The scientific status of psychoanalytic clinical evidence (I)

The main source of evidence for psychoanalytic theory comes from the clinical situation. Yet recent empirical studies in verbal conditioning and the social psychology of persuasion indicate that psychoanalysts and therapists of other schools are speciously validating their own theories by unwittingly influencing their patients’ behavior. In the light of this evidence it is small wonder that psychoanalysts consistently ‘validate’ psychoanalytic theory in their clinical practice while therapists of other schools ‘validate’ their own theories in their clinical practice. Although Freud was not unaware of the problems of ‘suggestion’ and the conflicting evidence of rival schools of psychotherapy, he never met these problems successfully. Contemporary psychoanalysts have added little to Freud's original position. One recent attempt, by Fritz Schmidl, to formulate new criteria for the correctness of psychoanalytic clinical interpretations, does not completely escape the problem of suggestion and has new problems of its own.     

Psychodynamic psychotherapy for children and adolescents: a critical review of the evidence base

For many years psychoanalytic and psychodynamic therapies have been considered to lack a credible evidence-base and have consistently failed to appear in lists of ‘empirically supported treatments’. This study systematically reviews the research evaluating the efficacy and effectiveness of psychodynamic psychotherapy for children and young people. The researchers identified 34 separate studies that met criteria for inclusion, including nine randomised controlled trials. While many of the studies reported are limited by sample size and lack of control groups, the review indicates that there is increasing evidence to suggest the effectiveness of psychoanalytic psychotherapy for children and adolescents. The article aims to provide as complete a picture as possible of the existing evidence base, thereby enabling more refined questions to be asked regarding the nature of the current evidence and gaps requiring further exploration.     

Process‐orientated psychoanalytic work in initial interviews and the importance of the opening scene

From the very first moment of the initial interview to the end of a long course of psychoanalysis, the unconscious exchange between analysand and analyst, and the analysis of the relationship between transference and countertransference, are at the heart of psychoanalytic work. Drawing on initial interviews with a psychosomatically and depressively ill student, a psychoanalytic understanding of initial encounters is worked out. The opening scene of the first interview already condenses the central psychopathology – a clinging to the primary object because it was never securely experienced as present by the patient. The author outlines the development of some psychoanalytic theories concerning the initial interview and demonstrates their specific importance as background knowledge for the clinical situation in the following domains: the ‘diagnostic position’, the ‘therapeutic position’, the ‘opening scene’, the ‘countertransference’ and the ‘analyst's free‐floating introspectiveness’. More recent investigations refer to ‘process qualities’ of the analytic relationship, such as ‘synchronization’ and ‘self‐efficacy’. The latter seeks to describe after how much time between the interview sessions constructive or destructive inner processes gain ground in the patient and what significance this may have for the decision about the treatment that follows. All these factors combined can lead to establishing a differential process‐orientated indication that also takes account of the fact that being confronted with the fear of unconscious processes of exchange is specific to the psychoanalytic profession.     

Psychodynamic counsellor training integrating difference

Abstract

Psychodynamic counselling has been criticized for being inflexible, authoritarian, antiquated and unresponsive to the issues of modern-day society. Psychodynamic counsellor training is sometimes seen as a poor relation of ‘proper’ psychotherapy therapy training. This article is written by two psychodynamic counselling course trainers who have wresded with the above criticisms and who have striven to deliver a training course that is coherent in its adherence to a psychodynamic counselling model but which embraces equal opportunities issues and takes account of a diverse society. The article focuses on ways in which sexual identity, race and culture are integrated into the course curriculum and indeed into the course philosophy and community. Traditional psychoanalytic interpretations of homosexuality are challenged and multicultural counselling ideas are merged with psychodynamic counselling theory and skills.     

‘The essay method’ a qualitative method for studying therapeutic dialogues

ABSTRACT

This paper presents a qualitative research method for analysing therapeutic dialogues called ‘the essay method’. A central part of the method uses the format of the literary essay as a model. The method consists of a close monitoring of clinical material guided by an overall psychoanalytic/psychodynamic theoretical frame. It combines both clinical details and global patterns of clinical material and is especially fitted for studying relational qualities of psychotherapeutic dialogues. In this paper, the background for qualitative analysis in studying psychoanalytic material is discussed, and the procedures for using the method are demonstrated. A study of therapeutic competence in a group of student therapists is used as an example of the method in practice, demonstrating that the essay method may have potential for revising theory and establishing new concepts based on empirical findings. The essay method is compared with other qualitative methods, and it is argued that it is suitable for psychoanalytic research.     

