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:
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:
