On the Revolutionary Nature of Psychoanalysis

Freud was aware of the need to establish a future for psychoanalysis and of the need to establish its scientific credibility. One of the ways to do this, he reckoned, was to anchor the psychoanalytic discipline in the sciences of the day. He realized that there was a significant challenge in trying to apply scientific methods to subjective experience. Currently, there seems to be a lot of backlash against psychoanalysis, as there are many claims that accuse it of failing to meet the modern standards of evidence-based practice. Beyond this, psychoanalysis faces the internal challenge that is currently undermining many academic fields, that of theoretical pluralism.

The questions that need to be asked are if psychoanalysis is a science and, if it is, whether it can be said to have represented a scientific revolution. To answer these two questions, we will start by looking at how well psychoanalysis integrates with Bacon’s definition for the concept of science by comparing psychoanalysis with medicine from the perspective of a treatment. We will do so in two steps, first we will compare the way a psychoanalyst works with the way a physician work, as physicians are considered to be scientists. Second, we will look through a couple of meta-analysis that compare the efficiency of the psychodynamic method, a modern form of psychoanalysis, against drugs in the treatment of various psychological symptoms, at this point I expect that it will be clear that psychoanalysis manifests the necessary elements to be seen as a science. Though, before engaging into this I will also show that we have strong ground to defend psychoanalysis as a different type of science as well, namely as a hermeneutic science. I will not go to deep into this line of argumentation as I think that the objective scientific facts that I will present will be more than enough to prove that psychoanalysis is a science and that beyond it performs better in treating mental disorders then it’s competitor, pharmacology. Finally, we will determine if psychoanalysis is a scientific revolution.

In the proess I will not concentrate on Freud, because Freud and his writings is not psychoanalysis as it manifests itself in present day. While the giants of the past are important and we must pledge our respect to them, I will start from Freud’s model, as he is the founder of the subject, but we will then proceed to analyze psychoanalysis as it is currently being practiced in this day and age. This makes by far more sense, for as we do not use Copernicus’ mathematical models to explain the movement of the planets within the solar system, the same is true for psychoanalysis. Meaning that we have abandoned in today’s practice the us of Freud’s methodology and processes.

Having said that, lets us start by looking into Freud and then continue looking into psychoanalysis as a subject and practice independent of him and other 20th century theoreticians. Freud was aware that all we have lived and all we have imagined is stored within us and remains so throughout the whole of our lives. He, hence, became aware of the fact that there must be a depth within the human psyche, that the human psyche is split into various degrees of awareness. Beyond that he realized that the self had various interests and, thus, it should have multiple dimensions to it. Throughout his life, he created two models of consciousness. The first was the topographic model and the second was the Structural Model of the Mind.

The topographic model splits the mind into three realms: 1) consciousness, 2) pre-consciousness, and 3) dynamic unconsciousness. The latter two realms form the descriptive unconsciousness, which represents all that is out of awareness at any given moment (pre-consciousness is what is out of awareness but can be accessed by attention or an act of will, and dynamic unconsciousness is what is blocked from access by the censor). In his later life he transformed the initial version of the model into one that took into consideration not only the depth of the mind but also the various dimensions of the self. For that his Structural Model of the Mind proposed the psyche as a two-dimensional realm (two-dimensional, as each realm is defined by the depth within a conscious-unconscious scale and by the position within the self-social line). The tree elements were:

  1. The ID in which impulses strive for discharge and that operates through primary processes. Primary processes are processes that belong to the unconsciousness, they are not bound by rules of logic, contradictory propositions can exist without conflict, and causal sequences are irrelevant, everything has an atemporal order.
  2. The Ego arises at the surface of the ID, at the union of the internal reality with the external reality. According to Freud, the Ego could not exist from the beginning. The ego comes into being from island of experience. It develops into a separate agency of the mental apparatus given his functions of perception, memory, and judgement. The Ego is the weak executive of the self, it has no energy of its own and derives its energy from the ID. Its role is mostly to mediate between the IDs demands for instant gratification and the restrictions of the super ego and the constrains of reality.
  3. The Super Ego or the Ideal-I, reflects the internalization of the cultural rules and on the basis of that creates an ideal picture. The Superego is constructed on the model of the most dominant and influential super-egos from one’s environment, those that culture perceives as most desirable. It aims for perfection and organizes the self, forms foals and criticized and prohibits drives, fantasies, feelings and actions.

Compared to previous thinkers that helped propel the understanding of the subjective world, Freud decided to not just state his position on the structures of the human subjective, but to also transform his realizations of said structure into a treatment method that can alleviate subjective diseases which inhibit a human’s performance even though he physically seems functional. Thus, he gave birth to psychoanalysis a method that should be able to treat behaviors that can’t be explained solely through physiological means.

 

1. Psychology and subjective knowledge

Francis Bacon considered science a discipline in which evidence is provided. The evidence is provided in a sort of public fashion, which presumes that one can show why one believes something and one can show the arguments that form the support for the assertion one is making. Bacon differentiated this approach from religion based on the way knowledge is attained. In religion knowledge is revealed via a figure of authority and, thus, it becomes and remains the truth in perpetuity. While in science the public forum places all “truths” up for debate and allows for evolution.

If we look within the psychoanalytic practice we can with ease see that its views and the evidence that support them are placed within a public forum that allows you to follow how conclusions are drawn from the existing evidence. The existing evidence can come in many forms which we will go through in part 3. However, this seems to be insufficient for many, as they compare psychoanalysis with physics or chemistry (two subject matters known for their adoration of mathematics). What people don’t seem to realize here is that the explanation terms are distinctly different. This difference in language should not ward people into concluding that psychoanalysis in not a science, for the language of any discipline is determined by its subject matter.

The subject of psychoanalysis is the exploration of the experiencing subject, it is a quest into how and why people create meanings out of experiences. All the analysis efforts that go into understanding the patient’s verbal and non-verbal behavior are adjudicated based on the patient’s experience. But, if its solely experienced based, how can we determine the truth value of the interpretation as the interpretation is something that goes beyond the experience (it is placed on top of it)? Do we not reframe the experience, thus manipulate it’s meaning throughout the process? And, if we do so, then what can still be said to be true? All of these are indeed fascinating questions as they stem from what can be said to be a misperception of the balance of power throughout the psychoanalytic process. First, one needs to note, that the psychoanalyst is not god. He can’t force the patient to change his perception of the meaning of a certain experience, or of how he deals with it. All the psychoanalyst does is to throw possible interpretations based on the story that the client is exposing. The more a certain interpretation fits with the initial story, the higher the truth value of the interpretation. And as you may have guessed from the language, psychology does not deal with absolute truths and only with relative truths. Given the ever-changing nature of the individual, psychoanalysis is dependent on constant reaffirmation with what can be said to be the subject matter expert, the client himself (for no one spend more time with the him [the client] than himself [the client]).

As we can see, in psychoanalysis, knowledge is claimed or realized through the interaction with a subjective entity. It is precisely this claim of knowledge that bothers people with regards to the language of psychoanalysis. To understand the problem better, let us go back to the roots of the world ‘science’ which comes from the Latin ‘sciencia’ or if translated it comes from knowledge. The break from its original meaning started to happen due to the philosophical foundations of the modern world view, which were launched by the Eleatic school and reintroduced during the renaissance by Descartes. These foundations are based on the dualistic division of reality into mind and matter, subject and object. Thus, knowledge about objects in homogeneous space became known as natural science. The spectacular achievements of these sciences led to their dominance of the modern age. However, confusion arose as the advancements in astronomy, biology, chemistry, physics, and computer science led to science becoming synonymous with the above fields and the criteria for all legitimate knowledge became the experimental method that represented the foundation of the before mentioned subjects.

This mindset was given a more articulated form by Comte, the founder of positivism, who very eloquently formalized that the confession of all branches of knowledge need to follow a single scientific method and that this had to be the experimental method as defined within the natural sciences. Due the positivistic movement, even today the only subject matter that is recognized as science is the natural sciences, the objective part of the mind-body duality launched by the Eleactic school. Nowadays, if you hear the question ‘Is this science?’ you need to equate it to “does it use the experimental method of natural sciences?”

The unwarranted assumption that the method of the natural sciences is the only type of science and the standard for all knowledge claims is one of the greatest mistake made by modern thinkers and is part of the fallacy known as ‘scientism’. Rather than deriving the method from its subject matter, scientism assumes the method that judges every discipline according to its conformity to the preconceived idea of the correct method. There are of course other methods of ascertaining knowledge that do not require hypothesis testing. Every instance of a person understanding another, every discovery or interpretation of historical events and every biographical narrative demonstrate that new knowledge is won without an experiment being conducted. The listener, historian interviewer, etc., gain knowledge by understanding the speech acts or documents or one another. Natural sciences are sciences of explanation that search for laws that can be applied deductively in individual instances. When a law is discovered its used to predict the behavior of the natural world. By contrast human sciences have as their object of investigation lived experience which cannot be grasped by laws or by testing the hypothesis derived from them. Unlike natural sciences the human sciences seek to discover meaning and are therefore sciences of understanding. The goal is not to explain but to understand the meaning of psychological and social phenomena.

Psychoanalysis is the in depth study of the experiencing subject. The truth to be gained is such an inquiry is the understanding of the behavior or symptom by rendering it intelligible. The criteria for the validity of any psychoanalytic claim to knowledge of the subject is its ability to render intelligible what has not been previously understood. The illumination of meaning takes place via the discovery of mental phenomena that demonstrate how the symptom coheres with the lived experience of the patient. In going from what is said to what is meant, psychoanalysis is, by definition, a hermeneutic discipline The purpose of analytics inquiry it to find out what behavior means not to deduce it from an explanatory law.

 

 

2. Psychology in treatment

I could go on defending psychoanalysis as a humanistic science process in which I would no doubt be successful. But, I think that further proceeding in that direction is not necessary because as I’ve stated psychoanalysis can manifest itself in a public forum. To showcase this we will look at the method of psychoanalytic treatment and then we will show data that have been gathered for years and that are up for grabs for anyone who is willing to go through them of how well this medicalized method functions in comparison to other methods that are recognized as scientific.

There are 3 core elements to the method of the psychoanalytic treatment: 1) Essentializing people, 2) Medicalizing the case, 3) Individualizing and focusing on the analytic diet and family history. These 3 elements are part of what can be called technical rational. Through the technical rational the psychoanalytic community aims to create an objective knowledge approach in understanding and treating subjective diseases. It aims to create a standardized understanding of the situation (i.e. is the client depressed, is he bipolar, is she suffering from anxiety, etc.) following which they have a clear stated treatment process map that should, when tested across multiple patients, provide the same results. After testing the results are noted and shared throughout the community, which is the public forum.

Essentializing people diagnostically is placed in contrast with respecting and exploring the consequential uniqueness of each person’s experience and potentials. With this, people are seen as a disorder rather than being considered as unique individuals. The person, in front of the therapist, is nothing more, during treatment, than the traits and dynamics of his condition. Through essentialism the patient is reduced, simplified, dehumanized, and potentially degraded to the diagnosed trait. Beyond that the analyst is also rendered inconsequential as he or she is required to apply a standardized way of relating to the patient that constitutes the treatment of choice for these disorders.

Instead of recognizing agency, creativity and moral responsibility, in the process of treating pathologies, the treatment method requires medicalizing the patient. The rationality is that by doing so one gravitates towards recognizing the medical responsibility and the disorder so that the person in front is reduced or eliminated. As a result, it removes the emotional states and the actions associated with them from the arena of moral struggle. How much depression is warranted if a person feels overworked and underpaid? How much anxiety is warranted if a person in angry but knows that expressing his or her anger might get him of her fired? The sooner you can throw people in the existential blackhole of a disorder the sooner you have their feelings and attitudes transformed into diseases, which encourages the patient’s passivity and acceptance of the current state of affairs. At the same time the environment is completely neglected and the patient is transformed into an object in homogeneous space. The analyst, as a whole person capable of creative agency, moral judgment and proactive interests and social critique and change, is rendered irrelevant in this medicalized context.

The patient is taken as an object that is defined by his history and the therapist uses an analytic diet to dive into his past to analyze it. This is done without taking into account the socio-economic environment of the patient. The focus is on the individual abstracted from the context in which he or she lived or lives, pulls towards locating the problem in that individual, while encouraging inaction to or denial of the destructive aspects of the socio-political environment in which the person lives and to which he or she is pressured or forced to adapt to. Extending to this the relational movement in which one identifies with himself, has emphasized the nature of the analytic process and of childhood history in the context of family dynamics, without attending to the political dimension and without reflecting critically on the psychoanalytic enterprise itself as one that may be in collision with certain destructive aspects of our culture.

According to the philosophical readings on psychoanalysis, the work of analysts should often entail joining the patients in their struggle with such conflicts including paying close attention to associated political, moral and existential issues. When we resist as the relational movement at its best requires us to do, the reification of emotional disorders as abnormalities located in us as individuals. We open the door to critical appraisals of the sociopolitical context, in which we are imbedded. We may be complicit in sustaining those contexts however destructive they may be.

In the process as it is practiced clinically, the whole person of the analyst is completely removed. The same happens to the whole person of the client. The first, the analyst is transformed into an objective observer and acting subject that applies processes by the book to an object defined within the bounds of a disorder, the patient. If the treatment does not work the analysts sees if his initial assessment was wrong, if so he goes to the required healing process of the new disorder. If not, he experiments, and presents his results through a public forum in the scientific community.

Now that we have explained the clinical method let us look at some of the results it generates. For this we will not be looking into individual studies, but into meta-analyses, which are studies of studies. A meta-analysis examines multiple individual studies and it tries to integrate and compare the findings present within the various studies.

We will first look at the effectiveness of antidepressant medications, based on a meta-analysis from the “New England Journal of Medicine”[1], that looked at all registered FDA antidepressant studies done between 1987 and 2004. In this, we can see that 48% of studies were Negative studies, meaning that in 48% of studies the placebo beat the active drug. Let us compare this result with the results from a 2011 meta-study[2] done on 63 Studies of Psychodynamic Therapy, that were considered statistically, empirically and scientifically sound and that were published between 1977 and 2010. When the psychodynamic method was compared to a placebo, or inactive comparator 74% of the cases were Positive, while only 26% were Negative.

Next, we need to be able to check the effect size of the therapy. The effect size is the difference between treatment groups, expressed in standard deviation units. We will start with a 2006 review[3] done by the Cochrane Library, a respected and independent organization that does review for a variety of medical treatments to help improve evidence based decision making. The meta-analysis collected 23 randomized controlled trials that accounted for a total of 1,431 patients treated for less than 40 hours through psychodynamic psychotherapy. The effect size, when compared to the wait list, to patients that would receive nothing, not even a placebo, the effect sizes ranged between 0.59 and 1.08 depending on the disease (0.2 is a small effect size, 0.5 is a medium effect size, 0.8 is a large effect size). A Harvard Review Meta-analysis[4] looked at the effect size of long-term psychoanalytic therapy on people suffering from a range of DSM diagnoses. For ease, they broke these diagnoses down into two categories, Mild/Moderate Symptoms and Sever Personality Disorders. The former had an effect size of 0.78 and the latter of 0.94 when compared to the waiting list. The patients that participated in the reviewed studies were all adults and had undergone on average 150 therapy sessions.

All of the results we looked at up till now are end of study results not long-term results. The end of study results does state how a person is feeling after the treatment. The problem is that it doesn’t tell us if the benefits that are measured are lasting (there are other methodological issues with this, though it goes beyond the scope of the current paper). I would consider that longer term measures are more important than short term effects, as when you go to the doctor you hope for a cure not for a short-term solution. If we look at a couple of Meta-analysis that tracks depression relapses with a variety of antidepressant drugs[5][6] we can see up till 30% relapse within 1 – 2 years after the treatment after being considered to be in full remission. If we look at the data we can see that medications regularly work for limited periods of time and then stop working. If we now look at a study done by Journal of the American Medical Association[7] that looked at the effect size 2 years after finishing a long-term treatment, this resulted in an increase in effect size, from 1.03 at the end of the treatment to 1.25 after 2 years. This means, that while the people that were treated with medicine are doing worse as a group the group of people that have been treated with psychodynamic therapy are doing better as a group. Hence, at group level with psychodynamic psychotherapy more people get better as with time, which can let us state that psychodynamic therapy has a psychoactive dimension which integrates within the psyche of the patient even post-treatment. We can see the same for the Cochrane Library meta-analysis, were the effect sizes went to between 0.98 to 2.21, depending of disease, from between 0.59 to 1.08. Before, concluding that based on the evidence presented in this part we can say for sure that psychoanalysis is a science, I want to present one more individual study that is of tremendous importance when we will argue for the revolutionary aspect of psychoanalysis. Fonagy and Bateman[8] developed a psychoanalytical treatment protocol for one of the most difficult to treat diseases, namely for Borderline Personality disorder, one of the most difficult conditions to treat in mental health which for a long time was strongly considered as being untreatable with such thought coming out of the lips of many clinicians even today and being even supported by the DSM, as BPD is a personality disorder and it is not clear if one can change their personality. Their treatment used what is known as a mentalization based therapy that was applied on the patient for 18 months. This study was done with active controls. After the 18 months 57% of patients no longer met the criteria for the disorder, while in the control group only 13% were that lucky. 8 years after the initial treatment the patients were retested, and the results were astonishing: 87% now of the patients that were treated with the psychoanalytic method were now cured, while for the control group the result stood at a firm 13%.

 

3. Conclusion

Now that we have seen with our own eyes that psychoanalysis can be treated clearly as an objective science whose truths can be put out for debate into the public forum, we can move on to the final part of this paper, the question of the revolutionary nature of said science. For this I will shortly introduce Kuhn’s phases of science and then argue whether or not psychoanalysis should fit into the forth phase, that of scientific revolution. I will not aim to integrate it within any of the other three phases as that would go beyond the subject at hand.

According to Kuhn science goes through 4 phases: pre-paradigmatic phase, normal science, crisis, and scientific revolution. The pre-paradigmatic phase defines itself as a phase where there is as of yet no shared, or commonly accepted theories, concepts and methods within the community. It is almost impossible for science to evolve at this point as there is no defined way of telling who is correct and of communicating the results of various experiments so that one may determine who is correct.  Normal science, on the other hand, is defined by the existence of a paradigm (all the theories, concepts and methods that a scientific period takes for granted). In this second stage scientists trust this paradigm, and the main activity can be seen as solving scientific puzzles within the rules of the paradigm. The transition from the first phase to the next takes place as various paradigms fight within the public forum and one starts achieving dominance.  As paradigms are being used anomalies start to pop up. These anomalies are problems within the paradigm that scientists are at present unable to solve. Once the paradigm is confronted by an anomaly that it cannot adapt to, it has to be changed. Thus, an anomaly leads to a crisis when the scientists lose their confidence in the ability that the current model can resolve such a problem in due time. In times of crisis, new paradigms are being suggested that fight for dominance with the existing one and between one another. Once a new paradigm has been accepted by the majority in the scientific community, then we can say that we have a scientific revolution.

As stated in the introduction, psychoanalysis was created in order to treat those diseases that did not seem to have any physiological source but that were still deeply troubling people in their colloquial lives. While it is true that Freud did consider that any psychological issue is actually a neuropsychological issue, this does not change the fact that he developed a therapy that did not require anyone playing around with the neurons of the patients. Even today it is still believed, by many, that if we obtain full control over our neurological structure we can cure all psychological ailments. I’m willing to deny nor to support such statements here, but for now we need to deal with the fact that we have no such understanding nor control and that we can’t evaluate the evolutionary nature of the psychoanalytic process based on some ideas that were not put into practice. On the other hand, I wish to evaluate it in confrontation with the standard medical approach that was and very often even today still is being used in dealing with psychological diseases, drugs and electroshock therapy (while the latter has been used less and less). The method that Freud gave birth to needs and can be compared to at least one of the above, namely to drugs (which, dough I’m not arguing for this with sources but with common sense, I think the medical community has realized is much more effective, given that neurological activity is mainly driven by neurochemical reactions, than electroshock therapy). Based on the date I have provided at the end of chapter 3, we can see clearly that the elements of the medical approach, that Freud set forth to replace at the beginning of the 20th century, have been shown to be underperforming in comparison to psychoanalysis, if not almost completely ineffective in severe cases such as BPD.

What we can clearly say given the above data and taking into account Kuhn’s phases, is that if not for other diseases, at least for the treatment of personality and mood disorders psychoanalysis has proven to be much more effective than the before paradigms. Though, I could not say with just this that psychoanalysis is a scientific revolution. The only way to state such a thing is if we consider that psychoanalysis as the root and all other psychological treatments, but even in this case the only subject that can be said to be revolutionary is the psychotherapy with all the methods that fit within this category, as only this has  both the results and the following needed to be considered so in accordance to Kuhn.

However, on a personal level, I have to say that given the insurmountable difference in efficacy between the psychoanalytic method and the traditional medical method, I support with the deepest of convictions that the psychoanalytic method is a scientific revolution in the curing of personality and mood disorders.

 

 

 

Bibliography:

 

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Thomas Kuhn, Stanford Encyclopedia of Philosophy, https://plato.stanford.edu/entries/thomas-kuhn/ , 28/06/2018

 

 

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[8] Bateman A, Fonagy P; Randomized controlled trail of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder; American Journal of Psychology; 20009; 165: 556-559

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