Freud,Jung and The Great Chain of Being

For some time, it has been clear that psychoanalytic theories are built upon the kind of master narratives Roy Schafer, a New York psychoanalyst, described in 1980. As such, psychoanalytic theories may today have lost some of their initial scientific credibility in that they can no longer be seen as summarizing findings from data collected in a research environment. As aids in participating in their patients’ process of healing, however, narratives continue to be used by practitioners and reflect allegiance to core beliefs and propositions with roots in long‐standing Western thought. In this article, the metaphors in master narratives of Freud and Jung are compared with a conceptual system identified by cognitive linguists as ‘The Great Chain of Being’. Based on this analysis, the article proposes that theoretical formulations have mainly a secondary role to play in achieving good outcomes. The most critical element is the therapist's capacity to access a specific narrative for what transpires throughout each treatment.     

Clients’ experiences of dynamic interpersonal therapy (DIT): opportunities and challenges for brief,manualised psychodynamic therapy in the NHS

Dynamic interpersonal therapy (DIT) is a brief manualised psychodynamic intervention for depression. This is a first study exploring clients’ experiences of DIT specifically and brief, manualised psychodynamic psychotherapy (PP) in general. Interpretative phenomenological analysis was the methodology employed. Five participants completed a semi-structured interview, three weeks to ten months after completing DIT. The scores of pre- and post-therapy outcome measures of depression and anxiety were also available. Two emerging superordinate themes are presented here: (1) ‘The Distinct Features of DIT’, referring to how its therapeutic style and time limitations were experienced and (2) the ‘Impact of Therapy’, referring to perceived outcomes. While previous findings showed that therapist’s perceived limited activity in long-term PP was experienced as hindering/unhelpful, the perceived sense of direction in DIT appeared adequate to most participants. Secondly, the time limitations provoked complex responses. Reactions to the distinct elements of DIT are to be treated both as therapeutic opportunities and as challenges. Further, in line with psychoanalytic theory, most participants described relational changes that went beyond symptom relief and remained in progress after therapy ended. Intriguingly, there was no consistency between participants’ qualitative accounts of change and the scores of the outcome measures.     

Changing lives in the classroom

This paper sets out to describe the search for solutions as the complexity of the teacher’s role with vulnerable pupils gradually became apparent. The aim is to demonstrate how the application of psychoanalytic theories examining the unconscious processes in individuals and their influence on classroom behaviour enhanced the capabilities of the teacher and helped her to look beyond mere management of behaviour in the classroom. The use of these theories provided a ‘thinking’ space for the teacher whereby teacher–pupil relationships and behaviours could be thought about and ‘contained’ thereby facilitating the teaching process for both teachers and pupils. Examples of classroom practice are provided whereby an applied psychoanalytic framework proved to be a potent source of renewal and increased capacity in the teacher. The active participation of the teacher in her own learning process of applying psychoanalytic concepts contributes to an ongoing, developing project with her pupils.     

PSYCHOANALYSIS AND COGNITIVE BEHAVIOUR THERAPY ‐ RIVAL PARADIGMS OR COMMON GROUND?3

The author suggests that contemporary enthusiasm for cognitive‐behavioural therapy reflects our longing for swift, rational help for psychological suffering. Competition for funding threatens the psychoanalytic presence in the public sector. The psychoanalytic and cognitive‐behavioural models are contrasted, and the relative richness of the psychoanalytic paradigm outlined. The author suggests that a cognitive model is commonsensical, but less complex, with less potential explanatory and therapeutic power. She discusses how the analytic stance is always under pressure to ‘collapse’ into simpler modes, one of which resembles a cognitive one. This also occurs inevitably, she argues, when attempts are made to ‘integrate’ the two models. Cognitive and ‘integrated’ treatments nevertheless have the advantage that they are less intrusive and hence more acceptable to some patients. Selected empirical process and outcome research on cognitive and psychoanalytic therapies is discussed. Brief psychotherapies of either variety have a similar, modestly good outcome, and there is some evidence that this may be based more on ‘dynamic’ than ‘cognitive’ elements of treatment. Formal outcome studies of more typical psychoanalytic psychotherapy and of psychoanalysis itself begin to suggest that these long and complex treatments are effective in the more comprehensive ways predicted by the model.     

Sibling rivalry,separation, and change in Austen's Sense and Sensibility

The paper explores a process of growth represented in the interplay of Jane Austen's characterizations of Marianne and Elinor Dashwood in Sense and Sensibility, approaching the text through the lens of psychoanalytic theories on oedipal sibling rivalry, separation, and processes of change. A close reading of Sense and Sensibility tracks Marianne Dashwood's repudiation of any ‘second attachment’ as the surface of an unconscious fantasy, denying a rival for the mother's love. A psychoanalytic view contrasts Marianne's lack of separation from her mother, her use of denial and projection, and her near death after losing the man she loves, with her older sister Elinor Dashwood's capacities for depression, reflection, and greater acceptance of loss and separation. The narrative portrays Mrs. Dashwood's identification with and idealization of her daughter Marianne, which contribute to her oedipal sibling ‘victory’. In the language and structure of the novel, the projections, identifications, aggressions, and separations (conscious and unconscious) of the sisters in the vicissitudes of their adolescent loves and rivalries constitute a process of growth. Austen's novel brings to life, with the vividness and coherence of great literature, forces and fantasies in oedipal sibling rivalries, inspiring renewed attention to their subtle presence in the transference and countertransference of the psychoanalytic process.     

