what do you guys think of Psychoanalysis

[ronaldo23]

my dad , an old-school psychiatrist, thinks it is all a crock. how do mainstream psychiatrists feel about this, and is my dad alone in this feeling among the MD/DO community? he says that the main reason is that he notices that alot of the time psychologists and other coworkers who have been trained in this seem like they have no idea what there talking about.

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[manwhoisthursdy]

my dad , an old-school psychiatrist, thinks it is all a crock. how do mainstream psychiatrists feel about this, and is my dad alone in this feeling among the MD/DO community? he says that the main reason is that he notices that alot of the time psychologists and other coworkers who have been trained in this seem like they have no idea what there talking about.

No offense to your father, but does that seem like sound reasoning to you? I'm sure I could find surgeons who would say, "psychiatry is all a crock" based on their "observation" that psychiatrists in general have no idea what they're talking about.

But I highly doubt your dad is all alone in his opinion!

My opinion, since you asked: While I don't know if I will every train to become a bona fide psychoanalyst (though I'm certainly considering it), I am very enthusiastic about training at a program where I will get a good exposure to psychodynamic psychiatry, so that I can draw on that as one of the several theoretical frameworks available to me. I think it's fascinating, and has a very venerable tradition, which should be continuously challenged and tempered by evidence-based medicine. But EBM does not, in my understanding, say "psychoanalysis is junk." In fact, there are hardly any appropriately designed studies to explore that fact. But EBM can, along with greater genetic and biochemical understanding, provide psychoanalysis and psychodynamic psychiatry sort of a stone against which they can sharpen themselves and develop.

After all, psychoanalysis is not about some ritual dating back unchanged to Freud ... it's an approach that grows and develops as our knowledge increases.

 

[toby jones]

just because he doesn't have any idea what they are talking about doesn't entail that they don't have any idea what they are talking about.

 

[whopper]

Psychoanalysis & psychodynamics IMHO (& I do have a psychology degree-you have more oppurtunities to study it in psychology) definitely have their characteristics that make it difficult to study.

However, it still is a useful tool & therapeutic method if applied properly. IMHO and there's data to back it up, it seems to be better for treating neurosis or personality disorders.

I do though agree that especially for a psychiatrist working in managed care, it makes it even more difficult. Another problem is residency training seems to focus on psychotherapy less & less these days.

Is it BS? Well there's things about it if not done properly are BS, but same goes for anything.

 

[crys20]

who gets the classical psychoanalysis these days? isn't it lik 4-5x/wk for multiple years?

 

[Therapist4Chnge]

my dad , an old-school psychiatrist, thinks it is all a crock. how do mainstream psychiatrists feel about this, and is my dad alone in this feeling among the MD/DO community? he says that the main reason is that he notices that alot of the time psychologists and other coworkers who have been trained in this seem like they have no idea what there talking about.

I think there are two different issues:

1. Psychoanalysis as an orientation
2. The application of psychoanalysis by practitioners

I think #1 has partially been addressed in the research. There has been some good research done to support the use of psychoanalysis and related psychodynamic orientations with certain Dx's. It is not a one size fits all, so that always has to be considered. I think there are other Dx's that haven't yet been properly studied in regard to psychodynamic treatment, so just because it hasn't yet been found to be effective doesn't mean it won't, but that has to be considered within reason. If someone tried to use it to treat a phobia, I'd probably just shake my head.

As for #2, there are many people out there who are not properly trained and do not fully understand what is involved, and their 'psychoanalysis' is a bastardized version of actual theory. Unlike DBT, CBT, etc....the various flavors of psychodynamic work require much more work, understanding, and practice to be effective. I think it is a viable path, though I'd suggest going to an institute to receive formal training, and then continuing with a mentor afterwards.

-t

ps. My preferred orientation involves a couple different flavors of psychodynamic work (depending on the best fit for the pt), though not traditional analysis....so I'm a bit biased on this subject.

 

[toby jones]

Though of course there is a lot of controversy over how you differentiate 'psychoanalysis' from 'psychodynamic therapy'. Some features of the latter is that it is (typically) face to face (rather than couch work) more directive (rather than free association) briefer (so as to be comparable to CBT for studies / cost) less frequent (for the same reason) etc etc.

I would think that the majority of people would start out with psychoanalysis by being seen by someone at one of the psychoanalytic training institutes. Since the person is in training they offer cheaper rates / sliding scales more typically. Some are very good with respect to seeing students at fairly minimimal cost. Then... As you (and your therapist) graduates... The rate would be renegotiated, I guess...

But yeah, traditional analyses are still being done (and there is still a market for it). Perhaps not as big as it once was (pharma probably collects them now for better or worse) but still there, yup.

 

[neurologist]

Hmmmm . . . . what do YOU think about psychoanalysis?

 

[gioia]

Hmmmm . . . . what do YOU think about psychoanalysis?

Heh!

 

[Psychintern2006]

I remember at the Marriott, NYC, American Conference of Psychiatric Disorders, Steven Roose, Columbia (if I am not wrong) - was joking, 'I should have brought my three analyst with me'. People have different opinion, but Analysis used to be the defining methodology for the Practice of Psychiatry.

Now with the managed care not reimbursing the Therapy sessions with MDs, probably due to lower cost therapy Provided with Social workers and Psychologists. More stress on numbers of patients seen- it definitely impacts the practice. Atleast thats my understanding.

Some senior Old school Psychiatrists are just marvellous with their analytical skills, it definitely helps improve the interview skills and the art of listening.

 

[TheWowEffect]

Analysis used to be the defining methodology for the Practice of Psychiatry.

I guess it's time to move on.....

QUOTE]

Some senior Old school Psychiatrists are just marvellous with their analytical skills, it definitely helps improve the interview skills and the art of listening.

