Friday, January 8, 2016

Oliver Burkeman - Therapy wars: the revenge of Freud

Cheap and effective, CBT (Cognitive Behavioural Therapy) became the dominant form of therapy, consigning Freud to psychology’s dingy basement. But new studies have cast doubt on its supremacy – and shown dramatic results for psychoanalysis. Is it time to get back on the couch?

'Freud the man scaled heights of arrogance. But his legacy is a reminder that we shouldn’t necessarily expect life to be all that happy, nor to assume we can ever really know what’s going on inside – indeed, that we’re often deeply emotionally invested in preserving our ignorance of unsettling truths..'

Dr David Pollens is a psychoanalyst who sees his patients in a modest ground-floor office on the Upper East Side of Manhattan, a neighbourhood probably only rivalled by the Upper West Side for the highest concentration of therapists anywhere on the planet. Pollens, who is in his early 60s, with thinning silver hair, sits in a wooden armchair at the head of a couch; his patients lie on the couch, facing away from him, the better to explore their most embarrassing fears or fantasies. Many of them come several times a week, sometimes for years, in keeping with analytic tradition. He has an impressive track record treating anxiety, depression and other disorders in adults and children, through the medium of uncensored and largely unstructured talk.

To visit Pollens, as I did one dark winter’s afternoon late last year, is to plunge immediately into the arcane Freudian language of “resistance” and “neurosis”, “transference” and “counter-transference”. He exudes a sort of warm neutrality; you could easily imagine telling him your most troubling secrets. Like other members of his tribe, Pollens sees himself as an excavator of the catacombs of the unconscious: of the sexual drives that lurk beneath awareness; the hatred we feel for those we claim to love; and the other distasteful truths about ourselves we don’t know, and often don’t wish to know.

But there’s a very well-known narrative when it comes to therapy and the relief of suffering – and it leaves Pollens and his fellow psychoanalysts decisively on the wrong side of history. For a start, Freud (this story goes) has been debunked. Young boys don’t lust after their mothers, or fear their fathers will castrate them; adolescent girls don’t envy their brothers’ penises. No brain scan has ever located the ego, super-ego or id. The practice of charging clients steep fees to ponder their childhoods for years – while characterising any objections to this process as “resistance”, demanding further psychoanalysis – looks to many like a scam. 

“Arguably no other notable figure in history was so fantastically wrong about nearly every important thing he had to say” than Sigmund Freud, the philosopher Todd Dufresne declared a few years back, summing up the consensus and echoing the Nobel prize-winning scientist Peter Medawar, who in 1975 called psychoanalysis “the most stupendous intellectual confidence trick of the 20th century”. It was, Medawar went on, “a terminal product as well – something akin to a dinosaur or a zeppelin in the history of ideas, a vast structure of radically unsound design and with no posterity.”

A jumble of therapies emerged in Freud’s wake, as therapists struggled to put their endeavours on a sounder empirical footing. But from all these approaches – including humanistic therapy, interpersonal therapy, transpersonal therapy, transactional analysis and so on – it’s generally agreed that one emerged triumphant. Cognitive behavioural therapy, or CBT, is a down-to-earth technique focused not on the past but the present; not on mysterious inner drives, but on adjusting the unhelpful thought patterns that cause negative emotions. In contrast to the meandering conversations of psychoanalysis, a typical CBT exercise might involve filling out a flowchart to identify the self-critical “automatic thoughts” that occur whenever you face a setback, like being criticised at work, or rejected after a date.

CBT has always had its critics, primarily on the left, because its cheapness – and its focus on getting people quickly back to productive work – makes it suspiciously attractive to cost-cutting politicians. But even those opposed to it on ideological grounds have rarely questioned that CBT does the job. Since it first emerged in the 1960s and 1970s, so many studies have stacked up in its favour that, these days, the clinical jargon “empirically supported therapies” is usually just a synonym for CBT: it’s the one that’s based on facts. Seek a therapy referral on the NHS today, and you’re much more likely to end up, not in anything resembling psychoanalysis, but in a short series of highly structured meetings with a CBT practitioner, or perhaps learning methods to interrupt your “catastrophising” thinking via a PowerPoint presentation, or online.

Yet rumblings of dissent from the vanquished psychoanalytic old guard have never quite gone away. At their core is a fundamental disagreement about human nature – about why we suffer, and how, if ever, we can hope to find peace of mind. CBT embodies a very specific view of painful emotions: that they’re primarily something to be eliminated, or failing that, made tolerable. A condition such as depression, then, is a bit like a cancerous tumour: sure, it might be useful to figure out where it came from – but it’s far more important to get rid of it. CBT doesn’t exactly claim that happiness is easy, but it does imply that it’s relatively simple: your distress is caused by your irrational beliefs, and it’s within your power to seize hold of those beliefs and change them.

Psychoanalysts contend that things are much more complicated. For one thing, psychological pain needs first not to be eliminated, but understood. From this perspective, depression is less like a tumour and more like a stabbing pain in your abdomen: it’s telling you something, and you need to find out what. (No responsible GP would just pump you with painkillers and send you home.) And happiness – if such a thing is even achievable – is a much murkier matter. We don’t really know our own minds, and we often have powerful motives for keeping things that way. We see life through the lens of our earliest relationships, though we usually don’t realise it; we want contradictory things; and change is slow and hard. Our conscious minds are tiny iceberg-tips on the dark ocean of the unconscious – and you can’t truly explore that ocean by means of CBT’s simple, standardised, science-tested steps.

This viewpoint has much romantic appeal. But the analysts’ arguments fell on deaf ears so long as experiment after experiment seemed to confirm the superiority of CBT – which helps explain the shocked response to a study, published last May, that seemed to show CBT getting less and less effective, as a treatment for depression, over time. Examining scores of earlier experimental trials, two researchers from Norway concluded that its effect size – a technical measure of its usefulness – had fallen by half since 1977. (In the unlikely event that this trend were to persist, it could be entirely useless in a few decades.) Had CBT somehow benefited from a kind of placebo effect all along, effective only so long as people believed it was a miracle cure?

That puzzle was still being digested when researchers at London’s Tavistock clinic published results in October from the first rigorous NHS study of long-term psychoanalysis as a treatment for chronic depression. For the most severely depressed, it concluded, 18 months of analysis worked far better – and with much longer-lasting effects – than “treatment as usual” on the NHS, which included some CBT. Two years after the various treatments ended, 44% of analysis patients no longer met the criteria for major depression, compared to one-tenth of the others. 

Around the same time, the Swedish press reported a finding from government auditors there: that a multimillion pound scheme to reorient mental healthcare towards CBT had proved completely ineffective in meeting its goals… Read more: