28 Jan 2015
January 28, 2015

Does Psychoanalytic Therapy Really Work?

By GERALD SCHOENEWOLF, PH.D.

PTSDOver the years many people have questioned whether psychoanalysis really works. It has especially come under attack in recent years, as psychotherapy has become controlled by insurance companies, who bemoan any long-term treatment. Those who practice psychoanalytic psychotherapy have asserted strongly that it works. They point to qualitative improvements in social functioning, self-esteem, work relationships, and other such factors. And there are thousands upon thousands of case histories, written since the time of Sigmund Freud, that testify to its success.

However, the acid test of the efficacy of any method lies in the availability of hard evidence in the form of research. And, as it happens, we have two recent studies of psychoanalysis that offer evidence of its validity.

A study by Shedler in the February-March 2010 edition of the American Psychologist (put out by the American Psychological Association), examined the results of treatments using psychodynamic psychotherapy for a variety of psychological disorders. This was a meta-analysis that covered studies done around the world. It concluded that psychodynamic psychotherapy works as well as, or is at least equivalent to, other psychotherapy treatments deemed as supported by empirical evidence, such as CBT.

Prior to this study there was a meta-analysis of short-term psychodynamic therapy by Leichsenring and colleagues. published in the Archives of General Psychiatry in 2004. This study looked at seventeen random controlled studies of treatment with depression, bulimia, post-traumatic stress disorder, generalized anxiety disorder and various personality disorders. They measured results using the Hamilton depression scale and other such methods and found that symptoms improved when compared to control groups of patients on waiting lists or in non-psychodynamic therapies.

Of course, these days most psychotherapists, including most psychoanalysts, practice eclectic therapy, as no one modality is right for everybody. In my psychotherapy practice over 38 years, I have used behavioral and cognitive therapy as well as psychoanalytic therapy. I sometimes find that all three are needed with the same client, and that all can play an important role.

A person may have ongoing anger at a spouse, who may suffer from some form of depression that causes emotional paralysis and prevents getting a job. It then falls on this healthier individual to take responsibility for the family’s income. On a cognitive-behavioral level I encourage the client to focus on the reality of the situation, which is that the spouse cannot look for a job because of the emotional problem, not because “the spouse is lazy.”

On a behavioral level I may also discuss the importance of detaching from the anger, noting that it is causing health problems. However, at the same time, on a psychoanalytic level I will focus on the transference–that is, on how unresolved anger at one’s father (who had similar anger and paralysis) is now being displaced onto the spouse. All these approaches may be needed to bring about real change.

However, there is one ingredient of psychoanalytic therapy that has been there from the beginning and remains the special feature that makes it a vital form of therapy: the relationship between the client and the psychoanalyst. Clients, by being completely honest about their thoughts and feelings about the psychoanalyst, learn to understand themselves and how they relate to the analyst (and hence others) in an immediate way that goes right to the core of their issues.  In doing this, they work through the misinterpretations (cognitive flaws) by being confronted with their immediate effect.

A client once came into treatment who would hardly talk for many weeks.  There were long silences during which I would ask, “What are you thinking now?”  Eventually the client got around to talking about how her parents had always been on her case as she grew up.  In the treatment she was transferring her parents onto me and expecting me to be on her case if she told me too much.  She also realized that she related to others in this same way.  Thus the psychoanalytic method helped her to resolve some of her deepest issues right from the beginning.

Methods, however, don’t do therapy; people do. Methods are only as good as the people who use them. If you can form a good therapeutic alliance with a client, he or she will usually get better, no matter what the method is. If you can’t form a good therapeutic alliance, no method will work.

Having said all this, the bottom line is that evidence does exist to support the benefits of psychoanalytic therapy. It does really work when it is done the way it needs to be done and when it is received the way it needs to be received.

As is so often the case, the doubts are not in the method, but in the mind of the beholder.

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