a blank slate; like all
other species, we are born with innate needs.
These needs (demands upon the mind to
perform work, as Freud called them, his
id) are felt and expressed as emotions.
The basic emotions trigger instinctual
behaviours, which are innate action plans
that we perform in order to meet our
needs (e.g. cry, search, freeze, ee, attack).
Universal agreement about the number of
innate needs in the human brain has not
been achieved, but mainstream taxonomies
(e.g. Panksepp, 1998) include the
following.
1
We need to engage with the world
since all our biological appetites (includ-
ing bodily needs) can only be met there.
This is a foraging or seeking or wanting
instinct. It is felt as interest, curiosity
and the like. (It coincides roughly but
not completely with Freuds concept of
libido.)
We need to nd sexual partners. This is
felt as lust. This instinct is sexually
dimorphic (on average) but male and
female inclinations exist in both genders.
We need to escape dangerous situations.
This is fear.
We need to destroy frustrating objects
(things that get between us and satisfac-
tion of our needs). This is rage.
We need to attach to caregivers (those
who look after us). Separation from
attachment gures is felt not as fear
but as panic, and loss of them is felt as
despair. (The whole of attachment the-
oryrelates to vicissitudes of this need.)
We need to care for and nurture others,
especially our offspring. This is the
so-called maternal instinct, but it exists
(to varying degrees) in both genders.
We need to play. This is not as frivolous
as it appears; play is the medium
through which social hierarchies are
formed (pecking order) and in-group
and out-group boundaries maintained.
The (upper brain-stem and limbic) anat-
omy and chemistry of the basic emotions
is well understood (see Panksepp, 1998
for a review).
(2) The main task of mental development is to learn
how to meet our needs in the world. We do not
learn for its own sake; we do so in order to
establish optimal action plans to meet our
needs in a given environment. (This is
what Freud called egodevelopment.)
This is necessary because innate action pro-
grammes have to be reconciled with actual
experiences. Evolution predicts how we
should behave in, say, dangerous situa-
tions, but it cannot predict all possible dan-
gers (e.g. electrical sockets); each
individual has to learn what to fear. This
typically happens during critical periods
in early childhood, when we are not best
equipped to deal with the fact that innate
action plans often conict with one another
(e.g. attachment v. rage, curiosity v. fear).
We therefore need to learn compromises,
and we must nd indirect ways of meeting
our needs. This often involves substitute-
1
Here I am focusing on emo-
tional needs which are felt as
separation distress, rage, etc.
not bodily drives which are felt
as hunger, thirst, etc. or sen-
sory affects which are felt as
pain, disgust, etc. (See Panksepp,
1998.) The way in which I use
the term action plansin this
article is synonymous with the
use of the term predictionsin
contemporary computational
neuroscience.
BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 1 FEBRUARY 2018 5
formation (e.g. kicking the cat). Humans
also have a large (cortico-thalamic) capacity
for satisfying their needs in imaginary and
symbolic ways. It is crucial to recognise that
successful action programmes entail successful
emotion regulation, and vice versa. This is
because our needs are felt as emotions;
thus, successful avoidance of attack reduces
fear, successful reunion after separation
reduces panic, etc., whereas unsuccessful
attempts result in persistence of fear and
panic, etc.
(3) Most of our action plans (i.e. ways of meeting
our needs) are executed unconsciously.
Consciousness (working memory)isan
extremely limited resource, so there is
enormous pressure to consolidate and
automatise learned solutions to lifes pro-
blems (for a review see Bargh &
Chartrand, 1999, who conclude that only
5% of our goal-directed actions are con-
scious). Innate action programmes are
effected automatically from the outset, as
are the programmes acquired in the rst
years of life, before the cortical (declara-
tive) memory systems mature. Multiple
unconscious (non-declarative) memory
systems exist, such as proceduraland
emotionalmemory (which are mainly
encoded at the level of the basal ganglia).
These operate according to different
rules. Not only successful action plans are auto-
matised. With this simple observation, we
can do away with the unfortunate distinc-
tion between the cognitiveand dynamic
unconscious. Sometimes a child has to
make the best of a bad job in order to
focus on the problems which it can solve.
Such illegitimately or prematurely automa-
tised action programmes are called the
repressed. In order for automatised pro-
grammes to be revised and updated, they
need to be reconsolidated(Tronson &
Taylor, 2007); that is, they need to enter con-
sciousness again, in order for the long-term
traces to become labile once more. This is
difcult to achieve, not least because most
procedural memories are hard to learn
and hard to forgetand some emotional
memories which can be acquired through
just a single exposure appear to be indel-
ible, but also because the essential mechanism
of repression entails resistance to reconsolidation
of automatised solutions to our insoluble pro-
blems. The theory of reconsolidation is
very important for understanding the
mechanism of psychoanalysis.
B.
The clinical methods that psychoanalysts use ow
from the above claims.
(1) Psychological patients suffer mainly from
feelings. The essential difference between
psychoanalytic and psychopharmacological
methods of treatment is that we believe feel-
ings mean something. Specically, feelings
represent unsatised needs. (Thus, a patient suf-
fering from panic is afraid of losing some-
thing, a patient suffering from rage is
frustrated by something, etc.) This truism
applies regardless of aetiological factors;
even if one person is constitutionally more
fearful, say, than the next, their fear is still
meaningful. To be clear: emotional disorders
entail unsuccessful attempts to satisfy needs.
(2) The main purpose of psychological treat-
ment, then, is to help patients learn better
(more effective) ways of meeting their needs.
This, in turn, leads to better emotion regulation.
The psychopharmacological approach, by
contrast, suppresses unwanted feelings. We
do not believe that drugs which suppress
feelings can cure emotional disorders.
Drugs are symptomatic treatments. To
cure an emotional disorder, the patients
failure to meet their underlying need(s)
must be addressed, since this is what is
causing their symptoms. However,
symptom relief is sometimes necessary
before patients become amenable to psy-
chological treatment, since most forms of
psychotherapy require collaborative work
between patient and therapist. It is also
true that some types of psychopathology
never become accessible to collaborative
psychotherapy.
(3) Psychoanalytical therapy differs from other
forms of psychotherapy in that it aims to
change deeply automatised action plans. This
is necessary for the reasons outlined
above. Psychoanalytic technique therefore
focuses on the following.
Identifying the dominant emotions (which
are consciously felt but not necessarily
recognised as belonging to the self, etc.).
These emotions reveal the meaning of
the symptom. That is, they lead the
way to the (ineffective) automatised pro-
grammes that gave rise to the feelings.
The pathogenic action programmes
cannot be remembered directly for the very
reason that they are automatised (i.e.
unconscious). Therefore, the analyst
identies them indirectly, by bringing to
awareness the repetitive patterns of behav-
iour derived from them.
Reconsolidation is thus achieved through
reactivation of mainly subcortical long-
term traces via their derivatives in the pre-
sent situation (this is called transference
interpretation). Only cortical memories
can be declared.
Such reconsolidation is nevertheless dif-
cult to achieve, mainly owing to the ways
in which non-declarative memory sys-
tems work, but also because repression
entails resistance to the reactivation of
6BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 1 FEBRUARY 2018
insoluble problems. For these reasons,
psychoanalytic treatment takes time i.
e. numerous and frequent sessions to
facilitate working through.
Mental healthcare funders need to learn
how learning works. For a more detailed
account of the mechanism of psychoana-
lytic therapy, see Solms (2017).
C.
Psychoanalytic therapy achieves good outcomes
at least as good as, and in some respects better
than, other evidence-based treatments in psych-
iatry today.
