Dear Peter Fonagy
27th September 1999
The grandiose claims of psychoanalysis, and its subsidiary therapies, have never looked shakier. This is partly the result of the drip-effect of decades of criticism by real scientists, but also, more recently, the beneficial effect of pills such as Prozac and "cognitive" therapies, which focus on conscious as opposed to unconscious events. I am told that even in its American heartland analysis is in retreat in the face of these more effective alternatives.
But first, let me explain why I, like so many others, cannot take seriously psychoanalysis's claim to scientific status. The problem is that its ideas are so vague and all-inclusive that it is not possible to test them and thus show whether they are right or wrong. How, for example, do psychoanalysts know that repression of traumatic events occurs, or that children, as Melanie Klein claims, experience a depressive state at the time of weaning, or that depression is aggression turned against the self? The concept of repression of unwanted thoughts which are too painful or disgusting is one of the cornerstones of psychoanalysis, and repression is claimed to be responsible for some neuroses. But under what conditions does repression occur? And what is to be regarded as a trauma in childhood that is repressed? Freud famously considered seeing a dog drink from a glass as traumatic. Each of the key concepts of ego, id and superego has a character almost as complex as the phenomena for which they are employed to account. And the concept of psychic energy seems very like the idea of evil spirits, which some cultures use to explain why things have gone wrong.
A characteristic feature of all fields of science is that they relate to other fields to which they contribute and from which they take ideas. For example, cell and molecular biology relate to chemistry and to the biology of multicellular organisms. There can be no contradiction where these fields meet. By contrast, psychoanalysis is sealed off from outside influences. It is not possible to relate its ideas to any other body of scientific knowledge.
As for the clinical effectiveness of psychoanalysis, let me take a condition which I know only too well: depression. How should we think about the causes and nature of this most common mental illness (it affects about one in ten of the population); and has psychoanalysis anything to offer? It is difficult to take seriously the main psychoanalytic idea that depression, like mourning, conceals aggression towards a lost person or object. The analyst Julia Kristeva puts it thus: "I love that object, but even more I hate it; because I love it, and in order not to lose it, I embed it in myself; but because I hate it the other within myself is a bad self, I am bad, I am non-existent, I shall kill myself." As we celebrate the 100th anniversary of the publication of Freud's The Interpretation of Dreams, it is quite proper to pay tribute to psychoanalysis's poetic appeal; but it is difficult to take seriously such thoughts on depression.
Depression can have an important biological component. Indeed, about 50 per cent of the vulnerability to depression is genetic. Hormonal changes-a pathological increase in the hormone Cortisol (in Cushings Syndrome)-can also cause depression. Certain parts of the brain, such as the amygdala, are more active in depressed patients. There is also an important cognitive component to depression-the persistence of defeatist and pain-inducing attitudes even when objective evidence for positive factors is present. Drugs and cognitive therapy help; psychoanalysis does not.
The reason is that psychoanalysis more or less ignores biological and conscious causes; it only stresses unconscious processes and early childhood events for which the evidence is poor. Neglect or abuse in childhood does predispose people to depression, but this does not mean that it is to be accounted for in terms of psychoanalytic concepts. Is there a single paper in the psychoanalytic literature which deals with the genetics of depression? And has psychoanalysis produced any clinical trials for its treatment of depression which would fit the criteria for evidence based medicine?
Yours,
Lewis Wolpert
Dear Lewis Wolpert
3rd October 1999
I agree with a number of your points-your criticism of some psychoanalytic theorising and the unfortunate isolation of psychoanalysis from other scientific disciplines. But you reach the wrong conclusion about my discipline. Although you rightly state that "obituaries" of psychoanalysis have rarely been more prominent, it is also true that scientific evidence for psychoanalytic ideas has never been stronger. The huge advance in our understanding of the mind in recent years has inadvertently confirmed Freud's core hypotheses.
The central proposition of psychoanalysis is that the complexity and paradoxical character of human behaviour may be better understood if we assume that unconscious mental processes and unconscious motivation are at work in determining our actions. Freud asserted that non-consciously held beliefs and desires are involved in mental disorder, and therefore "interpretive" approaches which explain these-the talking cure-may be helpful in overcoming psychological distress.
To take an example: Rob, a five-year-old I treated, caused great distress to his parents by insisting on putting several scarves around his mother's neck because he was terrified that she would catch a cold and die. The obsessional ritual increased in severity over the months before the parents brought their child to see me, and during the consultation the mother wore at least a dozen scarves, shawls and wraps. I talked to Rob and tried to explain how little boys could sometimes feel very frightened of being angry with their mothers, particularly if they were frightened that if their mothers noticed them being cross, they might pack up and leave. Rob told me that he was indeed frightened that his mum might leave one day. When I talked to the parents, I was told that the marriage was on the rocks. The mother was having an affair with a work colleague and there were frequent arguments-which, they assured me, Rob had never heard. I said that I understood their difficult situation, but that perhaps it was better to be honest with Rob, as "trying to protect him" was generating more anxiety than it alleviated. Unusually, perhaps, they took my advice, spoke honestly about their marital difficulties to their child, reassured Rob that even if they decided to separate they would live close together, and within a few weeks the child's problems disappeared.
A single case can do no more than illustrate a point. However, modern neuroscience has revealed that most of the computational work of the brain is unconscious. So, almost by definition, much emotion and motivation must often be unconscious too. We know that emotion entails two sets of neural structures: one via the thalamus to the amygdala conveying simple perceptual information; the other involves the activation of cortical centres and deeper information processing. Patients with cortical lesions, who lose their capacity for conscious discrimination, may apparently retain the capacity to discriminate using emotional intuitions. Numerous studies have demonstrated that consciously denied but unconsciously held attitudes, such as racial prejudice, can powerfully influence behaviour. Studies also show that children as young as ten evolve the assumption that unconscious factors may motivate behaviour. So why do adults have so much trouble with the notion?
Rob unconsciously, but mistakenly, believed that his anger with his mother was the cause of her threat to leave, which he overheard and understood. He did not know why he felt compelled to put scarves around her neck. Yet when it was explained to him that maybe he only wanted to protect her from his crossness, and that her wish to leave did not mean a separation for ever, his anxieties became conscious and realistic, and no longer disrupted his relationship. His treatment worked. Clinical trials with dozens of Robs (and his adult equivalents) receiving psychoanalytic therapy have confirmed its effectiveness.
Similarly, with depression it seems useful to explore unconscious thoughts and feelings, as well as issues of which the sufferer is aware. In the largest scientific test of psychological and biological treatments for individuals with depression, psychological therapies were found to be as effective as medication (although the two in combination may be ideal). There is no doubt that biological mechanisms go awry in depression. All functions of the mind, however, reflect functions of the brain. It is also a mistake to assume that the notion of genetic transmission leaves no space for environmental causation. The ability of a given gene to control the production of specific proteins in a cell is subject to environmental factors. The big question is how biological processes modulate mental events, and how biological structure comes to be shaped by social experience. That experiences of social adversity such as parental divorce play a role in adult psychopathology cannot be doubted. In one recent study in New Zealand it was demonstrated that children who experienced the highest levels of social adversity are 100 times more likely to suffer from multiple psychological problems in adolescence than those who did not encounter such experiences.
Critics of Freud confuse his general statements on the role of unconscious belief and desire with particular ideas, such as castration anxiety or aggression turned against the self, which may be specific to a particular culture or individual. There are universals, however, which reach out to us from 100 years ago, such as the importance of early relationships, the ubiquity of unconscious conflict, fear of one's own destructiveness, sexual anxieties, fears of inadequacy, problems of identity and self-esteem.
Freud pointed out that we are motivated by beliefs and desires which are sometimes outside our capacity to introspect. We therefore need the help of another person to understand ourselves. By contrast, reducing mental experience to genes or organic anomalies trivialises what is most important about being a person-the social meaning of experience, conscious or unconscious.
Yours,
Peter Fonagy
Dear Peter
4th October 1999
You seem to be unreasonably reasonable. It is hard to recognise the standard picture of psychoanalysis in your reply. I have no difficulty accepting that unconscious thoughts play an important role or in recognising Freud's seminal contribution. But your example of the young boy Rob does not support the case for psychoanalysis; rather, it seems to be an example of short-term cognitive therapy based on conscious emotional events. It seems a long way from the years of sessions, five times a week, required by analysts, or from the complex, untestable, theory of psychoanalysis with its mystic triad-ego, id and superego. Have they at last been relegated to some other world? And Oedipus-where has he gone?
