Psychoanalysis

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cbrons

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There is to be a lecture at my medical school (US, M.D.) coming up soon by a "psychoanalytic psychiatrist" who is apparently an alumnus. The topic is going to be on psychoanalysis and modern applications to clinical psychiatry.

Now I was hoping to collect some opinions about psychoanalysis here - is it actually scientifically valid? I went through an undergrad program in psychology and was told it was not.

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Define scientifically valid in this context.

Is it useful? Has the theoretical systems validated to actual illnesses (a broad question as psychoanalysis has many many schools of thought within it)? Has it been proven to be effective ("evidence based")?

All different questions. Contrary to lay understanding, there is not one form of psychoanalysis. There's many schools within it (even more than one type of Freudian). There's ego psychology, self psychology, "the middle school," attachment based, Bionian (very hot right now), Lacanian. Each have some theoretical differences and different approaches in treatment. They have similarities in the frequency of visits (4+ days a week in US, 3+ in France).

Most psychotherapies aim to be evidence based that they're effective for a specific condition. That says nothing about whether their theories are valid. It only says that when someone is enrolled in that type of therapy for that problem, they get better.

Overall, most of psychoanalysis is understudied, but there is some research out there suggesting it's effective for certain problems (like personality disorders).

Whether it's cost effective, or if other psychotherapies work better (head to head trials) has NOT been studied, to my knowledge. These kind of things are more often found in psycinfo rather than pubmed.
 
The whole idea of having "accurate" models and theories that are held to no account of usefulness is suspicious to me. That's a ground rich for the cultivation of self-contained nonsense. A bridge builder could never make such claims. A martial arts instructor can no longer talk about the mystical powers of a Monkey fist technique--mma has helped that along. And so on.

Also 4 days a week....how could you not be selecting for wealthy, self-absorbed @ssholes with that mode of therapy.

I seriously wonder to myself if I can drop enough suspicion of it to even entertain a proper introductory study. For the same reason I don't visit road side revival tents just on the off chance I get myself ready for the Rapture.
 
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Can you define "valid" in this context? I've heard it used before in reference to psychoanalytic theories and I don't follow. To me, valid means supported by a broad and rich literature of studies performed over the course of many years. So to me CBT would be both effective and valid for the treatment of many mood and anxiety disorders, and others. I guess to me nothing can be valid without hard evidence. It's a meaningless word if you can't support it beyond hand waving and conjecture.

Quick edit: I also hear the understudied line a lot. Just because something hasn't been looked at fully does not mean we get to assume it's valid. We haven't studied whether the sound of mating toads in the autumn twilight in the backwoods of South Carolina is helpful for treatment-resistant depression. I may strongly suspect that it may be the one true therapy for treatment-resistant depression, and I may really believe it is valid and effective. But until there are studies supporting its use, I don't think I can walk around and tell people it's "valid."
 
Two issues here:

Valid is also, and primarily (for clinical purposes), "does it actually do what it purports to do?" There is a rich literature on psychoanalysis, sure. Is it well designed? Certainly not. Is there a strong correlation beween the "corrective emotional experience" (the supposed mechanism of change in classic analysis) and symptom reduction/ameliroation? Not that I know of.

Second, is it cost effective? Can I get the same result in 12 sessions of CBT as I could with a year, or two, or three of classic analysis? This second point impacts the patient, you, other patients, insurace companies, reimbursment rates, and the overall reputation of the field.
 
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Whether it's cost effective, or if other psychotherapies work better (head to head trials) has NOT been studied, to my knowledge. These kind of things are more often found in psycinfo rather than pubmed.

Thats like half of what the psychotherapy literature is....
 
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We give psychoanalysis a free pass sometimes, but look at it from the perspective of a surgical procedure. Say you are a surgeon who performs an evidence-based procedure that has been shown to be safe, effective, and cost-effective to the patient and society. You get good results that mirror the multiple RCTs that guide your practice. Your colleague performs a procedure with the same outcome in mind, but takes a completely different approach that has no support from well-designed, controlled studies, takes longer to perform, is usually more expensive, and has a longer recovery period before the patient feels better. But he feels strongly that it's the right approach and that he is improving the patient's long-term outcome. Is that enough?
 
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Additionally. What activity couldn't be done 4 times a week with serious developmental intention and discipline that couldn't help with disruptive patterns of behavior in a person's life. A yoga or meditation practice? Jiu-jitsu? What could be better for ego excess than getting your butt kicked by people more skilled than you? And cheaper with a baseline placebo effect of actual value?