A feminist psychotherapeutic approach to working with women who eat compulsively1

Feminist psychoanalytic theorists argue that eating problems demonstrate ways in which conscious and unconscious gendered feelings about women are split off and projected on to their bodies. As such, they are complex ways in which women attempt to negotiate and express their identities within their paradoxical social position in contemporary western society. They are not just consumers but also objects of consumption. This paper explores material from a feminist psychodynamic therapy group for women with a variety of eating problems, focusing on how interweaving both discursive and unconscious approaches to understanding the gendered function of weight can facilitate change. Feminist psychodynamic therapists work with the concept that the body is an interface between conscious and unconscious mind within both an internal and a social world. This framework enables the client to understand the connections between socially constructed frameworks of femininity, emotions and bodily sensations, rather than to act on them through some form of bodily abuse. This approach is based on my adaptation of Susie Orbach's (1978) ‘Fat is a Feminist Issue’ therapeutic model for working with compulsive eaters. While arguing that a feminist psychoanalytic framework is crucial in this type of work, I suggest that it is essential to combine this with cognitive and behavioural therapeutic interventions in order to provide a pedagogic structure in which food, eating and body size come to be seen as meaningful.     

A HISTORICAL OVERVIEW OF THE PSYCHODYNAMIC CONTRIBUTIONS TO THE UNDERSTANDING OF EATING DISORDERS

The objective of this paper is to give an historical overview of the development of psychodynamic theories and to acknowledge their contribution to the understanding of the aetiology of these complex disorders. Relevant psychodynamic and psychoanalytic papers on the historical development of eating disorders were identified through a search of (1) Medline and PsychoInfo, (2) the library of the London Institute of Psychoanalysis, (3) Psychoanalytic Electronic Publishing (PEP), and (4) a number of textbooks on eating disorders.

The search revealed a dearth of psychoanalytic historical perspectives about the aetiology of eating disorders in general. Overall most psychoanalytic publications were based on single case studies and concerned primarily with anorexia nervosa. No single model was identified, but a number of psychoanalytic ideas remain consistent throughout. Several psychoanalysts and contemporary psychodynamically‐informed authors refer to, apply and have further developed a number of these original ideas. This overview highlights the unique contributions of psychodynamic concepts towards a better understanding of the aetiology of eating disorders and how much they have influenced and informed modern thinking on the meaning of these complex conditions. A range of psychodynamic views has emerged and gradually evolved from concentrating solely on intra‐psychic factors to a more comprehensive multi‐modal model. This tendency has become a fertile ground for cross‐fertilization which, along with the bio‐social counterparts, remains the fundamental pillars on which modern understanding of eating disorders still rests.     

Psychodynamische Diagnostik

The paper describes the development and objectives of psychoanalytic diagnostics. It shows that one of the key tasks of psychoanalytic/psychodynamic interviews is to initiate the doctor-patient relationship and that the patient’s motivation for treatment is to be examined and promoted in the interview. Different sources of information for the interview are then described; following a presentation of various systematic approaches of psychodynamic diagnostics, the principles of biographic history-taking are also explained. Modern psychodynamic diagnostics provides complex access to the patient, covering both elements of open interviewing and more exploratory approaches. Options for integrating these various methodological approaches are highlighted. Finally, more recent approaches in psychodynamic diagnostics that have a stronger relation to treatment planning are presented. These include the Structural Interview developed by Kernberg and Operationalised Psychodynamic Diagnostics (OPD).     

Minding the gap between positivism and hermeneutics in psychoanalytic research

Two quite different cultures are to be found within psychoanalysis, one more clinical in orientation, more focused on meaning and interpretation, and relying primarily on the traditional case study method, the other more research-oriented, focused on cause-and-effect relationships, and relying primarily on methods borrowed from the natural and social sciences. The history of this divide is reviewed and arguments, pro and con, about the potential contributions of specific types of empirical investigation are discussed. Increasingly, it seems, criticisms concerning the scientific status of psychoanalysis are being responded to by empirical research. This has contributed to a growing recognition within the scientific community of the credibility of aspects of psychoanalytic theories and of the effectiveness of psychodynamic treatment. However, some segments of the psychoanalytic community are concerned that this increase in the quantity and quality of empirical research on psychoanalytic concepts risks creating an empirical one-sidedness, while other segments are concerned that not engaging in systematic empirical research can lead to intellectual isolation, fragmentation, stagnation, and orthodoxy. To counter this polarizing tendency, a recommendation is made for methodological pluralism. Adopting this stance could contribute to an enriched understanding of the clinical process and to the development of new research methodologies to investigate complex psychodynamic hypotheses, thus bridging the gap between the two psychoanalytic cultures, as well as the gap between research and clinical practice.     

The sandwich model: The ‘music and dance’ of therapeutic action

My premise is that a ‘layered’ approach is necessary to understand the process of exchanges that result in therapeutic change. I imagine these processes occurring in three layers – although the number of domains in which change is taking place is actually infinite – such as in a sandwich. The top layer, or top slice of bread of the sandwich, represents a broad view of the change process; it is non‐linear and includes the feature of uncertainty, a general principle of dynamic systems theory. The middle layer, or the meat of the sandwich, is explained by theories that are immediately and clinically useful to a therapist, such as psychoanalytic theories. These are primarily linear theories and use language and symbols to ‘tell a story of what happened’. The bottom layer, or bottom slice of bread of the sandwich, is the micro‐process; this layer includes the moment‐to‐moment patterns of coordinated rhythms that both communicate meaning and provide the essential scaffold for all higher‐level change processes. The micro‐process also requires a non‐linear theory to make sense of its variability and emergent properties. Taking a bite out of the sandwich will include a ‘polysemic bundle of communicative behaviors’ (Harrison and Tronick, 2011). I will illustrate the ‘sandwich model’ with the clinical case of the analytic treatment of a 5 year‐old boy.     

Acting,feeling and thinking: psychoanalytic psychotherapy with Tracey

This paper consists of a case study and commentary which formed a part of the inaugural lecture in a series entitled ‘Working with Psychosomatic Issues’*. The audience consisted of psychoanalytic, body psychotherapy and integrative practitioners. The presentation was divided into three parts, (1) an outline of philosophical themes that inform perspectives on health, illness and psychosomatic phenomena, (2) the case study reproduced below and (3) a summary of Winnicott's work (1960, 1966, 1988) on ‘the indwelling of the psyche in the soma’. The case study describes work with a young woman who harms herself through self-hitting and, in addition, expresses other physical manifestations of psychological distress. The core approach of the practitioner is psychoanalytic. The work is informed also by postmodern sensibilities and phenomenological themes.     

Critical refl ections on intersubjectivity in psychoanalysis1

The authors review the philosophical trend known as postmodernism and the way it has infl uenced a part of psychoanalytic thought, concluding with some comments on the qualities and shortcomings of the new developments. The authors consider the origins and the cultural and aesthetic‐philosophical meaning of postmodernism, identifying some key concepts such as deconstructionism, the disappearance of the ‘individual subject’ and individual identity, and the rejection of ‘in‐depth’ models of psychoanalysis. Then they examine various, wide‐ranging developments in psychoanalytic thought and treatment. They review the intersubjective fi eld in psychoanalysis, especially in the USA, and then explore whether the underlying lack of truth to be discovered, stressed by these ‘new view’ statements, or the fact that the ‘truth’ only exists in linguistic‐narrative constructions is consistent with basic analytic concepts such as the unconscious, phantasy, transference and countertransference, which recall the tri‐dimensional nature of inner psychic reality. The psychoanalytic process is a condition activated through a bond that is able to hold and contain the relationship of the analytic couple and the patient's unconscious world and not through hermeneutic or narrative constructions.     

Telling a traumatic story through Art: Arshile Gorky’s ‘The Artist and his Mother’

For more than a decade, through re-working a composition based on a sepia photograph, Arshile Gorky (ca. 1904–1948) tried to give form and represent that which by definition defies forms and shatters one’s capacity for representation. Having witnessed the systematic ethnic cleansing of his people as a child, Gorky began a ‘journey’ in his attempt to comprehend his traumatic ordeal through Art. In 1926, with the safety of a constructed name and life, the artist started working on ‘The Artist and his Mother’ series. Focusing on the two versions of Gorky’s early painting and using relevant aspects of psychoanalytic theory, the paper explores his work through a psychoanalytic lens. Psychoanalytic theories on extreme traumatisation along with psychoanalytic notions of temporality will be utilised in an attempt to follow the artist’s struggle to re-create and rework aspects of his traumatic history.     

Toward a Psychodynamic Approach to Bioethics

Although many first-generation bioethicists were psychiatrists and some received psychoanalytic training, the field of bioethics has developed largely in isolation from psychodynamic theory. While much has been written regarding the ethics of psychoanalysis, only a few scholars have attempted to explain bioethical phenomena in psychodynamic terms. This paper argues for the development of a comprehensive theory of "psychodynamic bioethics" that attempts to explain individual and collective attitudes toward bioethical controversy in psychodynamic terms.