This might be the only reason I have any respect for psychoanalysis/psychodynamic.

It might also be a good adjunct treatment for a certain category of patients. It should not and will not be the first line treatment for most major DSM-IV diagnoses, contrary to what people in the psyhodynamic community insist.

 

[toby jones]

> It should not and will not be the first line treatment for most major DSM-IV diagnoses

I would expect that the first line of treatment should be the most effective first line of treatment. There is a lot of controversy over what precisely psychoanalysis is (compared with psychodynamic therapy or humanistic therapy etc) but under a fairly liberal view of psychoanalysis (which includes not just ego psychology but object relations and self psychology etc and that also allows for briefer forms etc) then surely it is an empirical matter what the first line treatment should be.

Anxiety (phobias) count as a major axis 1. So does depression. And yet therapy outcomes are comperable to drug interventions. It might be that as therapy improves over time... Therapy outperforms medication.

I guess I'm wondering whether you are theorising from the armchair as to which is most effective and arriving at what we should do under the assumption that we should do that which is most effective...

Or if you figure that medications always will be the first port of call because of the major pharmaceutical company investment on advertising etc and the fact that it takes all of about 15 minutes to prescribe a drug and that we should do what is cheapest / in the interests of the drug companies...

Or quite what you mean by your claim...

 

[TheWowEffect]

Anxiety (phobias) count as a major axis 1. So does depression. And yet therapy outcomes are comperable to drug interventions. It might be that as therapy improves over time... Therapy outperforms medication.

Are you suggesting that psychoanalysis is more effective than medication and CBT for these conditions? If you are, I would refer you to this.

Or if you figure that medications always will be the first port of call because of the major pharmaceutical company investment on advertising etc and the fact that it takes all of about 15 minutes to prescribe a drug and that we should do what is cheapest / in the interests of the drug companies..
...

I will not be drawn into a discussion that will degenerate into people sitting on a high horse and preaching. So, I will maintain silence on this.

 

[Therapist4Chnge]

*Ignore....I pretty much butchered what I meant to say*

 

[TheWowEffect]

(In agreement)

There is always a chance, but the research doesn't support it, and I think it'd be hard to find colleagues who would agree this is the best course of Tx. I believe in psychodynamic work, and I think it is the best thing for certain cases, but one size does not fit all.

-t

WHAT??? I did not say what you are implying. In fact, I believe the opposite. Look again at my post carefully which is a question and not a statement.

 

[Therapist4Chnge]

WHAT??? I did not say what you are implying. In fact, I believe the opposite. Look again at my post carefully which is a question and not a statement.

I butchered your quote, and what I wrote is not what I meant...I blame my complete lack of sleep over the last week.

This is what I meant to say.....

The majority of research does NOT support psychoanalysis over CBT+ Med, and I think it'd be hard to find other professionals that would choose psychoanalysis over CBT + Med. I believe in psychodynamic work, but one size does not fit all.

That's what I meant to say.



-t

 

[TheWowEffect]

I butchered your quote, and what I wrote is not what I meant...I blame my complete lack of sleep over the last week.

This is what I meant to say.....

The majority of research does NOT support psychoanalysis over CBT+ Med, and I think it'd be hard to find other professionals that would choose psychoanalysis over CBT + Med. I believe in psychodynamic work, but one size does not fit all.

That's what I meant to say.



-t

Thanks for the clarification.

 

[toby jones]

Does the research show that medication and / or CBT are more effective than psychoanalysis or... Is it the case that... There really isn't much research that has been done on psychoanalysis?

We might think that lack of evidence for x means that not x but they are, of course, two distinct things.

Like I also said... It depends quite significantly on precisely HOW you define psychoanalysis. Are we to include self psychology / object relations etc as forms of psychoanalysis or reserve the title 'psychoanalysis' for ego psychology? Are we going to consider the brief forms of psychodynamic therapy to be psychoanalytic?

I thought that studies showed that therapy tended to help and that different forms of therapy were fairly roughly similar to each other with respect to efficacy. Easy enough to find studies (when those studies have been done) to support whatever your favourite view is, of course, the problem is that the studies seem to contradict each other... Or fail to be replicated... Kind of like looking for the genetic basis of schizophrenia, really...

 

[Therapist4Chnge]

We might think that lack of evidence for x means that not x but they are, of course, two distinct things.

Like I also said... It depends quite significantly on precisely HOW you define psychoanalysis. Are we to include self psychology / object relations etc as forms of psychoanalysis or reserve the title 'psychoanalysis' for ego psychology? Are we going to consider the brief forms of psychodynamic therapy to be psychoanalytic?

This is my biggest gripe with some of the research (or lack there of), it is quite hard to quantify the work. It will be interesting to see if the work gets done in the future, unfortunately I think people will push more for manualized treatments and I don't really think that is a great way to go.

-t

 

[toby jones]

Yeah. Since the randomised double blind control trial is the best methodology we have currently for medication trials (which isn't to say that it isn't without significant problems) there is pressure for therapies to be tested in as similar a way as possible. That is hard to do, however. Hard to give someone 'placebo' therapy, and hard to conceal the kind of therapy that someone is having so that they don't know.

I agree that there is a push for manualized treatments. I also think that that is a shame.

In a way psychoanalysis opts out (the longer term varieties at any rate). One might think that there is an element of self-deception in that (they have a hunch they aren't particularly effective so they would rather have a lack of evidence that it isn't effective then evidence that it isn't effective). Alternatively, one might think that they are resisting manualization. Partly because... They really aren't convinced that manualization would help their clients. Hard to test that indeed...

 

[jocg27]

Bumping with a question...

I'm curious about the training for psychoanalysis...I'm a student, just started on my psych rotation, and just heard that complete training to become a psychoanalyst can be 8-10 yrs beyond the MD and psych residency...Is this correct??? Or did I misunderstand somehow? Trying to understand how this can be so...what's in all those years?!

