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The implications of contemporary neuroscience, psychology and the ‘cognitive revolution’ for psychoanalysis
Paul Williams: First off, as we move into the new millennium, what
would you consider are the main scientific challenges psychoanalysis has
to face? Linked to this is the fact that we have seen in recent years,
particularly in the US and in Britain but also elsewhere, a rapid
increase in the importance accorded to evidence-based medicine. This has
implications for research, for funding, for choice of treatments and
perhaps also for the direction of scientific inquiry in the future. How
would you characterise the implications of this trend for psychoanalysis? Peter Fonagy: There can be no doubt that psychoanalysis, and
particularly Freud’s ideas, have exerted a profound influence on 20th
century thought. I, for one, am not complacent that the continuity of
the impact of these ideas on the 21st century is assured.
There have been numerous obituaries of psychoanalysis over the past
decade. Whilst one can comfort oneself by saying that such attacks are
by no means new (for example, John Watson in the 1930s gave
psychoanalysis 20 years and thus ushered in what is generally regarded
as the heyday of the development of psychoanalytic ideas), the
pervasiveness and intensity of recent critiques cannot be shrugged off.
My concerns are both external and internal to the discipline. I’ll start with the external
challenge. The economic survival of psychoanalysis is essential for the
continuation of the discipline. The intellectual output, the development
of theory, is sustained by psychoanalytic clinical work. For clinical
work to take place, practice conditions have to be favourable. We all
depend on fellow professionals making referrals or patients referring
themselves for analysis or therapy and accepting the suggestion of a
conversion. Of course, analysts also have to be accessible to such
referrals. Insurance companies have to be willing to provide payment or
individuals with the means have to be willing to fund their own
treatment. Thus practice conditions depend on the professional culture
as well as general cultural values concerning psychoanalysis and
psychotherapy. These factors in turn (professional perception and lay
perception of psychoanalysis) are determined by societal conditions
which are always in interaction, creating rapid feedback loops which can
dramatically alter the feasibility of psychoanalytic work. An
increasingly pragmatic society with an implicit value placed on swift
and equal access to quick solutions to mental health problems creates a
professional culture which hides behind the ideology of evidence-based
medicine to deal with the problem of unequal distribution of healthcare
resources. Governments and healthcare
purchasers find it convenient to ration expensive forms of healthcare by
restricting reimbursements to treatments which, according to the
available evidence, are ‘proved to work’. Unfortunately, in the
current state of methods of psychological measurement many important
outcomes can be only very inadequately measured. Psychoanalysis concerns
complex internal states. Current measurement of psychological distress
is reductionist in relation to these. It is doubtful that some domains
of outcomes will ever be measurable. How do you quantify ‘an ethical
life’ or ‘a sense of purpose’? Just by naming a measure ‘quality
of life’ does not mean that the numbers obtained in any way reflect
this complex construct. Nevertheless, we live in a culture where a form
of treatment that is ‘without substantial evidence’ may well be
thought of as ‘without substantial value’. Once this idea is allowed to
flourish in relation to psychoanalysis, a change in professional and
general culture becomes inevitable. Such a change has the power to stop
the development of our discipline. It can do so through the rejection of
psychoanalysis as a therapeutic choice, through discouraging young
people from entering the professions and through bringing psychoanalytic
contribution to mental health disciplines and other subjects into
disrepute. The internal scientific
challenge is no less worrisome. Some years ago, with a postgraduate
student, Andrew Gerber, I looked at the frequencies with which
psychoanalytic articles were cited in major journals, both medical and
psychological and psychoanalytic. We looked at trends over the last 25
years. What we found surprised us. There was some evidence of decreasing
interest on the part of psychiatrists and social scientists in
psychoanalytic publications, measured in terms of the number of times a
paper was cited by other papers in the leading journals in these fields.
However, the more puzzling trend over the last decades was for
psychoanalytic journals to carry fewer recent psychoanalytic references.
There seems to be a trend in more recent psychoanalytic writings for
authors to quote from ‘classic’ papers and be increasingly reluctant
to include contemporary psychoanalytic literature in their citations. If these observations are to
be believed, the clear implication is that we no longer take sufficient
notice of each others’ publications to want to refer to them in our
papers. We are no longer accumulating knowledge, but rather (to
exaggerate the point somewhat) we are all developing the discipline in
our own individual directions, no doubt building on the classics, but by
and large and increasingly, ignoring contemporary contributions. The
consequence is obviously theoretical fragmentation. Ultimately, we shall
all be on our own, fiercely protecting our personal psychoanalytic patch.
Some way of counteracting this tendency for theoretical entropy must be
the major internal scientific challenge for us. PW: Neuroscience has made important strides in recent years.