(1) Psychotherapy in general is a highly effective
form of treatment. Meta-analyses of psycho-
therapy outcome studies typically reveal
effect sizes of between 0.73 and 0.85. An
effect size of 0.8 is considered large in psy-
chiatric research, 0.5 is considered moder-
ate, and 0.2 is considered small. To put
the efcacy of psychotherapy into perspec-
tive, recent antidepressant medications
achieve effect sizes of between 0.24 and
0.31 (Kirsch et al,2008;Turneret al,
2008). The changes brought about by psy-
chotherapy, no less than drug therapy, are
of course visualisable with brain imaging.
(2) Psychoanalytic psychotherapy is equally effective
as other forms of evidence-based psycho-
therapy (e.g. cognitivebehavioural therapy
(CBT)). This is now unequivocally estab-
lished (Steinert et al,2017). Moreover,
there is evidence to suggest that the effects
of psychoanalytic therapy last longer and
even increase after the end of the treat-
ment. Shedlers(2010) authoritative review
of all randomised controlled trials to date
reported effect sizes of between 0.78 and
1.46, even for diluted and truncated forms
of psychoanalytic therapy. An especially
methodologically rigorous meta-analysis
(Abbass et al,2006) yielded an overall effect
of 0.97 for general symptom improvement
with psychoanalytic therapy. The effect
increased to 1.51 when the patients were
assessed at follow-up. A more recent
meta-analysis by Abbass et al (2014) yielded
an overall effect size of 0.71, and the nding
of maintained and increased effects at
follow-up was reconrmed. This was for
short-term psychoanalytic treatment.
According to the meta-analysis of de Maat
et al (2009), which was less methodologically
rigorous than the Abbass studies, longer-
term psychoanalytic psychotherapy yields
an effect size of 0.78 at termination and
0.94 at follow-up, and psychoanalysis
proper achieves a mean effect of 0.87, and
1.18 at follow-up. This is the overall nding;
the effect size for symptom improvement (as
opposed to personality change) was 1.03 for
long-term psychoanalytic therapy, and for
psychoanalysis it was 1.38. Leuzinger-
Bohleber et al (2018) will shortly report
even greater effect sizes for psychoanalysis
in depression. The consistent trend toward
larger effect sizes at follow-up suggests that
psychoanalytic therapy sets in motion pro-
cesses of change that continue after therapy
has ended (whereas the effects of other
forms of psychotherapy, such as CBT,
tend to decay).
(3) The therapeutic techniques that predict
the best treatment outcomes, regardless of
the form of psychotherapy, make good sense
in relation to the psychodynamic mechanisms out-
lined above. These techniques include (Blagys
& Hilsenroth, 2000):
unstructured, open-ended dialogue
between patient and therapist
identifying recurring themes in the
patients experience
linking the patientsfeelings and percep-
tions to past experiences
drawing attention to feelings regarded
by the patient as unacceptable
pointing out ways in which the patient
avoids such feelings
focusing on the here-and-now therapy
relationship
drawing connections between the ther-
apy relationship and other relationships.
It is highly instructive to note that these
techniques lead to the best treatment out-
comes regardless of the type of psychother-
apy the clinician espouses. In other words,
these same techniques (or at least a subset
of them; see Hayes et al,1996) predict opti-
mal treatment outcomes in CBT too, even
if the therapist believes they are doing
something else.
(4) It is therefore perhaps not surprising that
psychotherapists, irrespective of their sta-
ted orientation, tend to choose psychoana-
lytic psychotherapy for themselves!
(Norcross, 2005)
I am aware that the claims I have summarised
here do not do justice to the full complexity and
variety of views in psychoanalysis, both as a theory
and a therapy. I am saying only that these are our
core claims, which underpin all the details, includ-
ing those upon which we are yet to reach agree-
ment. These claims are eminently defensible in
the light of current scientic evidence, and they
make simple good sense.
References
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THEMATIC
PAPER Psychodynamic psychotherapy training
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 Elvira
5
and
Aida Syarinaz Ahmad Adlan
6
1
Associate Professor of
Psychiatry, Columbia University
Medical Center, New York, USA;
email caa2105@cumc.columbia.
edu
2
Universitas Brawijaya, Malang,
East Java, Indonesia
3
Universiti Kebangsaan Malaysia
Medical Centre, Kuala Lumpur,
Malaysia
4
Chulalongkorn University,
Bangkok, Thailand
5
Universitas Indonesia, Jakarta,
Indonesia
6
Universiti Malaya, Kuala Lumpur,
Malaysia
Conicts of interest. None.