Clearly I understand that people are complicated and as a result psychoanalysis is complicated...But that's longer training than I'm aware of for anything except, I dunno, becoming a Dalai Lama or something. Anything I'm not understanding about this?

 

[OldPsychDoc]

Bumping with a question...

I'm curious about the training for psychoanalysis...I'm a student, just started on my psych rotation, and just heard that complete training to become a psychoanalyst can be 8-10 yrs beyond the MD and psych residency...Is this correct??? Or did I misunderstand somehow? Trying to understand how this can be so...what's in all those years?!

Clearly I understand that people are complicated and as a result psychoanalysis is complicated...But that's longer training than I'm aware of for anything except, I dunno, becoming a Dalai Lama or something. Anything I'm not understanding about this?

Well, it IS kind of like doing brain surgery without using any hands...

 

[sunlioness]

Bumping with a question...

I'm curious about the training for psychoanalysis...I'm a student, just started on my psych rotation, and just heard that complete training to become a psychoanalyst can be 8-10 yrs beyond the MD and psych residency...Is this correct??? Or did I misunderstand somehow? Trying to understand how this can be so...what's in all those years?!

Clearly I understand that people are complicated and as a result psychoanalysis is complicated...But that's longer training than I'm aware of for anything except, I dunno, becoming a Dalai Lama or something. Anything I'm not understanding about this?

You can be a therapist without being an analyst. But while I don't know all the details in analytic training (never was interested in it myself), it DOES take a very long time and is very very expensive.

 

[solumanculver]

What is psychoanalysis anyway? I mean, in real biological terms. What is a theoretical orientation? Isn't the only justifiable theoretical orientation that behavior is caused by brain function?

How does having a theoretical orientation affect prescribing habits? It seems like this theoretical orientation stuff is something about philosophy, not science... Am I wrong about that?

If any therapy is shown to be effective, which of course I believe is the case, doesn't that mean that the action of the therapy is reducible to changes in brain function? So is thinking about mental illness in psychodynamic terms just an abstract way to think about brain function? Is it a way to conceptualize mental life without having to think about the brain itself?

 

[189213]

I'm curious about the training for psychoanalysis...I'm a student, just started on my psych rotation, and just heard that complete training to become a psychoanalyst can be 8-10 yrs beyond the MD and psych residency...Is this correct??? Or did I misunderstand somehow? Trying to understand how this can be so...what's in all those years?!

Psychoanalytic training is undertaken on a part-time basis, and basically consists of three parts. Analytic candidates take didactic classes, which are typically one day a week (often on Saturdays). Candidates also undergo a personal analysis conducted by a training analyst (i.e., the candidate is psychoanalyzed by a faculty member). Finally, the candidate begins to take on at least two analytic cases while being overseen by a supervising analyst at their institute.

Typically, people have a full-time job while undertaking this training. The didactic courses typically last four years. How long a personal analysis and supervised analyses take will vary, but the entire process can be completed in 4-5 years. But because it is part-time, the process can be stretched out depending on an the wishes of the candidate, so some people do take longer to complete their training as their circumstances might dictate.

What is psychoanalysis anyway? I mean, in real biological terms. What is a theoretical orientation? Isn't the only justifiable theoretical orientation that behavior is caused by brain function?

How does having a theoretical orientation affect prescribing habits? It seems like this theoretical orientation stuff is something about philosophy, not science... Am I wrong about that?

If any therapy is shown to be effective, which of course I believe is the case, doesn't that mean that the action of the therapy is reducible to changes in brain function? So is thinking about mental illness in psychodynamic terms just an abstract way to think about brain function? Is it a way to conceptualize mental life without having to think about the brain itself?

Whether you are a proponent or opponent of psychoanalysis, all psychiatrists should recognize that all the various modalities of modern psychotherapy are rooted in classical analysis -- either as an evolution of psychoanalysis, as a way to make it more practical, or a reaction against it. In my opinion, that makes it vital for any psychotherapist to at least have a clear understanding of the basic principles of psychoanalysis.

The questions that you're asking, solumanculver, can be asked of any psychotherapy. What is the relationship between my physical body and my abstract feelings/thoughts? People have been asking these questions for centuries. Philosophers, doctors, poets, theologians, and researchers have all attempted to define the link between mind and brain -- with no definitive answer yet formulated. Perhaps the answer will always elude us.

 

[whiskey]

What is psychoanalysis anyway? I mean, in real biological terms.

The biologic basis of psychoanalysis is still being worked out. Thus you're not going to get a satisfactory answer in this forum!

What is a theoretical orientation? Isn't the only justifiable theoretical orientation that behavior is caused by brain function?

Causation is a slippery concept. I'd be more comfortable saying that the materiality of the brain mediates behavior, namely that it occupies the space between the chaos of the social world and the things that we choose to do with our bodies.

How does having a theoretical orientation affect prescribing habits?

In every way possible, depending on the theoretical orientation.

It seems like this theoretical orientation stuff is something about philosophy, not science... Am I wrong about that?

I'd challenge you to differentiate between the two (while keeping in mind that what gets elevated to the status of "evidence" is hotly contested).

If any therapy is shown to be effective, which of course I believe is the case, doesn't that mean that the action of the therapy is reducible to changes in brain function?

Psychoanalysis definitely affects brain function, as do other worldly (and pharmacologic) experiences. Yet we haven't yet been able to identify and reproduce the precise biochemical changes incited by complex interpersonal experiences, which is why shouldn't yet lock up our brains in jars, or swear off psychodynamic psychotherapy.

So is thinking about mental illness in psychodynamic terms just an abstract way to think about brain function? Is it a way to conceptualize mental life without having to think about the brain itself?

