The Assault On Self-Knowledge

04/07/2010 05:12 am ET | Updated Nov 17, 2011

I am a huge critic of psychoanalysis. I am wary of the religious aspects of it, as well as the institution of psychoanalytic training. Historically, unquestioned authority of analysts has done a lot of damage, not to mention the profound neglect of reality that some psychoanalysts espouse.

Obviously I am not alone. The New York Times, once a bastion of reading on psychoanalytic topics, has seemed to abandon favor of this form of treatment. In its place are topics on social contagion theory and problematic aspects of psychoanalytic couples therapy. Even more recently, an article by the acclaimed Ethan Watters, suggests that mental illness can be reduced to an American sociopolitical stampede, in which we aim to project our mental illnesses on the world.

And while I agree with many critiques of psychoanalysis, there has been tremendous fallout related to the perception of psychoanalytic psychotherapy, a form of treatment that helps many people. Recently, many (including the authors of a recent Washington Post article), have attacked therapies that use long-term and psychoanalytic techniques, though under the hidden agenda of psychology doctorate program credentialing concerns.

The problem is that many alternatives of long-term psychoanalytic (or psychodynamic) therapy approaches do not work for the much of the population. Repeatedly we have heard that cognitive-behavioral therapy (CBT) is effective for many problems. Yet is not clear that these techniques are what help people get better in therapy. For example, research summarized by Ronald Levant points out that specific techniques explain a small amount of how we understand psychotherapy outcomes. However, patient's experiences of the therapeutic relationship are more meaningful. Most important, the majority of patients are excluded from typical CBT studies--the ones that reportedly suggest its efficacy. Why? Because to participate in these studies, an emotional condition has to meet specific diagnostic criteria. Recruited patients can only have one non-complex mental disorder. Yet, less than 20% of all mental health patients present with such symptoms.

Long-term psychodynamic therapies have just as much empirical support as short-term therapies and the benefits can be seen in people with complex psychological issues. Such support has included research in the Holy Grail of empirical medical literature--the Cochrane Library.

The question should not be if long-term psychoanalytic therapies are useful-- but why don't we know about the efficacy of this approach?

Of course drug companies and insurance companies don't want us to know; the former are invested in suggesting that therapy of any kind does not help much at all, and the latter find it cheaper to have patients ingest pills as opposed to exploring insights. But I don't think these facets of corporate America are solely to blame. We live in a culture of easy fixes. We imagine that an attractive and charismatic new president can change our lives, that war is still the answer, and that bailing out corrupt bankers will solve our economy. Intellectual pursuits, or even just being thoughtful, seem out of vogue and we demand simple answers to complex problems. In this context, of course no one gives credence to complicated approaches to the mind. We don't have time. And we don't have the energy.

Further, external and internal resources are needed in order to think about what is important individually and societally. Right now we don't live in a culture that provides an environment for thoughtfulness. When people are struggling to pay the rent or their mortgage, it's hard to think about much of anything. More succinctly, when people are struggling economically, insight is not as useful as cash.

Yet, there is good evidence that understanding thoughts and feelings does help people with psychological difficulties and provides long-term benefits. If this was ten years ago, I would say if you need therapy, get CBT. But what we know today is that there is not data that CBT and other short-term approaches work for complex problems. So, based on what we know now, I would have to say that like the government, what ails you likely needs a long-term solution. Fortunately, psychodynamic therapy can provide it. Now we just need to find a way to pay for it.