It seems to me like a technique that has more potential to elevate the pathos of the practitioner to the level of the patient than anything else.
 
Thats like half of what the psychotherapy literature is....
Ugh. I'm not in the business of defending psychoanalysis, people. I quit my training in it for a reason. I'm just trying to sharpen the question of the OP, and point out that most ppl base their investigation of it on what they've heard from their mentor, and dismiss it out of hand.

While therapy research may examine CBT vs. other, I have never seen a head-to-head trial of say CBT vs. psychoanalysis for X condition. Not Psychodynamic therapy, but Psychoanalysis. Erg if you know of such studies, I'd love to see them. Please post!
 
Can you define "valid" in this context? I've heard it used before in reference to psychoanalytic theories and I don't follow. To me, valid means supported by a broad and rich literature of studies performed over the course of many years. So to me CBT would be both effective and valid for the treatment of many mood and anxiety disorders, and others. I guess to me nothing can be valid without hard evidence. It's a meaningless word if you can't support it beyond hand waving and conjecture.

Quick edit: I also hear the understudied line a lot. Just because something hasn't been looked at fully does not mean we get to assume it's valid. We haven't studied whether the sound of mating toads in the autumn twilight in the backwoods of South Carolina is helpful for treatment-resistant depression. I may strongly suspect that it may be the one true therapy for treatment-resistant depression, and I may really believe it is valid and effective. But until there are studies supporting its use, I don't think I can walk around and tell people it's "valid."
I never said it was valid.

Distinguish the difference between evidence proving something doesn't work, and lack of evidence proving something works (not being studied).
The former shows it isn't effective. The latter just means we don't have enough data to form an opinion.

A useful example for validity (and reliability) is to look at the DSM. There's plenty of articles on that. The DSM is not valid. It's reliable, in that the goal was to improve inter-rater reliability between clinicians. But we all know that the diagnostic categories don't map out well to what we see in the real world. Which is the [one of] the big complaint(s) about it.

IMO, psychoanalysis can give you insight into yourself, different than in other forms of therapy, for those that're introspective. If not, they stay stuck for a long time. Often I believe it creates a holding environment, and the real change occurs when something else shifts in their life (and analysts unknowingly are waiting for that to happen then attribute it to the analysis). I think it's terribly inefficient and impractical, but is unique in some benefits compared to other therapies (but those benefits are largely unimportant to most people).

A good book to read would be "How Psychotherapy Works" by Weiss, who HAS done a good body of research on psychodynamic therapy at UCSF. That may be one of the most useful therapy books I ever read.
 
no it's voodoo. as nitemagi points out the whole field of psychiatry (based on diagnoses) is not scientifically valid so if that is a concern you should not do psychiatry.

the problem with psychoanalysis is that although there is some evidence for dynamic therapies in various psychiatric conditions including personality disorders (though it probably works better if you don't have a psychiatric disorder at all), the theoretical basis is completely unfalsifiable and unverifiable. some dynamic theories do have correlates with more positivistic theories from ethology, developmental psychopathology, cognitive psychology, developmental neuroscience and so on, but psychoanalytic theories are wide-ranging and anti-positivistic focusing instead on the uniqueness of human experience.

The most commonly regarded mechanism of change by analysis is the "mutatative interpretation", an interpretation within the transference that is so emotionally powerful that it leads to an "a-ha" moment in the patient. More recently the idea of non-interpretative mechanisms is being explored and the most accepted mechanism is something called "implicit relational knowing", those moments of meeting between therapist and patient in the therapeutic relationship. Obviously most of the power of psychotherapies is attributed to "common factors" but we cannot justify the practice of psychoanalytic therapies based on those factors which are common to all therapies.

The validity question is an important one even if we regard these therapies as having utility. For example, most allopathic people will accept that homoeopathy is not scientifically valid because the theoretical basis is ludicrously anti-science, such that its use constitutes a fraud. But some homoeopathic treatments appear to be beneficial for some ailments in some patients. Thus they have some utility. But many would argue that to use a treatment that constitutes a deception undermines the doctor-patient relationship, and makes a mockery of clinical practice. The same could be said for using psychoanalytic treatments.

Like I said, the problem is psychiatry in general is based on a shaky epistemological ground and the basic structure (diagnosis based) is also not valid. Except for the dementias, none of the DSM diagnoses are valid and even the reliability of most DSM diagnoses is woeful!

One thing I will say is that the basic premises of psychoanalytic theory are true and most people would agree with them. The problem is these basic premises (such as being less aware of our motivations for behavior than we like to think, our past experiences shaping our response to future experiences, the unique value of subjectivity and our inner psychic world, our use of defensive maneuvers to avoid confrontations with painful aspects of reality, and our tendency for our current relationships to be influenced by past relationships) are not really psychoanalytic insights and were popularized rather than discovered by psychoanalysts.

Hans Eysenck (one of the most ardent critics of psychoanalysis) sums it up: "what is true about psychoanalysis is not new, and what is new about psychoanalysis is not true".
 
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The DSM does not equate to the field of psychiatry. That's all I have time to say right now.
 
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I will advice for you to be in the couch first. Also, from 1895, till now, Psychoanalysis has been one of the mayor, and most proficient studying/investigating groups/sectors/persons around the world.

And last, but not least, it is a myth that someone, has to be 4d/w to have some positive outcome in analysis. It can be one hour per day a week, or whatever the Patient should follow through his/her "angst".

Here's some more info (Spanish/needs translate):

http://www.psicologosencostarica.com/psicologo-clinico-costa-rica/psicoanalistas-costa-rica/
 
I seriously wonder to myself if I can drop enough suspicion of it to even entertain a proper introductory study. For the same reason I don't visit road side revival tents just on the off chance I get myself ready for the Rapture.

Psychoanalysis has had a large influence on the development of psychiatry; I do encourage you to learn the basics of psychoanalytic theory (while maintaining a healthy skepticism). I also believe that every educated American needs to understand basic Christianity for similar reasons- but there is no need to get this knowledge from a revival tent.
 
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As psychiatrists, we need to demand research testing the effectiveness of psychoanalysis for the various anxiety/depressive/personality disorders that it is purported to be effective for. As for as the usefulness of psychoanalysis for developing insight, happiness, leading a better life, etc- I think that is more of the domain of psychology.
 
That's a good analogy. What little I know of psychoanalytic theory has been helpful in approaching patients, if only to broaden my thinking and to help me approach the problem from a different way. I agree that using psychoanalysis to improve already functional people is not the domain of psychiatry. Its effectiveness should be tested as a modality for improving outcomes and function in specific disorders and should be compared head-to-head with other proven modalities such as CBT and DBT.
 
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Psychoanalysis has had a large influence on the development of psychiatry; I do encourage you to learn the basics of psychoanalytic theory (while maintaining a healthy skepticism). I also believe that every educated American needs to understand basic Christianity for similar reasons- but there is no need to get this knowledge from a revival tent.

I will. It's in our academics. And I need to be conversant in the field. With regards to theology--they're essentially all the same. I've studied them enough that the patterns are no longer novel.

My point was that regardless of the cool Spock like style of psychoanalysis if it holds itself to no higher standard than a revival it does not warrant consideration of itself beyond the utility of communication with other humans--namely psychiatrists.
 
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I find it helpful in formulation. CBT is great for symptom relief, but if you just toss it at a symptom, in a complex case, you can start to feel like a Dutch kid in a dike.
 
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A lot of the premises and theories may not be well supported by evidence, but I look at it as the best thing we have so far. You can have equivalents in many fields of science (even the hardest of them all), say string theory in physics. Science consists of two parts: 1) making sense of the evidence and observations 2) go out and test them. I think in psychoanalysis we're still at 1. The evidence is not zero either; it's mostly individual case reports from therapists, but obviously this is not the quality of evidence you want. I don't think it's appropriate to just turn your nose on the whole field; it has its utility.

I agree that using psychoanalysis to improve already functional people is not the domain of psychiatry

Why is that? The level of expertise needed are similar and being good in one automatically helps in the other.
 
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The underlying premises and theories may not be well supported by evidence, but I look at it as the best thing we have so far.

Really?! You find this convoluted explanation of human behavior more parsimonious and probable than say, social cognitive theory and the general explanatory model underlying CBTs?!
 
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Really?! You find this convoluted explanation of human behavior more parsimonious and probable than say, social cognitive theory and the general explanatory model underlying CBTs?!

But I don't think they are trying to explain the same things. CBT doesn't pretend to explain the formation of human psyche.