And aren't brains just a way to think about mental life without having to think about the social world? I'd argue that the best model of the mind and the best therapeutic approach should accommodate both of them.

 

[nancysinatra]

So is thinking about mental illness in psychodynamic terms just an abstract way to think about brain function? Is it a way to conceptualize mental life without having to think about the brain itself?

Not to change the subject, but this reminded me of a question I have. Do all patients who receive psychotherapy (whether it's psychodynamic or something else) really qualify as having a "mental illness"? What about people who are in couple's therapy or family therapy? Or someone who seeks therapy to talk about an event that happened to them (say a war, or an assault)? I mean, there is a spectrum of severity of "illness" among psychotherapy patients, is there not? How would you go about conceptualizing brain function in that case, where someone may not be "ill" in some way that can be defined biologically, but still finds psychotherapy to be effective? And where do we draw the line between who's ill and who's not?

 

[pingouin]

Not to change the subject, but this reminded me of a question I have. Do all patients who receive psychotherapy (whether it's psychodynamic or something else) really qualify as having a "mental illness"? What about people who are in couple's therapy or family therapy? Or someone who seeks therapy to talk about an event that happened to them (say a war, or an assault)? I mean, there is a spectrum of severity of "illness" among psychotherapy patients, is there not? How would you go about conceptualizing brain function in that case, where someone may not be "ill" in some way that can be defined biologically, but still finds psychotherapy to be effective? And where do we draw the line between who's ill and who's not?

For billing purposes when I do therapy, yes- I have to put a diagnosis code on there if I'm billing to an insurance company. An adjustment disorder diagnosis can often fit the bill for addressing a short-term therapy which requires just a few sessions- ie, I just worked with someone who was anxious after a recent mugging, but had no other significant issues. As a general rule, V-codes are not reimbursable if they are the ONLY code listed. Insurance does not typically reimburse for "couples therapy", so it's either out-of-pocket or one member of the couple (usually the one who called to initiate treatment) is given a diagnosis code. It's usually fair to say that by seeking out couples therapy, there's some mild anxiety and/or depression about the relationship issues. Family therapy is expected for insurance reimbursement in the <18 crowd- the amount of involvement by the family will vary depending on the circumstances and the child's age. There's usually no problem getting that covered - at least initially- since there's lots of evidence to support family treatment.

 

[solumanculver]

Causation is a slippery concept. I'd be more comfortable saying that the materiality of the brain mediates behavior, namely that it occupies the space between the chaos of the social world and the things that we choose to do with our bodies.

But that doesn't have any meaning.

In every way possible, depending on the theoretical orientation.

This is also very close to meaningless. Can you think of a way that psychoanalysis would directly result in choosing one antidepressant over another?

I'd challenge you to differentiate between the two (while keeping in mind that what gets elevated to the status of "evidence" is hotly contested).

Philosophy is a priori knowledge and Science is a posteriori. It's the same thing that divides science from mathematics.

And aren't brains just a way to think about mental life without having to think about the social world? I'd argue that the best model of the mind and the best therapeutic approach should accommodate both of them.

No, brains are not a way to think about mental life, they are the explanation of mental life. If a therapy works to change behavior, then it's because it affects the brain.

 

[michaelrack]

Not to change the subject, but this reminded me of a question I have. Do all patients who receive psychotherapy (whether it's psychodynamic or something else) really qualify as having a "mental illness"? What about people who are in couple's therapy or family therapy? Or someone who seeks therapy to talk about an event that happened to them (say a war, or an assault)? I mean, there is a spectrum of severity of "illness" among psychotherapy patients, is there not? How would you go about conceptualizing brain function in that case, where someone may not be "ill" in some way that can be defined biologically, but still finds psychotherapy to be effective? And where do we draw the line between who's ill and who's not?

Some people without mental illness do undergo psychoanalysis because they want to reach their full life potential, are dissatisfied with life, etc. These people in general are paying cash in full for the psychoanalysis.

 

[Therapist4Chnge]

Some people without mental illness do undergo psychoanalysis because they want to reach their full life potential, are dissatisfied with life, etc. These people in general are paying cash in full for the psychoanalysis.

Agreed.

People often make a false assumption that those in therapy must have something wrong with them and/or a pathology-based reason....which isn't always the case. It is my belief that pretty much everyone can benefit from therapy, whether they have a pathology to manage or not. Many people in therapy do have diagnosable pathology, though there are others who use it as a place to learn about themselves and work through every day issues.

When I have the funds, I'm going to undertake a formal analysis because I believe it will offer worthwhile insight into my daily life. I think the stigma of therapy still keeps the 'well' away, even though there are benefits to be gained if people are willing to do the work.

 

[nancysinatra]

Philosophy is a priori knowledge and Science is a posteriori. It's the same thing that divides science from mathematics.

How would you categorize physics, then? Hypotheses in physics are based on mathematical discoveries (a priori knowledge, if you want to call it that), but they have to be proved--or rather, not disproved--through experimentation (there's your a posteriori) before they become accepted as theories. Even theories have to continue to stand up to experimentation over time.

I have a problem with a lot of things in "medical science" being called science. A lot of what gets called science in medicine is really just statistics. Statistics can't prove anything, they can just indicate probabilities. Hypotheses in medicine get accepted on the basis of statistical "evidence," but that's different than testing them through formal scientific method. Anyway, that's just a little gripe of mine--I felt like mentioning it...

 

[solumanculver]

Hi nancysinatra

How would you categorize physics, then?

Physics is a purely posteriori. You can tell this is true because we have no way of knowing that a physical theory is true unless we test it in the world.

What you're thinking about mathematics is partly true, in a sense. If we come up with a physical theory we definitely can't prove it true without experimentation, but we can prove it false without experimentation if we discover that it is mathematically incoherent.

