Current Medical Diagnosis & Treatment in Psychiatry

Psychoanalytic Clinical Findings

Psychoanalytic technique, especially the sustained empathic investigation of the patient’s lived experience, aims to foster ego-syntonic regression, which permits the patient to observe psychological processes that would otherwise go unnoticed. In this sense the psychoanalytic situation, like the telescope in astronomy, permits the observer to record new facts about human behavior. These newly discovered facts constitute the core clinical findings of psychoanalysis. Chief among these findings are (1) the decentering of consciousness, (2) the massive complexity of desire and self-experience, and (3) the ubiquity of transference events. The decentering of consciousness refers to the psychoanalytic aim of enlarging the scope of patients’ conscious awareness of their motivations and thoughts. Freud called this his Copernican revolution, because it revealed that human beings are not always masters of their own psyche, just as the earth is not at the center of the solar system. Second, central to psychoanalytic theory and practice is the attempt to follow the contours of a patient’s multiple desires (sexual, aggressive, narcissistic, and altruistic). In many important ways, contemporary research has refined classical theory about childhood fantasies about love.

The third finding—that transference events occur in most (some would say all) relationships—pertains to the core features of psychoanalytic technique. Minimally, it means that we construe contemporary relationships according to patterns we have established in previous relationships and that we do so unconsciously. Psychoanalytic research into infancy and childhood, severe character pathology, and even schizophrenia has added to this finding sustained insights into what constitutes “normal” character.

Given the intensity of most forms of psychotherapy, the patient quickly comes to experience the therapist as a transference figure (or figures—some benign, others malignant) and so distorts the new relationship. This distortion may be mild or severe (from momentary conscious slips to complete delusional beliefs). In all instances, such distortion impinges on the therapist and elicits in the therapist a large range of psychic discomfort (from fear of the unknown, to anxiety about seeing the “insides” of another, to homosexual panic and other forms of dread). Hence all therapists will experience “neurotic-like” moments with all patients. With adequate training and adequate safeguards, these moments (almost always countertransference issues) do not dominate the dyadic relationship. For experienced therapists working well within the therapeutic relationship, these neurotic moments act as signal events. For example, a disturbing sexual thought or sudden aggressive wish toward a patient elicits self-analysis, not action.

To lay the foundation for adequate protection of the therapist and the patient from overt errors and distortions generated by the therapist’s neurosis, therapists should undertake their own psychotherapy. The experience of patienthood for psychotherapists is vital for a number of reasons. First, it helps stabilize one’s own psychological states and so deepens one’s relationship to the therapeutic profession. In this sense, psychotherapy is a transformational experience. Second, being a patient permits one to understand directly the kinds of feelings and profound anxieties that one’s patients undergo. Third, one’s own therapy helps develop the “analytic instrument,” the use of one’s own inner experience, to grasp empathically the feeling state of another person.

To say that therapists who wish to understand dynamic psychotherapy must become patients first would seem to place dynamic theory within the realm of religiosity and not science. Although one may argue that the analytic setting (or similar psychotherapeutic setting) fosters an especially well-developed form of unconscious processes, one does not want to say that the former creates the latter. For this reason, Freud began his general lectures on psychoanalysis with a lengthy description of ordinary behaviors, parapraxes, to which everyone can give ready credence; then dreams, which most people recognize; and finally neurotic symptoms, which only a few people are willing to ascribe to themselves. In each step of his argument, Freud tried to show how what began as a narrow theory of special psychological states, the neuroses, became a general theory of behavior. Freud’s dominant concern was to found a general theory of all human behavior. He classified neurotic and even psychotic behaviors as subsets of nonneurotic behaviors. Basic psychoanalytic theorems will appear clearer and more persuasive when generated within an analytic situation, but they are observable in principle outside that relationship as well. (By analogy, the stars shine during the daytime, but only a total eclipse will reveal this truth.)

Understanding Past Behaviors

One could say humanists attempt to understand, social scientists attempt to explain, and natural scientists attempt to predict the behavior of complex systems. To the degree that psychodynamic theorems are advanced post facto they easily fall into the first kind of proposition: they are attempts to bring order and pattern to behavior that has occurred in the past. Post facto reasoning is not illegitimate, but it sometimes falls into post hoc ergo propter hoc claims [after that; therefore, because of that] that are not valid. That the rain fell after a rain dance was performed does not prove the efficacy of rain dances.

Motives As Explanations

We can distinguish hermeneutic reconstruction from explanation. (Of course, one usually finds both hermeneutics and explanations tied up together in a single account.) Hermeneutics is the attempt to find a coherent pattern post facto. Explanations for this pattern—why one finds a particular behavior and not another—typically require one to assign motives to the actors on the scene. To explain is to offer an analysis of motives: for example, John Hinckley, Jr., shot President Reagan because he wanted to be famous. At this level, finding the motives for behavior, one finds an important dynamic issue: One may have multiple reasons for doing something. Freud’s initial discoveries about the meaning of parapraxes fall within this category. One can often discover a dual set of motives: one public and overt, the other private and hidden (or repressed). Freud’s discovery of such dual structures (an unconscious wish and its conscious counterpart) has entered popular culture, never to be removed. An unfortunate aspect of this success has been an understandable urge to confuse psychoanalytic technique with precisely the discovery of such hidden motives. With adequate cleverness one can impute to others some base motive that often is a portion of that person’s thinking. Although early psychoanalytic authors offered shorthand definitions of analysis as the uncovering of repressed motives, it would be a mistake to assume that such uncovering constitutes the core of technique. Rather, the main task of technique is the fostering of the transference, which is the reenactment of the patient’s idiosyncratic and all too human conceptions and fantasies of why he or she suffers and how that suffering will be overcome.

