It is common to hear that psychoanalysis is unscientific, based on wild speculation and having no evidentiary basis.
Many psychotherapists assure patients and others that what they do is “evidence-based” unlike Freud’s wild speculations; those opposed to therapy deride all therapies as being ineffective and argue “You don’t need to spend years on a couch talking to a psychoanalyst to understand yourself.”
It is unusual to hear the very same view come from people at such divergent ends of the mental health landscape and so it can lure many into believing that it is true: if both proponents and opponents of psychotherapy consider psychoanalysis as worthless, it must be true. Right?
Wrong. In this post, I elaborate some of the startling successes and unbelievable excesses of psychoanalysis that lead it to becoming the most celebrated psychotherapeutic model of its time as well as one of the most ridiculed models of the present age.
A Brief History of Psychology
Physical medicine began around the time that humans began – from then on, we needed ways to repair our injured bodies. Improvements were fairly rapid due to the immediate resolution to many problems. Cauterization, for example, has been known to close wounds since at least antiquity, and, in an amazing recent discovery, the earliest evidence of surgical amputation was recently discovered in a 31,000 year-old skeleton in Borneo (Burakoff, 2022).
Even with that extensive history, it took medicine until the early 1900s for medical education to become standardized. The influential Flexner Report detailed the low standards for admissions and graduation, at medical schools in the U.S. and Canada, as well as their unsystematic curriculum and their teaching questionable or even defunct medical sciences. He called on them to abandon these questionable theories and adhere to the science of the day.
Although the ancient Egyptians described conditions resembling hysteria (Cosmacini, 1997); Hippocrates theorized about the causes and treatments of “melancholy,” and extreme behaviors, often classified as “madness”, were observed throughout the world, the understanding of mental health and illness generally lagged behind physical medicine. Centuries of religious and quasi-religious mystical beliefs shrouded mental disorder and it wasn’t until with Ribot in France and Wilhelm Wundt in Germany (both in the mid to late 19th century) that a scientific study of mental illness was born.
A Major Leap Forward
Some of the first credible stages in psychotherapy were by Sigmund Freud. Other notable figures prior to him, such as Philip Pinel (who, observing the terrible conditions in the famous Bicêtre and Salpêtrière hospitals, removed iron shackles and straightjackets form incarcerated patients), made important contributions, but it was Freud who elaborated a treatment method for those mental disorders that did not require confinement (as it was at the time) or residential treatment. Although Freud is often derided, his contributions to the field were immense. In a late article he was invited to write for an encyclopedia to explain the contribution of psychoanalysis – his life’s work – to a broader audience he wrote:
“The assumption that there are unconscious mental processes, the recognition of the theory of resistance and repression, the appreciation of the importance of sexuality and of the Oedipus complex– these constitute the principal subject-matter of psycho-analysis and the foundations of its theory.” (1923/1955b, p. 247).
Freud’s first point – “The assumption that there are unconscious mental processes” – is such a large contribution that it is often overlooked these days. In the mid and late 19th century, there was a substantial debate about whether the unconscious existed. Although several argued that it did (including one of my favorites, Friedrich Nietzsche), the predominant view was that mind equaled consciousness. It was Freud’s arguments that won the war, effectively shifting the subject matter of psychology from the study of consciousness to the study of mind. Consider what a monumental shift that is. That would be like changing biology’s subject matter from living things to include also inorganic things such as plastics. Not trained in the history of science, neuroscientists and cognitive scientists who focus on unconscious processes can sometimes forget this central contribution.
A Terrible Idea
Part of what makes it so easy to forget, however is Freud’s third “contribution” – the sexual theory of neurosis. As is well known, Freud postulated that all neuroses – that is, all disorders that are not psychotic disorders (so, anxiety, depression, phobias, etc.) – are the result of a sexual source, very often one’s own mother. He could not have been more clear about this: children sexually desire their own parents. This theory is so laughably false that scholars have devoted book length treatments to trying to understand why society could have bought in to this. (For a recent, and compelling, treatment of this topic, see: Wakefield, 2023 and Wakefield, 2024)
Rescuing a Bad Idea
However, in the 1950s the researcher John Bowlby re-examined the theory. He observed that babies and young children are not longing for their parents sexually but longing for touch, connection, and soothing. If you look around the animal kingdom you’ll notice that whereas deer are walking within hours and hyenas are already hunting at one year, human babies can’t do much of anything for years. There are interesting evolutionary reasons for this, but developmentally it means that they need auxiliary emotional regulation devices to help them figure out when to worry, to be relaxed, to be afraid, to be happy. These auxiliary regulation devices are called parents. The way they do this is by holding, swaying, caressing, hugging, singing, and cooing with their kids. This creates attachment and the theory is called attachment theory.
Bowlby’s attachment theory has received volumes of supporting research, but one notable area of evidence came from Mary Ainsworth’s Strange Situation experiment. Ainsworth devised a brilliant experiment to observe how toddlers react to their parents’ presence in low and high stress environments. She found that, children’s early relationships with their parents inform how they behave toward others and their environment. These insights were quickly folded into psychoanalytic thinking focusing on the relationship between children and other people called object relations.
Object relations is a branch of psychoanalysis that treats the objects (that is, people) in people’s life as the most essential features to their psychology. The insights from object relations and attachment theory – in particular the notion that relationships formed in childhood create an unconscious “schema” or “working model” for how others value you, what traits are appropriate to value, what counts as love, etc. – form the basis of, or inform, other psychotherapies including internal family systems (IFS), schema therapy, interpersonal therapy (IPT), and even Cognitive Therapies.
How Cognitive is Psychoanalysis? How Psychoanalytic is Cognitive Therapy?
Aaron Beck, the founder of cognitive branches of psychotherapy that emphasize the distortions in one’s beliefs and attitudes that make one depressed (or anxious, or angry, etc.), is often thought to have formulated his theory after being dissatisfied with the inabilities of psychoanalysis to treat his patients. However, that is not what Beck himself has stated:
It might be a point of curiosity therefore for you to know that my psychiatric training was completely and exclusively psychoanalytic […] I would consider my theoretical work as derivative from ego psychology rather than from cognitive psychology or learning theory. At the present time in fact I am trying to reformulate many of the basic psychoanalytic concepts into cognitive terms. (Beck as quoted in Rosner 2012, p. 2).
Beck thus considers his theory a reformulation of, rather than a rejection of, “basic psychoanalytic concepts.”
In an article discussing the importance of psychotherapeutic integration – that is, combining psychotherapeutic models to extract what is most effective and leave the rest (more on that later) – myself and colleagues (REF) discuss the way that Cognitive Therapy is borrows from and elaborates on psychoanalytic ideas. In particular, we note that what Beck refers to as “automatic thoughts” – those thoughts that arise, often without our awareness, that can influence our moods – are really generated by those unconscious schemas learned in childhood. As we write:
To a remarkable degree, Beck’s notion of schema comes close to Bowlby’s notion of “working model” and object relations theory’s notion of “internalized object,” and provides a bridge from cognitive to psychodynamic thinking. Just as classical psychoanalysis involves the analyst interpreting symbols and images that emerge in the course of free association in order to get at unconscious meanings, the cognitive therapist uses the content of spontaneous conscious thoughts and images to identify the cognitive distortions in the relevant schemas, which are not necessarily conscious. (Wakefield, Baer, Conrad, 2020)
Isn’t Cognitive Behavioral Therapy (CBT) the Best Anyway?
Cognitive Behavioral Therapy (CBT), born out of Beck’s Cognitive therapy and Skinner’s Behavioral therapy, has enjoyed decades of prominence as the premier psychotherapeutic model. Whereas psychoanalytic models relied for years on the force and coherence of their arguments, Cognitive Behavioral therapists got to work in the lab to turn their arguments into evidence. As a result, CBT is considered to be the “gold standard” psychotherapy (by some) and is a recognized and recommended treatment by both the American Psychological Association (Society of Clinical Psychology, 2022) and The National Institute for Health and Care Excellence (2011).
Although many psychoanalysts take their fight to be with CBT, there is no doubt that Cognitive Behavioral Therapy is an effective treatment for many conditions (I, myself, am a certified Cognitive Behavioral Therapist and trained in psychoanalytically based treatments). However, there is a reason for the disproportionate acclaim that CBT gets compared to its psychoanalytic counterparts that has nothing to do with effectiveness.
CBT is a highly structured, highly operationalized psychotherapy meaning that it can be broken down into discrete techniques (Ewbank et al., 2020) and employed by whomever to whomever. As well, CBT is designed to be a brief and directed treatment approach to an identified problem. Taken together, these features make it much easier to design a randomized control trial to examine its effectiveness than psychoanalytic therapies which vary in length (but often are longer in duration than their CBT counterparts) and which are less easily broken into discrete, operationalizable, components.
