Wednesday, April 1, 2015

Psychoanalytic Psychotherapy Today

Todd Essig, a practicing psychoanalyst believes that it’s time to return to psychoanalysis. Or better, to something that is called psychoanalytic psychotherapy.

I see it as a watered down version of Freudian treatment that is designed to be more effective clinically.

He is chagrined by the fact that patients are no longer interested in psychoanalysis. They prefer cognitive therapies and medication. 

For some reason he does not understand that the failure of psychoanalysis represents the free market at work. Free individuals have aright to choose where they want to go for therapy. Fewer and fewer of them arechoosing psychoanalysis.

Essig believes that they are misinformed.

Among the misconceptions that he sees in the culture is this one: psycho psychoanalytic psychotherapy cannot provide empirical evidence to support its claim to treat or cure.

He writes:

A frequent canard used to justify ignoring psychoanalytic psychotherapy is that there is no research documenting its effectiveness. Simply put, this is false. That’s right, the “talking cure” works at least as well as anything else and probably better for some. While much more needs to be done, and needs to be done against a funding headwind focussed on medications and short-term approaches, there is a lot of specifically psychoanalytic research available.

One might point out that Edward Erwin of the University of Miami wrote a book called The Final Accounting, wherein he demonstrated that research about Freudian theory has discovered it to be empirically invalid.

One recalls that Jeffrey Lieberman, head of the psychiatry department at Columbia Presbyterian Hospital has just written a book, duly noted on this blog, wherein he asserted that there is no evidence to suggest that Freudian psychoanalysis works.

When posting about this over the weekend I noted reviewer Natalie Angier’s account of her experience with Freudian psychoanalysis.

Among the differences between classical psychoanalysis and what is called psychoanalytic psychotherapy is this. In the latter, the patient makes a human connection with an analyst who is present, not absent.

One knows that Freudian psychoanalysis disallows any such connection. Its goal is to allow you to access your unconscious mind and to allow it to speak. Interacting with another human being would make that process more difficult.

More modern therapies seem not to believe that a human connection will undermine the process.

And yet, at that point, is it really psychoanalysis?

Freud, to his credit, was a great thinker. His system might not have had very much to do with human beings, but it is coherent, consistent and complete.

If you are going to take your analyst for your father or mother or Aunt Sally, you cannot at the same time be interacting with him as a human being. Freud understood this well. Modern psychoanalysts, less so.

Those who want to have it both ways are confusing the theory in order to introduce something that might really benefit their patients. In that case, their good results cannot be ascribed to psychoanalysis.

After all, patients are known to improve in therapy because they can make a human connection with their therapists. If this is the basis for therapeutic improvement in psychoanalytic psychotherapy, its practitioners would do best to cease to call it psychoanalytic.

Thus, the good results—assuming that they are as common as Essig thinks—are not deriving from psychoanalysis but from the fact that practitioners have partially freed themselves from Freudian theory.

As for the question of empirically demonstrable outcomes, psychoanalysis, in one form or another, has been around for well over a century now. People have undergone it. They have seen their friends and family undergo it.

If it had been an effective treatment, they would surely have figured it out by now. If people, in the free market, reject psychoanalysis perhaps they know something that the “research” has not been showing.

Essig describes the new non-Freudian treatment:

No longer does a psychoanalyst try to be a blank screen on which patients project their experience where it can then be examined uncontaminated by the person of the analyst. Instead, psychoanalysts today recognize that, like every relationship, there are always two people present influencing each other in unique individual ways. There are no blank screens. The person of the analyst is always present in some way. Rather than cultivating emotional absence, being a psychoanalyst requires a much more difficult radical acceptance of who one is and how one may or may not be influencing the treatment. Treatment is then a meeting of two people who are both always inevitably present.

Freud understood that if the analyst is present as a human being in his glorious individuality, there is no real place for transference.

Why do its defenders continue to cling to the label of psychoanalysis? Essig answers:

But, unlike other relationships, these two meet for the sole purpose of helping one of them explore and accept the patient’s history and possibilities, however painful, dirty, nasty, loving, glorious and even boring that person’s emotional truth may be.

Psychoanalytic therapy wants to help people to explore what is bad about them, what they have gotten wrong in the past, what is painful, dirty, nasty and boring.

Essig adds the notions of loving and glorious, but, in truth, the emphasis of what went wrong is strictly Freudian. Done right, Freudian free association forces patients to speak open and honestly, without regard for how ugly or obnoxious or boring their words are.

Those who want to emphasize what is positive in the patient’s life have gotten the idea from Aaron Beck’s cognitive therapy.

Essig believes that the patient improves when he comes to understand what is called his pattern. Thus, that psychoanalytic psychotherapy works, when it does, through some form of mental change.

Of course, Freud would have agreed. He stated that an unanalyzed neurotic was condemned to repeat the same mistakes.

Essig argues:

It’s a method of treatment that works by helping people understand how they unconsciously create problematic patterns of thinking, feeling, acting, and relating.

If you are looking at someone’s pattern, you are going to select out material that confirms the pattern. Thus, you will be truncating the patient’s life experience.

Obviously, the method is introspective, and backward looking. It does not attempt to correct any conflicts or dilemmas in the present, but it prefers to dredge up problems from the past.

When Essig suggests that people create these problematic patterns unconsciously, he is being incoherent. How can you create a pattern if you are not conscious you are doing so.

One might say that your behavior falls into a pattern, but you cannot demonstrate the truth of this idea by cherry-picking experiences that fulfill the terms of the pattern and ignoring those that do not.

Essig continues by stating that understanding your pattern will liberate you from it, that is from the after-effects of the way you were first loved.

In his words:

Unconsciously created problems (including the various problems in living that for purposes of diagnosis are called symptoms) usually recreate patterns, problems and solutions from early intimate relationships. Like never forgetting how to ride a bike, we never forget how we were first loved. Those relationship procedures remain. But by putting words to those implicit relationship procedures people become able to make freer choices and have new experiences.

Speaking of bicycles, if you happen to be afraid of riding a bicycle, knowing why you are afraid will have no effect on your ability to ride a bicycle. As everyone knows, psychoanalysis is notoriously ineffective against phobias.

Also, what does it mean to be “putting words to those implicit relationship procedures?” The phrase is poorly expressed and theoretically muddled.

Obviously, you do not need psychoanalysis to have a new experience. In some sense, every experience is a new experience.

Also, in Freudian theory there is no such thing as a free choice. Your choices are always determined by unconscious mental processes. It’s nice to promise liberation from past patterns, but it is just as likely that the process will merely free you to make new mistakes.

What makes you think that you are only being controlled by one pattern? What if your unconscious mind has trapped you in three or six alternative patterns? There is not just one way to make a mistake.

As I suggested in The Last Psychoanalyst, knowing why you got it wrong tells you nothing about how to get it right.

 If you have been living in a pattern, that is, a drama, and if you learn about the drama you were living in—the drama of Oedipus or Narcissus—nothing about the process will tell you how not to live in a drama. It might help you to find a new drama or a new way to be dysfunctional… no more or less.

One might add that people do forget infantile experiences. The brain has the capacity to overwrite memory. And why would the patient not be living out some other pattern, one that did not derive from his experience but that derived from the experience from a friend or a neighbor, someone he is emulating—even unconsciously?

As Wittgenstein said, the fact that you can construct a chain of associations that accounts for the production of a symptom or a dream does not mean that the same chain necessarily produced the symptom or dream.

Surely, the same applies to any meaning that you might attribute to a symptom. The fact that you can concoct a meaning for your headache does not mean that your headache was caused by it. 

Despite having proposed that patient and therapist are both present in psychoanalytic sessions, Essig—incoherently—suggests that the session reenacts the patient’s pattern. This suggests that the analyst, however present he is, is not present as a human being, but as a dramatis persona.

Freud understood well that you cannot be present as the person you are and also be present as a reincarnation of someone from your patient’s past.

Essig writes:

The moment to moment relationship between therapist and patient is a [pick your metaphor] laboratory/playground/theater for experiencing and understanding those early relationship procedures. Living through those moments together in the treatment allows for an immediate, non-abstract awareness. It is a deep knowing, one with transformative power.

He is trying to say that by reenacting the childhood experience in the session, the patient will gain a knowledge that is based on experience, not merely on abstract thinking.

Essig calls it “deep thinking,” but again that is theoretically incoherent. There is no reason why reliving and understanding a bad love relationship will transform you. It might very well mire you even further in bad love relationships.

Reliving the past might also persuade you—unconsciously—that the past is inescapable. Considering how much time you will be spending doing this, even if you learn how to make a better choice of lovers, you will not have gained any experience of how to conduct a relationship.

If you are constantly choosing the wrong lovers, why not simply take the advice of a third party, a friend, a family member or a therapist whose judgment is more objective than yours.

Then you might learn how to conduct a relationship by being in one rather than getting lost in your pattern and awaiting an enlightenment that will free you to choose right or wrong.

If you are taught through psychoanalytic psychotherapy to mire yourself in relationship patterns that you should have outgrown by the time you went to elementary school, what are you to do if your problems derive from your career, from your business, from questions concerning negotiation, management and leadership?

These skills must be acquired. If you imagine that once you free yourself from you pattern you will, as if by magic, know how to choose the right lover, know how to function in a relationship, know how to select a career path, know how to run a business, know how to plan your retirement, know how to manage your staff, know how to negotiate a deal, you will be assuming that you have an innate knowledge of how to do these things and that psychoanalysis will allow you to get in touch with it.

Unfortunately, the claim is not plausible.

1 comment:

Ares Olympus said...

All this makes me wonder if there's any hope for any certainty at all to help anyone?

I have been interested in the question of free will, and I wouldn't think Freudian theory rejects free will, the existence of choice, so I'd reject this paragraph as muddled:

re: Also, in Freudian theory there is no such thing as a free choice. Your choices are always determined by unconscious mental processes. It’s nice to promise liberation from past patterns, but it is just as likely that the process will merely free you to make new mistakes.

Either we're in control and have complete freedom, OR the unconscious is in control and we have no freedom?!

What I would imagine is the first step is "Objective observation", so you don't worry about choice, but just observe what happens, and your reaction.

Or like what my men's group called "The Awareness cycle", (1) Observation (2) Evaluation (3) Feeling (4) Reaction, and if you can separate these components, then you can see the existence of choice, even as you can choose actively or passively. You can be reactive and see what happens, and you can try something that breaks past patterns of reaction and see what happens. And once you see you have a choice in your reaction, you don't feel "driven" by external events, but a willing participant, responsible for whatever you do, or don't do.

This week I listened to a speech by John Lee from 2002, talking about regression: The Grace in Regression Part 2: Five Ways to Grow Back Up
His description sounds like regression is a frame of mind where the past gets overlaid with the present, and here "choice" is the hardest to see because there's something hidden, and worse if you're reacting through that regression, others won't understand your reaction, and if you're pushing blame and shame for instance, others push back, and you suddenly have to deal not just with someone else, but your own irrational reaction, that has pulled you into something that isn't entirely real to the situation, and can't be easily withdrawn without feeling even worse, so people would often rather double-down on their own irrationality than question what it is.

So I don't know how psychotherapy work with this, or what might work better. It certainly seems a crazy responsibility for a therapist to try to help someone in regression, or reflecting on some recent event that contained a regression, so hard to know how hard to push, how to hold back and not force something not ready.

But maybe the only "key" that exists is for a person to become aware "Oh, I'm in a regression", and accept this has corrupted their perceptions of present events, and to find techniques to delay judgment, delay decisions, until the regression is lifted.

And I can agree a Therapist probably can give better suggestions than mere "understanding", but once a pattern is recognized with unwanted outcomes, they can suggesting various strategies to try next time, and even practice role playing, etc, especially thinkings like assertiveness skills.

Passivity is a funny problem since it would seem to be a first step in observation, and delaying unconscious reactions/decisions. But once you have enough information to decide what you want to do, you still need the courage to do it.

Well, like anyone can say "Hey, I prefer to procratinate and write long winded blog comments rather than work on my taxes." So it would seem a simple need for will power, and strategies like recognizing will power is greater earlier in the day, or small agreements like "I'll do 15 minutes today" if that will feel like progress. There can be a "why" for me, perhaps anxiety over mistakes, but really it comes down to making an agreement with myself that I know I can do, and not give myself any way out.

So I don't need a pricy therapist to tell me this!