A New/Old Look at Psychoanalysis

The New York Times has an interview with Owen Renik, a psychoanalyst who has just written a book entitled, Practical Psychoanalysis for Therapists and Patients. It controls this wonderful interchange:

Q. You place great emphasis in the book on symptom relief as the central measure of the effectiveness of therapy. Shouldn't that be obvious?

A. Not necessarily. There is a tendency among psychoanalysts to pursue self-awareness as a goal in itself, rather than a means to an end. Originally, the idea was that the self-understanding that arose as a result of psychoanalysis was unique and impressive and valid because it afforded relief from symptoms that were otherwise impossible to treat.

If you don’t require that self-awareness be validated by symptom relief, there are two destructive consequences. The first is scientific. You have no independent variable to track; you set up a circular situation in which it’s the analyst’s theory that determines what is found in analysis. Many critics of psychoanalysis have recognized this.

But an equally important consequence is that you relieve the analyst of any accountability. The process can go on forever, and there are all kinds of temptations to extend it, including the therapist’s vanity, his inability to admit failure, his narcissism — and nobody likes lost income. The therapy then becomes an esoteric practice of proselytizing, rather than a discipline, and the proof of that is everywhere in the world, where fewer and fewer people go to analysis at all. If the therapy worked, people would be going.

This issue actually goes back to 1952 when H. J. Eysenck had argued that psychotherapy was ineffective (a 1957 paper is available here). At the time, psychoanalysis was the dominant form of psychotherapy. Although deficiencies with his research have been well documented, his paper touched off the field of psychotherapy research, and such studies continue to this day. Generally, it has been concluded that certain forms of problem-oriented psychotherapy (e.g., cognitive therapy, behavior therapy, and interpersonal therapy) are effective for treatment of anxiety, depression, and other specific psychological problems. Psychoanalysis, and other psychodynamic therapies have not fared so well, although I have seen a few positive studies in the past.

The issue is not just whether or not psychotherapy "works;" it's also whether or not this particular client is benefiting from a particular therapy, from this particular therapist. This is what we call accountability, and psychologists have not taken it seriously enough. I'm particularly impressed with Renik's eloquent comments about the dangers of not addressing symptom relief in therapy, i.e., not being accountable.

Today, it is becoming more common for therapists to begin sessions with a fairly straightforward questioning of a client about his or her level of symptoms. A quick minute of asking about mood, sleep, appetite, frustration tolerance, and so forth can provide adequate data for accountability. It also helps discourage the conduct of endless, directionless therapy, whose sole hallmark is to keep the client coming back for another fully paid session.