THE SUNDAY TELEGRAPH – 05 May 1996
Analysis can drive you mad
Why spend years in Freudian psychoanalysis, when ‘cognitive therapy’ brings relief in months? The days of the dream doctor are numbered, says Dr James Le FanuPSYCHOANALYSTS are an unhappy lot. Having to listen to the incoherent details of their patients’ dreams is tedious enough, but their angst is now compounded by a rising tide of scepticism from their medical colleagues. Psychoanalysis, according to Raymond Tallis, Professor of Medicine, writing in The Lancet a month ago, is "a scientific fairytale".
"The criticism that it is expensive and ineffective has given way to the grievous charge that it is often dangerous and destructive," he writes. "Its peculiar ideas confuse and undermine vulnerable individuals, while its practitioners manipulate the affections and misplaced faith of their clients to ensure continuing lucrative commitment to their remedies."
As for the founder of psychoanalysis, Sigmund Freud, the portrait painted by his most recent biographer, Richard Webster, is of a man of pathological unpleasantness, quite unrepentant about his many diagnostic blunders, and a compulsive manipulator of those around him.
Reacting to this tide of hostile criticism, 80 psychoanalysts and academics gathered recently in the library of the Anna Freud Centre in leafy Hampstead for a conference on "science and psychoanalysis". Under the steely gaze of photographs of the great man which line the walls, Peter Fonagy, Professor of Psychoanalysis at University College, sought to explain how, in his own words "we got into this mess".
Psychoanalysts need to adopt a rigorous, scientific approach to their work, he argued, because "science brings the credibility of objective trustworthy knowledge which most closely approximates to what people regard as true or real".
There are two aspects to the question as to whether psychoanalysis is "true". The first concerns the validity of the theory that underpins it. Do young boys fall in love with their mothers and fear castration by their fathers? Are infants driven by libidinal urges to seek sensual gratification through the mouth, anus and genitals? Does the source of neurosis lie in repressed and painful memories knocking around the echoing chambers of the unconscious mind?
Such fundamental concepts are now, according to Prof Fonagy, "so riddled with controversy" that "there is no longer a coherent set of principles that could be tested scientifically".
Psychoanalysis may lack a coherent theory, but its techniques, particularly the relationship with the analyst – otherwise known as the transference – could still be efficacious. So the second question that warrants scientific scrutiny is whether it works. Does it make people better, or at least less unhappy? Here, judgment is divided. Many people certainly believe they have been helped, but this could just be from having the opportunity to talk about themselves to someone they are paying to listen, while the specific insights offered by the analyst could be irrelevant. Certainly, when Prof Gavin Andrews, of the University of New South Wales, reviewed all the studies in which the outcome of psychoanalysis had been objectively measured in the British Journal of Psychiatry a couple of years ago, he was unable to show that it worked any better than "just talking". Over the past few years the credibility of psychoanalysis has been eclipsed by the remarkable success of another type of psychotherapy – cognitive therapy – which is based on a theory of neurotic illness that is almost the direct antithesis of that proposed by Freud 100 years ago. Cognitive therapy dispenses with the couch, with dream analysis and free association. It looks for the causes and solutions of mental problems, not in long-forgotten events from early childhood but in patients’ everyday life. Treatment lasts months rather than years and, crucially, it has consistently been shown to be effective even in those conditions usually considered to be "too difficult" for psychoanalysis, such as serious anxiety states and depression. Cognitive therapy, as its name implies, is concerned with what, or more precisely how, people think about themselves and the world around them. Thoughts exert a profound influence on feelings and emotions, and so distorted patterns of thinking – such as the belief that one is unloved – can profoundly affect the emotions. In cognitive therapy such distorted patterns of thinking are identified, and in theory, once corrected, the feelings they cause of depression and anxiety should be ameliorated.
It is hard to conceive of a theory of psychological illness more distinct from the Freudian concept of repressed libidinal urges locked up in the unconscious mind. Nevertheless, the roots of cognitive therapy lie in psychoanalysis as described by one of its early pioneers, Aaron Beck. Back in the Sixties, while practising as an analyst in Philadelphia, Beck was treating a young woman with an anxiety state which he initially interpreted in true Freudian fashion as being due to her unhappy sex life.
During one session, he noticed that his patient seemed particularly uneasy when talking about her sexual hang-ups, and, on inquiring why, it emerged that she felt embarrassed because she thought she was expressing herself badly and that she sounded trite and foolish.
"These self-evaluative thoughts were very striking," Beck recalls. "Because she was actually very articulate." Probing further, he found that this false pattern of thinking that she was dull and uninteresting permeated all her relationships. He concluded her chronic anxiety had little to do with her sex life, but rather arose from a constant state of dread lest her lover might desert her because he found her so tedious.
Over the next few years Beck found he was able to identify similar and quite predictable subliminal patterns of thinking in nearly all the patients who came to him for analysis. He labelled these "automatic thoughts", which operated at the margins of consciousness, a type of continuous internal monologue of which his patients could be made aware once their attention was directed towards them. When these automatic thoughts were brought out into the open, examined and discussed, his patients reported an enormous improvement in their emotional well-being – much greater than he had achieved from years of submitting them to psychoanalysis.
For the first time he felt he was getting inside his patients’ minds and beginning to see the world as they experienced it.
For Mark Williams, Professor of Psychology at Bangor University in North Wales, cognitive therapy is "a liberation" because it liberates people from having to depend on their analysts to interpret their problems for them. In cognitive therapy, the therapist acts as a collaborator, helping to identify and correct the distorted patterns of thinking that lie behind so many neurotic illnesses.
"Cognitive therapy has been criticised for being far too simple," Williams says. "But why shouldn’t it be simple? We can too easily be carried away with the complexity of the human mind, and miss the point that the only really important thing for patients with psychological problems is that they start feeling better, and be offered the means by which they can become so."
The most damaging legacy of Freudism, he believes, has been to convince people that there must be some mysterious root cause of mental illness, stemming from repressed events in childhood. Certainly, an unhappy childhood can predispose people to the development of neuroses, but the cause can equally be genetic – a subtle alteration in the biochemistry of the brain – or a reaction to adverse events in adult life. The major advance of cognitive therapy has been to show that, irrespective of the precise cause, the final common path of the neuroses can best be understood in terms of distorted patterns of thinking.
The most convincing evidence supporting the validity of cognitive therapy is that it works. Prof Gavin Andrews, in his review in the British Journal of Psychiatry, identified it as "the treatment of choice" in generalised anxiety disorder, obsessive compulsive disorders and depression. Further, it showed "promising results" in the management of marital and sexual difficulties, in bulimia, in chronic pain syndromes and many emotional disorders of childhood. Since Prof Andrews’ review, cognitive therapy has also been used for the treatment of schizophrenia, personality disorders and chronic fatigue syndrome.
This remarkable scope of cognitive therapy, argues Prof Andrews, has "devastating implications for the future of psychoanalysis". The duration and intensity of psychoanalysis means that at any one time analysts can treat fewer than one per cent of those suffering from a neurotic illness who could benefit from psychotherapy, and even for this small minority it has not been possible to show objectively that psychoanalysis "is better than a placebo". Rather, argues Prof Andrews, there needs to be a substantial shift towards cognitive therapy because "it is important to explain to people what is wrong with them, and if this is done properly the patient feels reassured and more in control."
Currently, there are some 250 consultant psychotherapists working in the National Health Service, almost all "psychoanalytically-oriented". Prof Andrews is blunt. "They should switch to practising cognitive therapy or be dismissed to make way for those who are willing to do so." In Cambridge last year, two psychoanalysts were dismissed from their NHS posts and replaced with therapists "sympathetic" to the cognitive therapy approach. The "scientific fairytale" of psychoanalysis is heading for oblivion.
Copyright: Telegraph Group Ltd