© The Authors 2018. This is an
Open Access article, distributed
under the terms of the Creative
Commons Attribution-
NonCommercial-NoDerivatives
licence (http://creativecommons.
org/licenses/by-nc-nd/4.0/), which
permits non-commercial re-use,
distribution, and reproduction in
any medium, provided the ori-
ginal work is unaltered and is
properly cited. The written per-
mission of Cambridge University
Press must be obtained for com-
mercial re-use or in order to cre-
ate a derivative work.
Populous countries in the AsiaPacic region have
adequate psychiatric residency curricula but inad-
equate psychotherapy clinical supervision, and
the paucity of training programs reects how
underserved psychiatry is in this zone (Ruiz &
Bhugra, 2008; Tasman et al,2009). Cognitive
behavioural therapy is systematically taught in
most of Asia but other modalities such as support-
ive, interpersonal, dialectic behavioural, group,
marital, family and psychodynamic psychothera-
pies are not well supervised. It is challenging to
bridge these gaps given the demands of high
volume services and few formally trained supervi-
sors. Initiatives have been implemented to improve
psychotherapy training in Asia (Alfonso et al,2018).
The most widely recognised among these in-
itiatives is the China American Psychoanalytic
Alliance program, which is largely conducted
through videoconferencing (Fishkin et al,2011).
This article describes an abridged program
designed to provide advanced psychotherapy
training in underserved areas with limited peda-
gogical resources. Although the program was
piloted in Asia, our hope is that it could be adapted
or replicated in other areas with similar needs.
The World Psychiatric Association (WPA)
Psychotherapy, Education in Psychiatry, and
Psychoanalysis in Psychiatry Sections identied that
Asian psychiatrists have a keen interest in improving
psychodynamic psychotherapy education. Liaisons
with the Royal College of Psychiatrists in Thailand,
the Malaysian Psychiatric Association and the
University of Indonesia gave rise to our multi-
national, collaborative, pedagogic endeavour
(Alfonso et al,2018). The WPA pilot program was
designed to take place over 5 years, targeting three
countries (see Table 1).Itwasdesignedtobe
self-sustaining with the aim of improving the psy-
chotherapy skills of those enrolled in study activities
and teaching psychiatrists how to supervise so that,
after completion, psychiatrists could work effectively
as psychotherapy supervisors.
Phase 1: full-day workshops to improve
clinical skills
Full-day psychodynamic psychotherapy workshops
took place at meetings sponsored by the national
psychiatric societies in Jakarta, Surabaya, Kuala
Lumpur and Bangkok between 2013 and 2014.
The hosting psychiatric society selected local psy-
chiatrists to run workshop modules according
to the expertsareas of interest (see Table 2).
Clinical correlations and applicability of psycho-
dynamic thinking in a variety of settings were
emphasised. Attendance ranged from 35 to 50 peo-
ple; a manageable number for the maintenance of
8BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 1 FEBRUARY 2018
... Research has also supported a wide range of psychodynamic perspectives on personality development (e.g., Gunnar & Quevedo, 2007;Lupien et al., 2009;Luyten et al., 2008;Lyons-Ruth & Jacobvitz, 2008), and has shown that psychodynamic constructs reliably relate to psychopathology and personality functioning (e.g., Vierl et al., 2023aVierl et al., , 2023b. Interdisciplinary researchers have further demonstrated that the core scientific claims of psychoanalytic theory are consistent with what is known about the neurobiology of affect, consciousness, and brain change in psychotherapy (e.g., Smith & Solms, 2018;Solms, 2012Solms, , 2013Solms, , 2017aSolms, , 2017bSolms, , 2018Solms & Friston, 2018). In closing, this final chapter brings together a wide array of clinical, developmental, and neuroscientific research findings to advocate for the enduring relevance and validity of psychodynamic theory and therapy in the age of evidence-based practice. ...
... Rather, this highlights the role of thinking, which understood as arising instead of, and prior to physical action. Solms (2018) associates this description of thinking with working memory, which enables us to supplement our "rough-and-ready" innate predictions with deliberations about virtual actions and their projected consequences. This type of thinking, which Freud referred to as preconscious, is now known to consist of declarative representations facilitated by cortical memory systems. ...
... Based on the arguments presented thus far, the central goals of mental development according to Solms (2018) may be summarized accordingly: to "consolidate our solutions to life's problems into long-term memory, and then ultimately automatize them" (p. 8). ...
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Full-text available
Psychodynamic theory and therapy is widely misunderstood by students, clinicians, and researchers at all levels of the mental health profession. This is an unfortunate consequence of bias and misinformation, which run rampant in academic and clinical environments alike. Despite the publication of numerous empirical research volumes and evidence-based treatment manuals over the past two decades, many students and professionals persist in their belief that the modality is ineffective and obsolete. After identifying several sources of bias and misinformation, Psychodynamic Theory, Therapy, and Research: A Reintroduction presents a detailed overview of key developments in theory and technique. Readers will then be introduced to the clinical, developmental, and neurobiological domains of evidence which establish the validity of psychodynamic models and the efficacy of psychodynamic therapies. Each chapter also provides topical reading lists for those who wish to explore the literature in more depth. *Paperback and hardcover available for purchase, please message for pricing and shipping*
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... For example, when encountering difficulties with satisfaction of basic needs, individuals may experience a feeling of pressure and internal conflict (autonomy), a sense of failure or inadequacy (competence), and/or feelings of loneliness and exclusion (relatedness). From this perspective, emotion regulation is intimately bound to the fulfilment of basic psychological needs (Benita, Benish-Weisman, Matos, & Torres, 2020;Harley, Pekrun, Taxer, & Gross, 2019;Roth et al., 2019;Solms, 2018). ...
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... For example, Haverkampf (2017) proposed theoretical integration between the two modalities on an epistemological level, whereas Garrett and Turkington (2011) suggest that both CBT and psychoanalysis should be used as an integrated approach for the treatment of psychosis. Solms (2018) has argued that, when it comes to predicting good treatment outcomes in psychotherapy, technique overwhelmingly triumphs over therapeutic modality. A similar argument, titled the 'Dodo bird verdict' (Rosenzweig, 2002), has been made more than half a century ago. ...
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... Research in Canada has shown that long-term PDT, and psychoanalysis, in particular, is provided to severely ill patients with major, longstanding psychosocial disturbances (Doidge et al., 2002a), who have failed prior treatments, and who have multiple diagnoses (Doidge et al., 2002b). Despite patient severity, a recurring finding in the scientific literature is that long-term PDT and psychoanalysis result in sustained improvement (Doidge, 1998;De Maat et al., 2009;Solms, 2018). That is, long-term PDT undoes the developmental inhibitions, or blocks, thus leading to renewed normal growth. ...
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Some investigators have argued that emotions, especially animal emotions, are illusory concepts outside the realm of scientific inquiry. With advances in neurobiology and neuroscience, however, researchers are proving this position wrong while moving closer to understanding the biology and psychology of emotion. In Affective Neuroscience, Jaak Panksepp argues that emotional systems in humans, as well as other animals, are necessarily combinations of innate and learned tendencies; there are no routine and credible ways to really separate the influences of nature and nurture in the control of behavior. The book shows how to move toward a new understanding by taking a psychobiological approach to the subject, examining how the neurobiology and neurochemistry of the mammalian brain shape the psychological experience of emotion. It includes chapters on sleep and arousal, pleasure and pain systems, the sources of rage and anger, and the neural control of sexuality. The book will appeal to researchers and professors in the field of emotion.
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