Does psychoanalysis and/or psychodynamic therapy have any sort of clinical relevance these days?

[Psycho Bunny]

I'm asking because some of the core tenants of psychoanalysis/psychodynamic therapy I find absolutely fascinating. The unconscious mind, defense mechanisms, how humans can repress extreme childhood trauma, and so on. Yet as a Psych undergrad, everywhere I go it seems to be talked down on and attacked. I've heard it's an antiquated and pseudoscientific form of therapy with no evidence of efficacy with a comically overemphasized sexual POV.


Yet when I actually look at the requirements of psychoanalytic institutes as well as the training involved, it seems extremely rigorous, similar to a Psych doctoral program but even more restrictive. They only admit applicants who already have a degree in a mental health field (Licensed Psychologist, Psychiatrist, Psych NP, etc), they must undergo their OWN analysis prior to training (and from what I've seen, at some institutes during training too), it's a mixture of written and clinical work that lasts for a minimum of 4 years before one can become a certified analyst. Could something so restrictive or esoteric really be useless? And these aren't hole in the walls either, to my knowledge. These are institutions in big major coastal cities that are training licensed Psychologists and Psychiatrists.


I've looked on the psychoanalysis subreddit but most there are not analysts or even had any analytic training, they are usually reading psychoanalytic literature at their own leisure/curiosity, whereas I'm much more focused on the clinical relevance/efficacy. Youtube videos ive seen tend to focus on just the history of Freud himself which is neither here nor there, and seeing patients online who have actually undergone this therapy is extremely rare (yet the few experiences I've read about have been positive!)


I know psychotherapy will be incorporated into my career no matter what, I really love the idea of being a psychoanalyst, but first and foremost I want to be an effective clinician that helps people. Is this modality really that much at odds with the data? Is CBT/DBT/other modalities really that superior, particularly for more extreme cases?


Bonus question if anyone knows how it's feasible from a financial perspective to see patients multiple times per week, is it possible to build up a sustaining clientele for the average analyst to make a good living?

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[cara susanna]

Brief psychodynamic therapy is still used and I think has efficacy for certain things. Old school psychoanalysis, like the kind Freud et al did where patients were seen for years and years and years? Not really relevant anymore.

 

[PsyDr]

A. Psychoanalysis isn't just one thing. It is a collection of theories, that generally revolve around a few technique.

B. I consider psychoanalysis to be a collection of techniques that are useful to learn about yourself (e.g., that one topic is associated with another in your mind, and why). Even if psychoanalytic techniques work for mood disorders, it is too labor intensive and slow to really be useful.

C. To run a psychoanalytic practice, you need a group of patients who:
1) Have $500+/week to burn (insurance doesn't pay for analysis)
2) Have 5+ hrs to take off from work per week (3x sessions + commute time)
3) Have verbal abilities that are above average (need to see how vague verbal concepts are related)
4) Are unhappy enough to want therapy, want to take responsibility for their own actions, but are not so unhappy that they are end up in a more aggressive treatment modality.

D. The best advice I received about psychoanalysis: "Have you ever met a happy psychoanalyst?"

 

[R. Matey]

Some folks still do psychoanalytic work for personality disorders, but to your second question, it's likely all private pay and you'd likely need to attend an institute to get training to do so (for the institute in my area, it's a four-year training program post-degree). The evidence I've seen for long-term psychoanalytic work is pretty mixed. Some studies support it; others don't. And brief models have stronger efficacy data than longer term care models.

But, I can empathize. I'm a bit of a history of ideas nerd so I've read some psychoanalytic writings and it is indeed very interesting stuff. I'm not sure I'd consider it clinically useful though, at least, not in the manner that it was originally conceived.

 

[Psycho Bunny]

A. Psychoanalysis isn't just one thing. It is a collection of theories, that generally revolve around a few technique.

B. I consider psychoanalysis to be a collection of techniques that are useful to learn about yourself (e.g., that one topic is associated with another in your mind, and why). Even if psychoanalytic techniques work for mood disorders, it is too labor intensive and slow to really be useful.

C. To run a psychoanalytic practice, you need a group of patients who:
1) Have $500+/week to burn (insurance doesn't pay for analysis)
2) Have 5+ hrs to take off from work per week (3x sessions + commute time)
3) Have verbal abilities that are above average (need to see how vague verbal concepts are related)
4) Are unhappy enough to want therapy, want to take responsibility for their own actions, but are not so unhappy that they are end up in a more aggressive treatment modality.

D. The best advice I received about psychoanalysis: "Have you ever met a happy psychoanalyst?"

Do you feel the same way about shorter term psychodynamic therapy?

Also these psychoanalytic programs exist throughout the country. Surely these analysts being produced find a way to make it work?

It's interesting that you say other treatment modalities would be more aggressive. I would've thought CBT would be good for the more mild cases, like someone who may be going through a breakup or the death of a loved one but otherwise lives a relatively well adjusted life and is just going through a rough patch, whereas in my mind psychoanalysis is for the extreme childhood trauma cases like if someone was beaten or sexually abused or something like that. But I guess that was an incorrect assumption on my end.

 

[PsyDr]

Do you feel the same way about shorter term psychodynamic therapy?

Also these psychoanalytic programs exist throughout the country. Surely these analysts being produced find a way to make it work?

It's interesting that you say other treatment modalities would be more aggressive. I would've thought CBT would be good for the more mild cases, like someone who may be going through a breakup or the death of a loved one but otherwise lives a relatively well adjusted life and is just going through a rough patch, whereas in my mind psychoanalysis is for the extreme childhood trauma cases like if someone was beaten or sexually abused or something like that. But I guess that was an incorrect assumption on my end.

Sell it to me, as a patient.

IDGAF about $500:month. I have a job that pays well, 5hrs/week isn’t an issue. If you go traditional, my therapist being gone for august isn’t an issue. In that context, I’m unhappy but I still do well in work and stuff. My options are lexapro for a $20 copay or working hard for 4hrswk.

Sell psychoanalysis to me.

If you can crack that, you’ll dominate the market.

 

[EnPsychlopedia]

The issue, as I see it, has a lot less to do with the efficacy of the therapy and more to do with the ethical problems of providing clients with an interpretive system based on unfalsifiable tenants. Let's grant that psychodynamic therapy works as well as competing therapies (which I think is far from clear, though there is at least moderate evidence to support its efficacy as a treatment for unipolar depression)...does evidence of efficacy in any way act as a proxy for validation of the underlying theory? What empirical evidence is there, at all, that the "unconscious mind" (by which I mean the psychodynamic unconscious, not the implicit processes observed in cognitive science) exists and works in the way it is proposed to work? What empirical evidence is there for "defense mechanisms" as defined/interpreted through a psychodynamic lens? I'd argue that the existence of the psychodynamic unconscious is not only implausible, but outright contradicted by known facts about cognitive neuroscience. I'm more open to discussion about "defense mechanisms," but I'll be upfront and say that I hold a high bar for being convinced that behaviors often interpreted as such can’t be better explained via another, more empirical lens. Your third example of a topic germane to psychodynamics--repression--is not simply not evidence-based, but rather outright falsified quite thoroughly.

So, I would argue that, even if evidence of therapeutic efficacy is granted, the lack of empirical support (and in some cases outright falsification) for major parts of the umbrella that constitute "psychodynamics" makes it ethically questionable to implement. Perhaps others do not have the same hangups as I have in this regard, but I personally find it very questionable to implement and advocate for systems of meaning and experiential interpretation for which there is no empirical validation upon which to base such a practice. Practicing psychology means practicing psychology, and psychology is definitionally a science...so, respectfully to anyone who disagrees, I find it to be unethical to use non- or unscientific modes of thought while operating in the role of "psychologist."

As for research psychology (as opposed to psychotherapy), psychodynamics are well past rigor mortis. Aside from a few very niche labs which investigate attachment and personality using a psychodynamic lens, I am unaware of any basic psychology research which works off any assumptions which would be associated with psychodynamics (e.g., the existence of an "unconscious" [again, in the psychodynamic sense], ego defense mechanisms, etc.) as a means of model-building. It just does not provide an appropriate framework from which to do basic psychological research and empirical modeling.

 

[EnPsychlopedia]

It's interesting that you say other treatment modalities would be more aggressive. I would've thought CBT would be good for the more mild cases, like someone who may be going through a breakup or the death of a loved one but otherwise lives a relatively well adjusted life and is just going through a rough patch, whereas in my mind psychoanalysis is for the extreme childhood trauma cases like if someone was beaten or sexually abused or something like that. But I guess that was an incorrect assumption on my end.

All the best trauma therapies we have are exposure-based and/or cognitive-based. None of them are psychodynamic by any reasonable stretch of the definition of that term.

 

[EnPsychlopedia]

Yet when I actually look at the requirements of psychoanalytic institutes as well as the training involved, it seems extremely rigorous, similar to a Psych doctoral program but even more restrictive. They only admit applicants who already have a degree in a mental health field...

This is not universally true. NY allows people to become a licensed psychoanalyst with a Ph.D. in any field as long as they enter an institute for psychoanalysis and undergoing personal psychoanalysis (and do whatever qualifying exams and practica are required). I know because I have personally met such people. But either way, these institutes are largely insular, traditionalist, and extremely elitist places where much of the curriculum is of questionable scientific or clinical value. It's not at all clear to me that attending such a place would in any way reliably/predictably increase a doctoral psychologist's clinical effectiveness.

 

[WisNeuro]

Do you feel the same way about shorter term psychodynamic therapy?

Also these psychoanalytic programs exist throughout the country. Surely these analysts being produced find a way to make it work?

It's interesting that you say other treatment modalities would be more aggressive. I would've thought CBT would be good for the more mild cases, like someone who may be going through a breakup or the death of a loved one but otherwise lives a relatively well adjusted life and is just going through a rough patch, whereas in my mind psychoanalysis is for the extreme childhood trauma cases like if someone was beaten or sexually abused or something like that. But I guess that was an incorrect assumption on my end.

I would suggest talking to people who do/have done PE/CPT work. Most of us have seen a good deal of CSA and similar, treated it with PE/CPT, and have seen treatment gains maintained over time. The whole "CBT doesn't work for trauma" thing is a laughable myth by people who have no idea what CBT actually is.

 

[cara susanna]

It's also worth mentioning that Freud and the psychoanalytical community set actual childhood sexual abuse treatment back decades because they refused to acknowledge it existed (you weren't sexually abused by your father! You just wanted to have sex with him so you imagined it!)

CBT is the most effective approach for PTSD - two of the top three recommended treatments for it are CBT based, and the third has CBT components (at least, I would argue that about EMDR). I've seen the idea of CBT being shallow back when I used to hang out in psychology meme groups that were full of people who loved psychoanalysis and psychodynamic theory, but did not seem at all connected to or knowledgeable of current practice in the actual field. They also seemed to be mostly male...