A Confluence of Empirical Findings

Thanks to the advent of videotaping, entire analyses, some of them more than a thousand hours long, are available for study. To evaluate this massive amount of material, researchers need organizing hypotheses and principles. Rigorous outcome studies in psychotherapy have been conducted for more than 30 years. These studies enable research analysts to refine clinical generalizations into much more precise concepts subject to empirical examination. Initial evidence suggests that the patient-analyst mix is much more important than earlier thought; that the term “unconscious” is too narrow and should be refined with new evidence about “nonconscious” events, especially data derived from the clinical neurosciences; and that early fears that rigorous and objective empirical work would contaminate the analytic process are unfounded. This last discovery is particularly important, for it gives to analytic clinicians additional criteria with which to distinguish useful from less useful theories, and it gives to psychodynamic psychiatry a renewed grounding in empirical studies that preserve the nuances of the analytic encounter.

Complications & Negative Outcomes

Psychoanalysis as therapy is the examination of a person’s interior life in the context of an intense transference-countertransference matrix. Although Freud claimed therapeutic value for such investigation, he realized quickly that it was not appropriate for every patient nor for every condition. Yet even when psychoanalysis is not pertinent as therapy, the analytic investigation of severe psychopathology has given to western thought an important vocabulary for understanding human interior experience. Given Freud’s insight that psychoanalysis is not for everyone, issues of complications and negative outcome are extremely important. For example, if we learn that specific forms of medication, or medication and focal psychotherapy, or focal-behavioral therapy, or long-term psychodynamic-cognitive therapy are best for specific conditions, then ethically one must prescribe those interventions for those maladies, at least until they fail. The problem is that there are no consistent findings that demarcate clearly the virtues of one form of therapy from another for specific diagnostic categories. Hence, although behaviorists have been particularly industrious in arguing for the superiority of strictly behavioral techniques, meta-analytic reviews of their findings and effects of different psychotherapies yield little consistent evidence for those claims.

Complications of psychoanalytic treatment include missed diagnosis, heroic efforts with unsuitable patients, and according to new research, errors in treatment modality. In a larger sense of complications, some of the most important advances in psychoanalysis derive from abject failures. For example, Freud abandoned the seduction theory of hysteria when he found that not all of his patients’ stories were true. Although a noisy debate has raged over the degree to which Freud thereby excluded discovering actual abuse, it is typically psychoanalytic that he revised his theory in light of his findings. So, too, when his famous patient “Dora” quit her treatment abruptly, Freud had to assess both his theory and his technique: From that failure came his dramatic discovery of transference repetition and, later, countertransference resistances. In a similar way, Kohut’s formulations on the theory of narcissism derived from his failures with narcissistic patients, some of whom he saw for a second analysis.

Efficacy & Outcome Studies

Given the complexity and richness of psychoanalytic theory, the many hundreds of hours over which psychoanalytic treatment occurs, the many patient variables (eg, diagnostic category, motivation, age, education), and the many therapist variables (eg, empathic ability, training, innate skills, negative countertransference), assessing the efficacy of psychoanalysis has long been a challenging and important task. The most naturalistic form of study is the sustained case history. This remains the dominant tradition: Novel theories find their first expression in case books.

The more rigorous scientific tests of efficacy are intergroup comparison and longitudinal studies, which can evaluate predicted outcomes. The latter has been a particular forte of psychoanalytic research. The most systematic and complete study, begun in 1945 at the Menninger Clinic, lasted for more than 30 years and devoted hundreds of pages of tests, reviews, interviews, physical examinations, and recordings to each of the 42 patients. Bachrach et al evaluated a large effort conducted at Columbia University, where researchers studied 700 patients receiving psychoanalysis and 885 patients receiving psychotherapy between 1945 and 1971. Still other efforts to systematically evaluate predictive values of analytic therapy took place at the Boston Psychoanalytic Institute, the New York Psychoanalytic Institute, and other institutions.

Treatment improvements lie in the 60% to 90% range when they are calculated using standard measures. Although this improvement is impressive, important issues remain. Bachrach et al noted five: (1) patients suitable for psychoanalysis derive considerable benefit from it, (2) assessment should be done after a suitable termination phase because analyzability (the capacity to carry out introspection, free association, and so on) does not predict reliably positive outcome, (3) initial consultations do not predict analyzability and treatment outcomes, (4) suitability for analysis remains ambiguous and requires much more study, and (5) the studies vary in the soundness of their design. The cost-effectiveness of psychoanaly-sis and intensive psychoanalytic psychotherapy compared to other modalities is a serious issue for third-party payers. Researchers have found that intensive outpatient psychotherapy is highly valuable and decreases subsequent hospitalization for all illnesses, not just psychiatric ones. Others have reported that overall treatment costs decreased when psychoanalysis was used. Similar findings have appeared in large-scale studies that compare cost-benefit structure of psychotherapy and psychoanalysis compared to hospital treatment or no treatment. Thanks to many decades of analysis of children, researchers have conducted retrospective studies comparing treatment outcomes in children seen in intensive analytic sessions with those seen in less intense therapy and found that analytic treatment was more effective.

Within psychiatry, the biopsychosocial model of disease describes three major sources of constraint and, roughly speaking, causation. The traditional tripartite model of disease production is attractive in its eclecticism, but it does not help clinicians and researchers organize treatment along priority lines. A rule of thumb that seems to be emerging now is to assess patients sequentially: beginning with biological, then psychological, and then psychosocial perspectives. For example, many psychiatrist-psychoanalysts treat psychiatric disorders with medication, especially for panic and depression, and analysis or intensive psychotherapy. Given this approach, issues of diagnosis and assessment loom even larger, especially for the psychiatrist-psychoanalyst.

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