Once researchers figured out how to operationalize psychodynamic therapies, it was shown to be clinically effective (Leichsenring & Rabung, 2008; Leichsenring, Rabung, & Leibing, 2004; Shedler, 2010) at rates similar to CBT (Leichsenring, 2001; Fonagy, 2015; Steinert et al., 2017, Leuzinger-Bohleber, et al., 2018). In one three-year follow-up study (Huber et al., 2012), psychoanalytically based psychotherapies had a more lasting posting effect on interpersonal relationships than CBT. Indeed, a landmark study by the U.K.’s National Health Service (NHS) found that long term psychoanalysis not only performed as well as CBT and antidepressents in the short-term, but outperformed CBT on long-term measures for severe depression (Fonagy, 2015). At the same time, studies showing CBT’s efficacy, seem to show it becoming less effective than the experiments from the 1970s showed it to be (Johnsen & Friborg, 2015).
Babies. Bathwater.
Philosophically and psychotherapeutically, I am an integrationist, meaning that I do not believe that a single theoretical model holds all the answers and employ features of cognitive behavioral therapy as well as psychodynamic psychotherapy. Despite the sweeping claims made by the progenitors of these systems, no single psychotherapy works for all people, in all circumstances, at all periods of life. And there is good reason for this. If you have a headache and prefer Tylenol over Advil (or vice versa) it is because they work along different pathways in the body. Similarly, the human mind is a complex system that includes more than just its physical substrate. The mental component – that part that thinks, values, and feels – has multiple meaning systems: cultural, familial, conscious, unconscious, and perhaps many others. It is possible that cognitive based therapies family systems therapies, and therapies focused on unconscious processes, all address different aspects of the same issue.
It is not difficult to see why some people balk at psychoanalysis and psychoanalytic concepts: some of his ideas were inane, some terrible therapists were terrible using psychoanalysis as a cover. Some people simply want to agree with others who seem to know what they are talking about; others no doubt want to be contrarian and enjoy the iconoclasty. The truth is somewhere in between: Freud forever altered psychology, transforming the subject matter of the discipline from consciousness to mind; his belief in sexual theories of the neuroses was extraordinarily wrong and did lasting damage to many people; but the core insight – that the relationships between parents and children have an important and lasting effect on one’s mental health, has persisted and is a tent-pole of modern psychotherapy. It would be a mistake to throw out so much that is right because of all that is wrong.
References
Burakoff, M. (2022). Stone Age skeleton missing foot may show oldest amputation. Associated Press. Retrieved from: https://apnews.com/article/science-health-606cbfe3040b8fed2b9435fb1fbc2d29
Fonagy P. (2015) The effectiveness of psychodynamic psychotherapies: An update. World Psychiatry. 14(2),137-50
Huber, D., Zimmermann, J., Henrich, G., & Klug, G. (2012). Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients–a three-year follow-up study. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 58(3), 299-316.
Johnsen, T. J., & Friborg, O. (2015). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological bulletin, 141(4), 747.
Leichsenring F. (2001). Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: a meta-analytic approach. Clinical psychology review, 21(3), 401–419. https://doi.org/10.1016/s0272-7358(99)00057-4
Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA, 300(13):1551-65. doi: 10.1001/jama.300.13.1551.
Leichsenring, F., Rabung, S., & Leibing, E. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Archives of general psychiatry, 61(12), 1208–1216. https://doi.org/10.1001/archpsyc.61.12.1208
Leuzinger-Bohleber M, Hautzinger M, Fiedler G, et al. Outcome of Psychoanalytic and Cognitive-Behavioural Long-Term Therapy with Chronically Depressed Patients: A Controlled Trial with Preferential and Randomized Allocation. The Canadian Journal of Psychiatry. 2019;64(1):47-58. doi:10.1177/0706743718780340
Rosner, R. I. (2012). Aaron T. Beck’s drawings and the psychoanalytic origin story of cognitive therapy. History of Psychology, 15(1), 1–18.
Shedler J. (2010). The efficacy of psychodynamic psychotherapy. The American psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378
Society of Clinical Psychology (2022). Psychological treatments. Division 12: American Psychological Association. Retrieved from https://div12.org/treatments/
Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174, 943-953.
The National Institute for Health and Care Excellence (2011). Common mental health problems: Identification and pathways to care. Retrieved from: https://www.nice.org.uk/guidance/cg123/chapter/Recommendations
Wakefield, J. (2024). Foucault versus Freud: Oedipal theory and the deployment of sexuality. New York: Taylor & Francis
Wakefield, J. (2023). Freud's Argument for the Oedipus Complex: A Philosophy of Science Analysis of the Case of Little Hans. New York: Routledge.
Wakefield, J. C., Baer, J. C., & Conrad, J. A. (2020). Levels of meaning, and the need for psychotherapy integration. Clinical Social Work Journal, 48, 236-256. doi: 10.1007/s10615-020-00769-6
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