In other words, any theory that is false a priori is definitely false. If you make a theory that makes sense a priori, but you don't know if it's actually true in the world, then we have to test the world to see if it holds.

Hypotheses in physics are based on mathematical discoveries (a priori knowledge, if you want to call it that)

Actually this isn't true. Physics is expressed in the language of mathematics, so every physical law has to make mathematical sense, but discovering new mathematics does not imply that new physics will follow.

Even theories have to continue to stand up to experimentation over time.

There's another indicator that physics is not a priori. A priori facts are proved, not observed. Once they are proved, they are proved for ever. A posteriori facts can never be proved, they can only withstand experiment.

I have a problem with a lot of things in "medical science" being called science. A lot of what gets called science in medicine is really just statistics.

Statistics are evidence about what happens in the world. Any scientific theory has to explain the evidence.

Statistics can't prove anything, they can just indicate probabilities. Hypotheses in medicine get accepted on the basis of statistical "evidence,"

You're equivocating between "evidence" and "proof" here. There is no proof in science, only evidence. Why do you think that facts about what happen in the world (statistics) aren't evidence for science? They're the only evidence that science has...

 

[189213]

First of all, the fact that we're having this interesting discussion on psychoanalysis and the nature of knowledge is just another example of why psychiatry is, to me, the most fascinating area of medicine.

Philosophy is a priori knowledge and Science is a posteriori.

I'm no epistemologist, but I do think that this discussion is grossly oversimplifying the nature of scientific discovery -- specifically in the area of medicine. Medical research utilizes both a priori and a posteriori reasoning to reach its discoveries.

Classically, we tend to think of a scientist as coming up with a hypothesis a priori and testing that hypothesis through experimentation to prove it a posteriori. For instance, based on our knowledge of the pathophysiology of schizophrenia, we might hypothesize a priori that a drug with a certain pharamcological action might prove effective in treating the disease. We then test it in a series of experiments and gain a posteriori knowledge.

But modern medical research often turns this paradigm on its head -- we are increasingly gathering vast amounts of data without a specific hypothesis and then utilizing it to formulate a hypothesis afterwards. For instance, we might utilize functional neuroimaging to study the hippocampi of a number of people, some with or without schizophrenia, and then based on the results formulate a hypothesis about how various regions of the hippocampus interact in schizophrenia.

But, of course, even this is an oversimplification. In truth -- and again, I'm no expert on epistemology -- a priori and a posteriori knowledge seem to interact back and forth in medical science, and future discoveries will depend on being able to utilize both modes of reasoning in a complimentary fashion.

No, brains are not a way to think about mental life, they are the explanation of mental life. If a therapy works to change behavior, then it's because it affects the brain.

The current state of cognitive neuroscience does not yet allow us to satisfactorily link mental phenomena with clearly delineated activity in the brain. I think your comment above is a bit glib. Obviously, the brain is the substrate for mental activity, but that doesn't mean that anything that doesn't have a brain-based explanation (yet) is specious.

For instance,the complex concept of the ego is central to many psychotherapies that have been demonstrated to have clinical benefits. Yet you cannot take an MRI film and point to the ego for me. We cannot ablate someone's ego -- it's not like Wernicke's area. Does that mean we should dismiss the ego as Freudian nonsense?

An overly mechanistic attitude towards the mind-brain relationship (e.g., "brains are the explanation of mental life") will lead us down an intellectually stunted road akin to 19th century phrenology. An overly abstract attitude towards the mind-brain relationship leads us to Dr. Phil. Freud was a neurologist by training and, utilizing the limited scientific knowledge of his time, continually sought to revise and amend his theories based on clinical data. We should perhaps remember that.

Sorry for the long post, everyone!

 

[solumanculver]

But, of course, even this is an oversimplification. In truth -- and again, I'm no expert on epistemology -- a priori and a posteriori knowledge seem to interact back and forth in medical science, and future discoveries will depend on being able to utilize both modes of reasoning in a complimentary fashion.

No, medical knowledge is purely a posteriori. There is no fact about medicine that can be known apart from experiment. A priori facts are generally facts about definitions, of which mathematics is the best example. There is nothing in medicine like mathematics... where axioms lead to theorems via logical proof.

The current state of cognitive neuroscience does not yet allow us to satisfactorily link mental phenomena with clearly delineated activity in the brain. I think your comment above is a bit glib. Obviously, the brain is the substrate for mental activity, but that doesn't mean that anything that doesn't have a brain-based explanation (yet) is specious.

No, I don't think that just because we don't have a brain-based explanation of psychotherapy it is necessarily specious... But I think for explanatory purposes psychotherapy will not be understood until we can relate it to biological phenomena.

For instance,the complex concept of the ego is central to many psychotherapies that have been demonstrated to have clinical benefits. Yet you cannot take an MRI film and point to the ego for me. We cannot ablate someone's ego -- it's not like Wernicke's area. Does that mean we should dismiss the ego as Freudian nonsense?

Well, physics worked just fine when we thought that there was an ether...

But until we can understand what "ego" means in biological terms, then I don't think that we're going to understand what ego-based therapies are actually doing that is beneficial...

An overly mechanistic attitude towards the mind-brain relationship (e.g., "brains are the explanation of mental life") will lead us down an intellectually stunted road akin to 19th century phrenology.

What other type of explanation is there? We don't have evidence that behavior comes from things other than brains... and even if we did, how would that knowledge benefit psychiatry? Should psychiatrists attempt to treat the soul?

 

[nancysinatra]

Physics is a purely posteriori. You can tell this is true because we have no way of knowing that a physical theory is true unless we test it in the world.

