Current Medical Diagnosis & Treatment in Psychiatry


Until the late 1980s, becoming a psychoanalyst in the United States meant doing postdoctoral work, primarily post-MD, in an approved institute of the American Psychoanalytic Association. Of the 3000 or so certified analysts, the majority were psychiatrists or other physicians who had completed 4–5 years of additional course work, undertaken a personal analysis, and passed written and oral assessments of their capacities as clinicians and therapists. In addition to the 29 institutes of the American Psychoanalytic Association, nonmedical institutes exist, some of them run by psychologists and other non-psychiatrists. With the death of Freud and the passing of the generation of psychiatrist-psychoanalysts who knew him personally, and with the rise of biological and laboratory methods in psychiatric research, American psychoanalysis confronts new demands.

The relevance of a patient’s internal world (defined as “unconscious ideas,” personal schemata, self-representations, ego states, core conflicts, and so on) to the patient’s overt behavior, including psychopathology, is indisputable. How best to conceive of that world, how to modify it toward health, and how to assess the various and competing theories that make up contemporary psychoanalysis and its points of view is an exciting and major research task for the future. One task will be comparative psychoanalysis. Also, thanks to new research instruments generated primarily by psychologists investigating psychotherapy effectiveness, we can look forward to sophisticated studies that can distinguish the most effective treatments for given diagnostic categories and for use with particular types of patient-therapist interactions.

In the political battles of the 1950s and 1960s, between strict behaviorists who denied the relevance or even existence of an inner world and Freudians who championed such a belief, little exchange took place. Both sides tended to caricaturize the other and rained polemics down upon the other camp. The simultaneous rise of cognitive-behavioral-developmental research efforts and a focus on cognitive aspects of the inner world in contemporary psychoanalysis suggests a confluence of two heretofore independent research traditions.

Researchers long ago answered the extreme skepticism of the placebo argument: We can show systematically that treatment enhances patients’ positive outcomes along most lines of interest. Indeed, some forms of intensive psychotherapy, such as cognitive-behavioral therapy, are more effective than antidepressant medication alone for treating some forms of depression. In its best moments, psychoanalysis has added immeasurably to our grasp of human self-understanding. That it was oversold and idealized for many years should not require now the reverse error of denigration and abandonment.

We know that some people are expert and highly effective clinicians whose talents and efforts cannot be duplicated with medication alone. We know that some patients, recalcitrant to all other forms of treatment, blossom with some therapists, overcoming lifelong disability and impairment. The question remaining before us is how, precisely, all these wonderful things occur.


Foundations of Psychoanalytic Theory

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, revised. American Psychiatric Association, 1987.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric Association, 1994.
Barron JW, Eagle MN, Wolitzky DL: Interface of Psychoanalysis and Psychology. American Psychological Association, 1992.
Benjamin L: Interpersonal Diagnosis and Treatment of Personality Disorders. Guilford, 1993.
Blatt SJ, Ford RQ: Therapeutic Change: An Object Relations Perspective. Plenum, 1994.
Demos V: A perspective from infant research on affect and self-esteem. In: Ablon S, Mack J (editors): The Development and Sustenance of Self-esteem. International Universities Press, 1984a.
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Emde R: Epilogue: A beginning—research approaches and expanding horizons for psychoanalysis. J Am Psychoanal Assoc 1993;41(Suppl):411.
Fenichel O: The Psychoanalytic Theory of the Neuroses. WW Norton & Co, 1945.
Freud S: Mourning and melancholia. In Strachey J (editor): The Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 14. Hogarth/Institute for Psycho-Analysis, 1917.
Freud S: The ego and the id. In Strachey J (editor): The Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 19. Hogarth/Institute for Psycho-Analysis, 1923.
Gay P: Freud: A Life for Our Time. WW Norton & Co, 1988.
Kernberg O: Aggression in Personality Disorders and Perversions. Yale University Press, 1992.
Kohut H: How Does Analysis Cure? Goldberg A, Stepansky P (editors). University of Chicago Press, 1984.
Kohut H: The Kohut Seminars on Self Psychology and Psychotherapy with Adolescents and Young Adults. Elson M (editor). WW Norton & Co, 1987.
Langs R: Making interpretations and securing the frame: sources of danger for psychotherapists. Int J Psychoanal Psychother 1985;10:3.
Masterson JF, Tolpin M, Sifneos PE: Comparing Psychoanalytic Psychotherapies: Developmental, Self, and Object Relations; Self Psychology; Short-term Dynamic. Brunner/Mazel, 1991.
McWilliams N: Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process. Guilford, 1994.
Miller NE et al (editors): Psychodynamic Treatment Research: A Handbook for Clinical Practice. Basic Books, 1993.
Stolorow R, Atwood G: Contexts of Being: The Intersubjective Foundations of Psychological Life. Analytic Press, 1992.
Wallerstein J: Forty-two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy. Guilford, 1986.

Psychoanalytic Theory Applied
Erikson EH: Gandhi’s Truth. WW Norton & Co, 1969.
Gabbard G: Psychodynamic Psychiatry in Clinical Practice. American Psychiatric Press, 1990.
Gedo JE: The Biology of Clinical Encounters: Psychoanalysis as a Science of Mind. Analytic Press, 1991.
Kernberg O et al: Psychodynamic Psychotherapy of Borderline Patients. Basic Books, 1989.
Winnicott DW: Playing and Reality. Tavistock, 1971.
Wollheim R. The Mind and Its Depths. Harvard University Press, 1993.

Psychoanalytic Clinical Findings
[An open-door review of outcome studies in psychoanalysis. Report prepared by the Research Committee of the International Psychoanalytic Association. Editor and Chair: Peter Fonagy.]
Luborsky L: The benefits to the clinician of psychotherapy research: A clinician-researcher’s view. In: Talley PF, Strupp HH, Butler SF (editors): Psychotherapy Research and Practice: Bridging the Gap. Basic Books, 1994.
Luborsky L et al: Psychological health-sickness (PHS) as a predictor of outcomes in dynamic and other psychotherapies. J Consult Clin Psychol 1993;61:542.  [PMID: 8370850]
Weiss J: How Psychotherapy Works. Guilford Press, 1993.

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