It is one thing to accept unconscious thoughts, and another to claim that these determine most mental illness. In depression the evidence for unconscious thoughts playing a key role is poor. Quite to the contrary, Aaron Beck has shown how it is conscious negative thinking which maintains the depressive state, and it is these conscious thoughts that the cognitive therapist tries to deal with.
The genetic basis of mental illness is best understood in terms of the malfunctioning of gene mutations resulting in the absence of key proteins or the production of faulty ones. The faulty genes can result in abnormal development of the brain or the absence of some receptors for chemical signals. On their own they may not result in mental illness but they can predispose the individual to respond more easily to environmental influences. To repeat: for depression and manic depression, genetic influence accounts for more than half of the vulnerability. Is there a single analyst who recognises this?
The presence of specific changes in brain activity associated with mental illness-the amygdala is overactive and there are reports of loss of supporting cells in the forebrain in depression-reinforces the importance of biological factors. But probably the strongest evidence comes from the effectiveness of drugs in treating mental illnesses. Antidepressants do not help all patients but there are a significant number who are helped and whose brain activity returns to normal. For mild depression, St John's Wort has been shown to be very effective. It is hard to see how psychoanalytic theory can account for the effect of these drugs. What happens to all those unconscious thoughts when a depressed patient is cured by an antidepressant which simply increases the level of serotonin in the brain? And how would you account for the remarkable effect of lithium in treating manic depression?
Yours,
Lewis
Dear Lewis
5th October 1999
Could it be that you failed to recognise the "standard" picture of psychoanalysis because the picture you have is outdated and distorted? What you missed from my answers are various concepts which are no longer central to psychoanalysis. And just as you have no difficulty with the concept of unconscious motivation, I have no problem in recognising that bringing about changes in the conscious construction of experience can be highly therapeutic. Few people know that Freud as a clinician was no purist. For example, when Bruno Walter, the conductor, went to see him in desperation because of hysterical paralysis of his arms (clearly part of an anxiety disorder), he had resigned himself to a prolonged course of self-exploration. Instead, Freud recommended an extended holiday. When that did not work, he suggested an approach that we would today classify as cognitive therapy. He advised Walter to go back to conducting, to use only one arm if necessary, and to observe that the kinds of disasters he anticipated would not, in reality, come to pass.
Your point about the roots of conscious negative thinking is of immense interest; this is an area where cognitive behaviourists, such as Mick Power in Britain and Donald Meichenbaum in the US, and psychoanalytic thinkers, have begun exploring fertile common ground. What can budge such negative ideas in therapy, or elsewhere, is of great practical importance, but may have nothing to do with their origin.
What helps individuals with mental disorders? We have only a partial answer. In a big British trial, brief psychoanalytic psychotherapy was found to be as helpful as cognitive therapy for depression. Well-focused psychotherapeutic approaches of many kinds tend to be quite successful with milder problems. But we know that brief therapies are ineffective in the long term for severe disorders. In our retrospective study of 764 children treated psychotherapeutically or in full psychoanalysis at the Anna Freud Centre, we found that intensive (four or five times weekly) treatment was only necessary for children with quite low levels of functioning. In adults, a recent Swedish study reported that intensive psychoanalytic treatment was far more effective than once-weekly treatments, but the difference emerged in the two to three years after therapy terminated. This, and data from many other studies, are available from the International Psychoanalytical Association (www.ipa.org.uk).
There is no doubt that drugs work, although not as well as people like to believe. The difference between the effectiveness of antidepressants and placebos which mimic some of their side effects may be as little as 20 per cent. I am not denying that drugs are effective, but I would suggest that the strength of their effect depends as much on the quality of the relationship established with the prescribing physician as on the impact they have on serotonin levels in the brain. Analysts do take biology seriously-a number are at the forefront of neuroscience research, and there are two new analytic journals devoted to the relationship between neuroscience and psychoanalysis. But psychoanalysts understand better than most how genetic predisposition influences experience. I know of no claim that depression is a purely genetic problem. The scientific frontier is understanding how the developing brain shapes the experience of the early environment, which in turn influences the individual's subsequent experiences in lasting ways.
The increase in the number of people with depression over past decades cannot be put down to genes alone. The risk with your position is that by focusing exclusively on biological determinants, we may miss opportunities for prevention. For example, if child abuse were found to have a big genetic component, its effects would still work via the destruction of trust in the abused child rather than a genetically caused abnormality in the brain.
Yours,
Peter
Dear Peter
6th October 1999
I am now confused. Have all those standard concepts in psychoanalysis gone? What are the grounds for abandoning them? What has replaced them? Your examples make it difficult to distinguish between psychoanalysis and therapies such as cognitive therapy, which, I agree, are very successful. The claim that long-term psychoanalysis has particular benefits could apply to long-term treatment by the other psychotherapies. And, looking at some of the evidence for the claimed success of psychoanalysis, I have yet to find a trial that fits the standard clinical criteria-having two groups which are compared. Furthermore, much of the improvement which is said to occur in psychoanalysis may be as a result of a placebo effect connected to the heavy personal and financial commitment which the patient has to make.
I am intrigued by these two new journals on the relationship between neuroscience and analysis. What have they reported? You claim that analysts understand better than most how genetic predisposition influences experience. I find that hard to believe, particularly since you resist the importance of the genetic influence on vulnerability to depression. Of course the individual's life experiences are important, but these may reflect events in adult life as well as in childhood; you overemphasise without evidence the importance of childhood experiences other than those which are acute, such as abuse.
Low serotonin levels are not necessarily the cause of depression, but they are clearly an indicator, and are the most promising site of action for antidepressant drugs. It is only by understanding the biology of depression that better drugs will become available. For severe depression and schizophrenia, drugs are clearly the best means of treatment. Indeed, a severely depressed patient cannot usually respond to any form of psychotherapy. When the genes responsible for mental illness are known, better drugs will become possible. That is where hope for the future lies.
Yours,
Lewis
Dear Lewis
7th October 1999
Psychoanalysis is not a unique form of the talking cure. You isolate it in order to ridicule it. Yet, broadly speaking, psychoanalysis works for the reasons that other psycho-therapies work-they provide conscious understanding of how the mind works, how relationships, past and present, influence current states of mind.
Your attack on psychoanalysis for not using certain kinds of clinical trial to prove its efficacy is out of date. Increasingly in Britain, as in the US and Germany, the gold standard of randomised controlled trials has been abandoned in favour of large-scale follow-along and follow-up effectiveness studies. Moreover, psychoanalysis is, I believe, helpful as a method of training for a range of psychotherapies.
Modern psychoanalysis does seek to build bridges to other disciplines. The recent issue of Neuro-Psychoanalysis, which has many important figures of both disciplines on its editorial board, discusses the psychoanalytic theory of "affect" from the point of view of a distinguished economist. Another issue discusses dreams: modern imaging studies have demonstrated that brain centres involved in emotional experience are active during dreaming, consistent with Freud's hypothesis.
It is clear that there is a genetic contribution to most psychiatric disorders. But the decoding of the human genome will require a better understanding of how individuals born with specific vulnerabilities, such as a predisposition to depression, can be protected from the experiences which increase the chances of the gene being expressed. My research group has recently gathered some preliminary data which suggests that an allele (a variant) of one of the dopamine receptor genes appears to be implicated in a sensitivity to abuse (particularly trauma before the age of 11). I could go on. But I fear that no amount of evidence I offer will meet the standards you require. Do you know that perhaps less than 10 per cent of current medical procedures meet your criteria for evidence-based practice?
The talking cure works for some people. I have no doubt that psychoanalysis over-sold itself in the 1950s and 1960s. I do believe, however, that long-term intensive therapy, guided by coherent psychoanalytic ideas, is uniquely effective for patients with severe and enduring disorders. I hope that pharmaco-therapy (pills) will also become more effective as we learn more about the brain. Such progress will increase our need for an empirically based science of human cognition in which psychoanalytic ideas will continue to have a significant impact.
Yours,
Peter