But take the Uncertainty Principle (which says you can't measure a particle's speed and position at the same time). It was arrived at through logic and math, not through observation that both these things weren't being measured accurately at the same time. Currently I think some quantum mechanics experiments are approaching "testing" it (as opposed to anticipating disproving it), but whether they can EVER get beyond "approaching" it I'm not sure is known. My point is that not every theory in physics lends itself to testing, and in those cases we are left with the math--math which is not considered insignificant just because we can't test it in the world. I understand your point that pure mathematics is unique, but I'm just saying that for practical purposes, a lot of respectable physics is permanently in the math phase, or it's simply untestable. That's different from biology, say. If someone proposed a biological hypotheses that was inherently untestable, they would sound like a lunatic.

I also agree that if something is mathematically incoherent, it's probably false. But our knowledge of math is not without limits. There are mathematical contradictions that physicists are still trying to work out. For example, something like the gravitational constant--it might not be constant at all, which will mess up all math related to gravity. The math that exists so far might seem to be incoherent, but future advances will hopefully work out this problem.

A priori facts are proved, not observed. Once they are proved, they are proved for ever. A posteriori facts can never be proved, they can only withstand experiment.

Good point. I agree.

You're equivocating between "evidence" and "proof" here. There is no proof in science, only evidence. Why do you think that facts about what happen in the world (statistics) aren't evidence for science? They're the only evidence that science has...

I don't think that statistics aren't evidence. But just because something is highly probably, doesn't mean that it is true. That's why the most brilliant scientific experiments are usually ones that definitively disprove one thing or another. And a lot of medical research--I'm talking mostly about clinical research here--is not the type of science where people are testing hypotheses in the sense that they are attempting to disprove them, and then failing, and the failures being what lends credibility to the theories. The studies we are always being told to read up on in medical school are just accumulations of data points supporting one drug or another! They are useful and convincing, but the hypotheses they support could still be proven incorrect, if the right experiment could be designed.

"Evidence-based medicine" is exactly what it says--medical practice based on the best, most current evidence. But we get so bombarded with this phrase in med school--it's like a mantra--that you'd think these medical researchers had gone and invented a new scientific method with results that are real, time-tested theory. They're not! I get tired of the trumped up use of the phrase, is all.

 

[Chimed]

Whether you are a proponent or opponent of psychoanalysis, all psychiatrists should recognize that all the various modalities of modern psychotherapy are rooted in classical analysis -- either as an evolution of psychoanalysis, as a way to make it more practical, or a reaction against it. In my opinion, that makes it vital for any psychotherapist to at least have a clear understanding of the basic principles of psychoanalysis.

Nicely said.

If anyone wants to read a great overview about the nuts and bolts of psychodyanimcs/psychoanalysis that avoids getting bogged down in details and is very well written, I highly suggest How Psychotherapy Really Works by Willard Gaylin. It's really an excellent read. It might be too basic for those more advanced in their training, though.

 

[solumanculver]

But take the Uncertainty Principle (which says you can't measure a particle's speed and position at the same time). It was arrived at through logic and math, not through observation that both these things weren't being measured accurately at the same time.

Hi nancy, actually the story of the uncertainty principle is a little more complex. The central idea behind quantum mechanics came from supposing that energy is not continuous but discrete. If you remember much about calculus, then you'll remember that discontinuous functions can't be integrated, they can only be summed over.

This modification in our idea about energy was made to match experimental observations. So it is really a posteriori knowledge. Once we came up with the idea of quantum mechanics, we were able to derive other laws mathematically and then test to see if they had physical truth to them. So the uncertainty principle is like this. It's the mathematical implication of an a posteriori law of physics.

I see what you mean though. Once we derive a law we can discover other relationships without doing experiments, but only those relationships that are directly entailed by our original physical law.

I understand your point that pure mathematics is unique, but I'm just saying that for practical purposes, a lot of respectable physics is permanently in the math phase, or it's simply untestable.

Yeah, string theory is an example of this. If it is true, it would entail all of the physics we know of, but we can't tell if it's true or not because there's no way we can test it. Obviously, though, this kind of science isn't going to lead to practical applications. If there were an application, then there would indirectly be a way to test the theory.

Biology can't do this because it's too practical. We're out to cure diseases, damnit.

I also agree that if something is mathematically incoherent, it's probably false. But our knowledge of math is not without limits. There are mathematical contradictions that physicists are still trying to work out.

Yeah, there are places where our laws of physics break down, like at black holes. They produce infinities and probabilities greater than 1. That just means that our theories are only approximations, though. In the places that the mathematics is meaningful, it works. And where the mathematics is meaningless... then we have to find a better theory.

 

[nancysinatra]

People often make a false assumption that those in therapy must have something wrong with them and/or a pathology-based reason....which isn't always the case. It is my belief that pretty much everyone can benefit from therapy, whether they have a pathology to manage or not. Many people in therapy do have diagnosable pathology, though there are others who use it as a place to learn about themselves and work through every day issues.

This is good to know, because what I was kind of trying to ask in that post above is whether the act of calling a psychiatrist and making an appointment, or attending said appointment, inherently identifies a person as probably having a mental illness. Patients can go to their internist for a check up and nothing may be found wrong with them, and in pediatrics there's the well-child visit. But in psychiatry--maybe because of the billing issues--just based on my casual observations, it's like most patients gets some diagnosis or other. Why is there less well-patient care, I'm wondering? Ok, there are other fields--radiation oncology comes to mind--with even less well patient care, for good reason. I'm sure there's a reason in psychiatry but it just seems like analysis could help a lot of rather well people increase their insight and so forth. Sports medicine helps people improve their athletic abilities! Cosmetic surgery improves people's noses! Why not more analysis? (Yeah, money, I know.)

I think the stigma of therapy still keeps the 'well' away, even though there are benefits to be gained if people are willing to do the work.

Since there is a stigma, then aren't there some ramifications to the practice of patients being "diagnosed" for billing purposes? Getting back to medical students and residents--what happens if someone is quite well but temporarily bothered about something in their life, sees a psychiatrist, gets a label of "mild depression" so they can bill insurance, and then this person a few years later is filling out a medical licensing form that asks if they've ever been diagnosed with a mental illness? (I think these questions exist in some states.) What should they do? This could happen in other fields too--pilots, law enforcement, etc.

 

[189213]

No, medical knowledge is purely a posteriori. There is no fact about medicine that can be known apart from experiment.

I hate to belabor a point I've already made, and I don't wish to imitate the somewhat dismissive tone you've adopted, but this is a reductionist statement made seemingly in the absence of an understanding of the realities of medical history, pathophysiology, and clinical practice.

For instance, if a patient sees an ophthalmologist with a chief complaint of bitemporal hemianopsia, the doctor knows a priori that the patient most likely has a lesion of the optic chiasm. This knowledge can be verified with a brain scan, but it can be deduced without it. I can think of numerous other examples of a priori knowledge in medicine, but I'll leave it at that.

But until we can understand what "ego" means in biological terms, then I don't think that we're going to understand what ego-based therapies are actually doing that is beneficial.

Sorry to disappoint you, but I think that you'll eventually find that we utilize numerous medical therapies (pharmacological, surgical, etc.) without fully understanding what they "are actually doing." Doctors (and doctors to be) have a long history of arrogance regarding how much they think they understand about how treatments work, only to be proven wrong again and again. I won't bore everyone with a litany of examples.

What other type of explanation is there? We don't have evidence that behavior comes from things other than brains... and even if we did, how would that knowledge benefit psychiatry? Should psychiatrists attempt to treat the soul?

Obviously, I'm not suggesting that behavior comes from anything other than the brain. I'm merely suggesting that attempting to understand the mind purely through our limited knowledge of the brain is an intellectually stunted attitude. We need to recognize that we should approach it from the other end as well, by attempting to understand the brain through our knowledge of the mind.

Phrenologists attempted to explain behavior using a simplistic, mechanistic model that seems silly to us today. Their intellectual shortsightedness should not be repeated today, and we should not think ourselves incapable of similar blunders simply because we have much more powerful scientific tools at our disposal.

Hey, and don't give up on that luminiferous aether -- it may yet make a comeback!

 

[nancysinatra]

Hi nancy, actually the story of the uncertainty principle is a little more complex. The central idea behind quantum mechanics came from supposing that energy is not continuous but discrete. If you remember much about calculus, then you'll remember that discontinuous functions can't be integrated, they can only be summed over.

This modification in our idea about energy was made to match experimental observations. So it is really a posteriori knowledge. Once we came up with the idea of quantum mechanics, we were able to derive other laws mathematically and then test to see if they had physical truth to them. So the uncertainty principle is like this. It's the mathematical implication of an a posteriori law of physics.

Great summary! I love physics so we could start a new thread if you'd like. In my post I was trying (and failing!) not to be longwinded, although I do know quite a bit of the history of quantum mechanics. But it's not like Heisenberg got to his principle simply by pouring over measurements of energy and time, location and speed, and running them through a spreadsheet. I mean, there was a lot of pure reasoning in the process. In medicine we look at data and crunch numbers. It's a totally different use of math and logic. But I think your explanation of a priori and a posteriori is excellent.

I am so up on my calculus. No one ever asks me anymore, so I'm glad you did! If I ever go back to school again for something else it will be math and physics. I want to do all these psych fellowships though, and then work with patients, so I might not get to it for awhile!

 

[nancysinatra]

I hate to belabor a point I've already made, and I don't wish to imitate the somewhat dismissive tone you've adopted, but this is a reductionist statement made seemingly in the absence of an understanding of the realities of medical history, pathophysiology, and clinical practice.

For instance, if a patient sees an ophthalmologist with a chief complaint of bitemporal hemianopsia, the doctor knows a priori that the patient most likely has a lesion of the optic chiasm. This knowledge can be verified with a brain scan, but it can be deduced without it. I can think of numerous other examples of a priori knowledge in medicine, but I'll leave it at that.

I think you guys might be using different definitions of the terms a priori and a posteriori? If I understand correctly, solumanculver is saying that for a hypothosis or suspicion to be "a priori," then the subsequent evidence for it HAS to be derived through pure, logical mental reasoning, and it can't rely on knowledge gained from past experiments either (such as early anatomical dissections that showed where the optic chiasm was located in the brain). Just by definition it can't be something where proof is found through a test or using a device. Really only a math theorem or a philosophical argument, and perhaps some linguistic ideas could be proved this way. But not whether a patient has a lesion.

Whereas Edmund Grifus--do you mean by a priori something akin to "prior to seeking evidence" and by a posteriori "after finding evidence?" In medicine I think the terms are used more that way. In philosophy of mind, I think the phrases are used solumanculver's way.

I'm not an expert on epistemology either, but I've heard different uses of these terms in different settings, so I just thought maybe this was going on.

 

[Therapist4Chnge]

But in psychiatry--maybe because of the billing issues--just based on my casual observations, it's like most patients gets some diagnosis or other. Why is there less well-patient care, I'm wondering?

If there is insurance involved, a Dx needs to be given (even if provisionally) to get reimbursed. Preventative care in regard to mental health is still not something people are seeking, and unfortunately it shows in problems down the road.

--what happens if someone is quite well but temporarily bothered about something in their life, sees a psychiatrist, gets a label of "mild depression" so they can bill insurance, and then this person a few years later is filling out a medical licensing form that asks if they've ever been diagnosed with a mental illness?

Something like an Adjustment Disorder Dx would probably be more appropriate, and carry less of a stigma.

 

[189213]

I think you guys might be using different definitions of the terms a priori and a posteriori? If I understand correctly, solumanculver is saying that for a hypothosis or suspicion to be "a priori," then the subsequent evidence for it HAS to be derived through pure, logical mental reasoning, and it can't rely on knowledge gained from past experiments either.

I think you may be onto something there, nancysinatra. Maybe I've been thinking too medically.

The original context in which these terms came up was when solumanculver suggested that psychoanalysis was more akin to philosophy rather than science (post #24). In response to whiskey pondering the difference, the argument was that philosophical knowledge was derived a priori, and scientific knowledge a posteriori (#29).

Let's use solumanculver's "philosophy of mind" sense of these terms, as you put it. If one takes the stance that "philosophical" a priori knowledge (e.g., mathematics) is derived through pure logic, and that "scientific" a posteriori knowledge is derived through experience and experiments, then it would seem to me that psychoanalysis falls into the latter category.

Freud based his ideas on clinical observations and revised them as the evidence deemed necessary. In this construct, then, psychoanalysis would appear to be closer to science than philosophy. But of course, this is all an oversimplification. Medicine is a boots-on-the-ground battle, not a theoretical exercise, so these are all just words in the end.

 

[nancysinatra]

Medicine is a boots-on-the-ground battle, not a theoretical exercise, so these are all just words in the end.

Exactly. Medicine is always moving forward. A lot of other sciences are happy to languish for awhile with no new discoveries, if they know that at some point, their work will pay off. Philosophers have all of time to prove their arguments. But patients need discoveries NOW!

 

[solumanculver]

I think you may be onto something there, nancysinatra. Maybe I've been thinking too medically.

Hi, yeah... nancy is right. I've been using the terms a priori and a posteriori in an entirely philosophical context. Actually, I didn't know that they were used at all in a medical context.

Also, I'm sorry if it seems like I've adopted a dismissive tone. I really don't mean to be dismissive

Let's use solumanculver's "philosophy of mind" sense of these terms, as you put it. If one takes the stance that "philosophical" a priori knowledge (e.g., mathematics) is derived through pure logic, and that "scientific" a posteriori knowledge is derived through experience and experiments, then it would seem to me that psychoanalysis falls into the latter category.

Actually, I didn't say that psychoanalysis was like philosophy, I said that "theoretical orientation" is like philosophy... whatever theoretical orientation is. To be honest, I don't really understand what theoretical orientation is, but it seems like any "orientation" is not supported by evidence or anything, it just depends on how 'therapists' conceptualize mental disorders.

I wrote therapist because it seems like something I found a lot more on the psychology forum... I don't know what it means in the context of a medical model.

 

[whopper]

Anyone consider that there is some empiricial data that backs some of Freud's theories?

I'm sure more has been done since I was a psychology major back in the 90s. In one of my classes-Developmental Psychology, there were some studies mentioned showing certain events in childhood did actually follow some of Freud's theories. E.g. children of single parents did show some behaviors that Freud had written would be expected given the oepidal & elektra complexes. Unfortunately I can't find any of those studies right as of this moment and the textbook I had with those studies is at a former home that is hours away.

The studies in no way proved Freud was right on everything, but it did show that some events in a developing human should be taken into consideration on a clinical level that Freud had talked about.

I'm surprised with the lack of studies being done to verify some of his theories since some of these theories can be easily tracked in a study. E.g. Freud theorized that boys playing with fire often did so because it showed they were not getting enough attention from their father--> and that on a unconcious level, the playing with fire was a subconcious action to get caught by the father, hoping to get some attention.

So someone could for example structure a study on males who have a history of playing with matches, and measuring for example how many hours their fathers were home & spent time with them.

I'm wondering if any of our psychology colleagues has any more recent data & expertise in this that would like to discuss this on the board. So far nothing in my psychiatric residency training has covered the empirical data backing up psychoanalysis other than that it has clinical benefits.

 

[Therapist4Chnge]

I'm wondering if any of our psychology colleagues has any more recent data & expertise in this that would like to discuss this on the board. So far nothing in my psychiatric residency training has covered the empirical data backing up psychoanalysis other than that it has clinical benefits.

I'm not as familiar with research supporting traditional psychoanalysis in regard to pathology treatment. Case studies are common in this area, though there are obvious limitations in regard to generalizing the treatment to others....as the treatment is tailored so much to each patient.

I am more familiar with the research in regard to psychodynamic approaches to treating anorexia nervosa, borderline personality dx, narcissistic personality dx, etc. I can probably dig up some publications if people are interested in treating a particular dx.

 

[OldPsychDoc]

Anyone consider that there is some empiricial data that backs some of Freud's theories?

I'm sure more has been done since I was a psychology major back in the 90s. In one of my classes-Developmental Psychology, there were some studies mentioned showing certain events in childhood did actually follow some of Freud's theories. E.g. children of single parents did show some behaviors that Freud had written would be expected given the oepidal & elektra complexes. Unfortunately I can't find any of those studies right as of this moment and the textbook I had with those studies is at a former home that is hours away.
...

Oh, I'm quite sure that each of my sons has wanted to do me in and have their mom to themselves....

 

[whopper]

Thanks.

from what I do remember and this is over 10 years ago (man am I getting old).

Studies showed that...females in a single parent family where the mother was that parent were more likely to be promiscuous--in tune with Freud's theory that a daughter without a father figure will search for that father figure, sometimes through sex.

Nuts--forgetting the other studies. However it was the topic for about 1 week's worth of lectures in that class.

Didn't prove that Freud was right on everything, in fact some of his work IMHO is validly criticized, but it did show that relationships between the mother & father are different for the daughter & son depending on the sex.

All intersesting stuff and nuts, my textbook is at my parents' house. On top of that, even if I digged it out under that mountain of old books, its old data.