Also, much of the tenets of psychoanalysis are taken for self-evident truths now and are supported by plenty of scientific evidence. The importance of the unconscious, irrational drives of human behavior, the influence of childhood, defense mechanisms...etc. As splik alluded, people long had an intuitive understanding of those things and maybe psychoanalysis didn't actually "discover" them but the fact that it systematized them into a whole with a more rigorous framework gave them more credibility as valid scientific hypotheses about human behavior. Certainly people have long thought that humans are those rational human beings driven primarily by their reason with little to no influence of the unconscious - and that's probably a still popular belief, despite the evidence.
 
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But I don't think they are trying to explain the same things. CBT doesn't pretend to explain the formation of human psyche.

Also, much of the tenets of psychoanalysis are taken for self-evident truths now and are supported by plenty of scientific evidence. The importance of the unconscious, irrational drives of human behavior, the influence of childhood, defense mechanisms...etc. As splik alluded, people long had an intuitive understanding of those things and maybe psychoanalysis didn't actually "discover" them but the fact that it systematized them into a whole with a more rigorous framework gave them more credibility as valid scientific hypotheses about human behavior. Certainly people have long thought that humans are those rational human beings driven primarily by their reason with little to no influence of the unconscious - and that's probably a still popular belief, despite the evidence.

If to psychoanalyze meant to study and understand our current evidence about how the human mind works I don't think anyone would object to it. Isn't that just called psychology. What we in the skeptical or bull****-averse community have a problem with is the use of the verb in a medical treatment setting with convoluted metaphorical exegesis as a basis for its use. That's actually called being a witch doctor--as Splik and countless others allude to.
 
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But I don't think they are trying to explain the same things. CBT doesn't pretend to explain the formation of human psyche.

To explain the "human psyche" (whatever you mean by that) is to study all its various influences (which I agree are many) via natural and experimental methods... not to buy into one theory because it sounds cool and is just complex enough to seem true. But the good news is, we aleady do this and have a entire dicipline devoted to it. Its called "psychology" (and all of its subfields). :)

And by the way, cognitive and social cognitive theory explain normal as well pathological behavior/decisions. So, if thats what you meant by "human psyche," then I think you are wrong.
 
IAlso, from 1895, till now, Psychoanalysis has been one of the mayor, and most proficient studying/investigating groups/sectors/persons around the world./
Siggie,

From 1921 up until about 20 years ago, the Rorschach was quite a popular "psychological test" amongst our community. In 1915 it was a parlor game.

The validity of a procedure is not proven by it "popularity" in society.
 
On a related, but somewhat tangential subject.

Am I the only one who often wonders if the primary reason for the academic success of the alphabet therapies compared to other interventions is more of an artifact of how we conduct research today and "measure" mental illness than it is of the actual superiority of the the approach?

Seems more than a little convenient that our modern research methods which inherently seek to isolate and sterilize variables would select for an approach that can be delivered from a generic workbook.

(Don't get me wrong though, I have no intention to get trained in analysis and plan to be trained in and employ CBT,etc.)
 
I find it helpful in formulation. CBT is great for symptom relief, but if you just toss it at a symptom, in a complex case, you can start to feel like a Dutch kid in a dike.

CBT is only superficial if you learn it superficially (which is how it is taught at many residency programs because of the emphasis on psychodynamic psychotherapy). You can certainly develop case conceptualizations (the same thing as formulation) using a cognitive-behavioral model and use this to guide treatment, and in fact in more complex cases or longer term work should be.
 
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Manualized therapies are hardly "generic." And the steps/inteventions/techniques outlined in them are there because they have been shown to work in large groups of patients.
 
I will. It's in our academics. And I need to be conversant in the field. With regards to theology--they're essentially all the same. I've studied them enough that the patterns are no longer novel.

My point was that regardless of the cool Spock like style of psychoanalysis if it holds itself to no higher standard than a revival it does not warrant consideration of itself beyond the utility of communication with other humans--namely psychiatrists.

Maybe you won't actually have 'psychoanalysis' in your didactics - in my experience, we talk a lot about psychodynamics when doing case formulation, but then in a relatively straightforward way (such as defenses mechanisms, transference/countertransference, personality diagnosis, etc). I haven't really learnt anything about how the whole setup with the couch works, and how you make sense of dreams, etc. We carry long term patients for psychodynamic psychotherapy, but we also do this for the other therapeutic modalities so I don't feel that it is over-emphasized. I think psychoanalysts can teach you a lot about formulation, although their perspective will need to be balanced with others. I really get a lot from their input, despite having no interest in pursuing substantial further study or practice in psychoanalysis.

Your skepticism is appropriate but perhaps it won't turn out to be as much of an issue?
 
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Manualized therapies are hardly "generic." And the steps/inteventions/techniques outlined in them are there because they have been shown to work in large groups of patients.

Thats my question, I sometimes wonder if these studies are truly answering "What interventions/techniques work the best" and instead are answering "What interventions/techniques are easiest to standardize and therefore easiest to show work the best"

But like I said there is nothing wrong about that. For example fast food/retail chains have taught us its that having absolute standardization at the cost of a possibly inferior product is by far the best way to deliver a product most efficiently to as many people as possible. And given the financial realities of today and the fact most psychotherapy is delivered by mid-level providers, standardization and efficiency is exactly what we need in mental health.
 
I used to be extremely critical/skeptical of both psychoanalysis and psychodynamic therapies and was so throughout my general residency. However, the longer I stay in psychiatry and develop, the more I've come to realize the utility and "truth" of some theoretical approaches of psychodynamic therapy (note I'm saying psychodynamics and not psychoanalysis). The thing that changed my perspective was going through a child/adolescent fellowship. The more I learned about child development and saw families, the more I came to realize that theories such as object relations are being played out in our patient's lives in ways that most are not even aware of. In fact, when I went back to seeing adults in my forensic fellowship as well as moonlighting gigs, it helps me understand a lot of the maladaptive patterns many patients continue to play out in their relationships. I still think, however, that a lot of Freud's original theories and psychoanalysis are a bit wacky....
 
y'all aren't serious right? in an age where neurologists are turning to psychoanalysis to better under the mind as their cognitive approach had taken them nowhere in the past two decades, you psych residents and resident gonna-be's are disparaging psychoanalysis itself! that's a bloody disgrace
 
y'all aren't serious right? in an age where neurologists are turning to psychoanalysis to better under the mind as their cognitive approach had taken them nowhere in the past two decades, you psych residents and resident gonna-be's are disparaging psychoanalysis itself! that's a bloody disgrace

So now we have someone who thinks scientifically validity is proven by the concensus/curiosity of another field?! What program trained you that way?

We previously had a poster contend that it was a valid approach because it had been popular for many years as well. What the French, Toast?!

Being unable to be a skeptical scientist in the age of evidence based practice is a "disgrace", IMHO.
 
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But we shouldn't critize and scrutinize it, least we be "disgraceful?" Is that what your saying?
 
I'm still waiting to be disparaged. I wouldn't trust anyone who wasn't disgraceful in at least some respects.

Regardless...I have a new found and welcomed obliviousness to online people unless, with enough time, I can sense that they're real. Thanks for that V.
 
@egg999: no

Then I am confused on your stance. Your post insinuated that critical discussion of the weaknesses of psychoanalysis (characterized as "disparging" by you) by psychiatric residents/practitioners was "a bloody disgrace"...did it not?
 
Then I am confused on your stance. Your post insinuated that critical discussion of the weaknesses of psychoanalysis (characterized as "disparging" by you) by psychiatric residents/practitioners was "a bloody disgrace"...did it not?

The guy is a troll, look at the post counts. don't feed him.
 
disparage = to describe something as unimportant
ref. merriam-webster

i don't care what you think about its validity. but seeing some people in the field of psychiatry and psychology "dismiss" psychoanalysis because it hasn't been thoroughly dissected in head-to-head outcome-based empirical studies is difficult.. at the very least, you're losing a valuable tool in your arsenal

but then again, maybe I'm wrong..maybe all of us who think it's a valuable tool like kendall and oliver sacks are wrong as well
 
disparage = to describe something as unimportant
ref. merriam-webster

i don't care what you think about its validity. but seeing some people in the field of psychiatry and psychology "dismiss" psychoanalysis because it hasn't been thoroughly dissected in head-to-head outcome-based empirical studies is difficult.. at the very least, you're losing a tool in your arsenal which "could" perhaps have been valuable


"A valuable tool in your arsenal?!" Can you provide the name of an insurance carrier that would reimburse me for such an intervention? If not, doesn't matter how good you think it is. People dont work for free.

Sorry. Last troll feed, promise. :)
 
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facepalm.gif
 
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I'll refer the cases to you then, since apparently you dont mind not getting paid for services rendered.
 
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