It is often said that these studies need to be taken very seriously by
psychoanalysts. How seriously do you take them? What, in your view, is
the impact of this work on the theory and practice of psychoanalysis? PF: Psychoanalysts over the last fifty years have tried to
define their field independently of two major neighbouring branches of
scientific activity: neurobiology and psychology. Your question
addresses developments in the first of these fields but I believe both
are relevant and important. The rejection of biology has
not been arbitrary but was reasoned: it was not political - it was
conceptual. Psychoanalysts were, if you like, traumatised by Freud’s
failure to create a psychoanalytic neurobiology and they opted for a
purely mentalistic model based around verbal reports of internal
experience. In the 1940s and ’50s neurobiology was dominated by mass
action theory, which denied the possibility of the study of the mind
from the point of view of the brain. Neuroscientists were unconcerned
with emotion, their focus was on cognitive function. Neurobiology also
meant constitutional rather than psychosocial causation and the
unhelpful distinction between so-called functional (poorly understood)
and so-called organic disorders prevailed. Psychoanalysis had no choice
but to separate itself radically from this impoverished intellectual
framework. Neuroscience has progressed
rapidly over the last 30 years. For example, the work of LeDoux has
taught us that there are two neural pathways for emotion, one via the
thalamus to the amygdala (which conveys primitive perceptual information
with affective valence but without the involvement of consciousness) and
the other which involves the activation of cortical centres and deeper
information processing prior to the activation of the amygdala.
Neurological patients also provide evidence for unconscious emotional
discrimination. The unconscious processing of emotional information
appears to be qualitatively different from conscious processing in terms
of the neural mechanisms involved, its psychophysiological concomitants
and its behavioural consequences. Connectionist (artificial intelligence)
models of neural functioning also suggest that intrapsychic conflict is
likely to be an emergent property of the nervous system. Whereas a
neurobiological approach was historically incompatible with the
psychoanalytic tradition, this is no longer the case. I believe that if Freud were
alive today he would be quite interested in the new knowledge about
brain functioning. The Project might be recast in terms of neural nets
and he would try to understand the interaction of psychic agencies using
functional neural imaging. His constitutional speculations would be in
terms of modern molecular biology and he would be at the forefront of
investigations of gene-environment interactions. Psychoanalysts,
traditionally defensive about these remarkable advances in knowledge,
are I believe beginning to see how their insights may be enriched by the
new methods of inquiry. Mark Solms, a remarkable young intellect in the
British Society, is, for example, able to integrate, at a high level of
sophistication, his exceptional Freud scholarship with his extensive
knowledge of modern neuroscience, particularly clinical neuropsychology.
The IJPA is publishing excellent papers on relevant developments
in neuroscience. New journals are appearing to integrate psychoanalysis
with neuroscience. I think our progress as a discipline crucially
depends on breaking down the relative isolation of our discipline from
the exciting scientific developments around us. Our isolation from psychology
is historically also well justified. Until relatively recently
psychology was almost exclusively concerned with behaviour modelled on
animal learning, was deeply antagonistic to psychoanalysis, retained a
positivistic epistemology longer than most social sciences, and took a
naïve approach to mental disorder. The ‘cognitive revolution’
marked an important change. The development of a cognitive therapeutic
model in clinical psychology brought with it the recognition of the
influence of, at least descriptively, unconscious mental processes on
emotional states, increased sophistication in recording and measurement
techniques and an exciting body of new data concerning the influence of
early development and transgenerational influences on personality and
psychopathology. PW: In the UK and perhaps elsewhere, psychoanalysis is
having to face the 'cognitive revolution', especially in the public
health sphere. I am aware that, in the IJPA, you recently
discussed cognitive science's ideas on procedural (implicit) and
declarative (explicit) forms of memory on the one hand, and unconscious
fantasy and transference on the other. How viable is it that the two
disciplines can establish worthwhile links? PF: The ‘cognitive revolution’ certainly represents a
challenge. Cognitive therapy, unlike its behaviourist predecessor,
cannot be easily disregarded as simplistic or mechanistic. In fact a
thorough scrutiny of psychoanalytic method might reveal that some of its
clinically effective components are shared with CBT. To me this is a
scientifically exciting contact point of growth for both fields rather
than a threat to either. The plurality of psychoanalysis has revealed
that it is increasingly hard to identify substantial common ground in
either ætiological models or clinical technique. It seems likely to me
that the effective components of psychoanalytic treatment are not
encompassed in our grand theories but concern as yet little understood
interpersonal processes at quite a micro-level. For example, I am
convinced that the experience of four or five times a week personal
analysis is extremely important in helping us deal with the emotional
interactions with our more severely disturbed patients. The work of
Rainer Krause, for example, on the facial expression of affect in
psychotherapy showed how successful face-to-face therapy is indexed by
the subliminal emotional interplay between the therapist and patient.
Congruent responses by the therapist (the therapist’s tendency to
match the patient’s affect) appears to be associated with poor outcome.
Complementary affective responses, where the therapist manifests an
affect which is consistent with the patient’s words, which are
themselves out of line with their facial display, tends to predict good
outcome. I am sure that similar subliminal processes take place on the
couch, capitalising on the capacity of the human voice to encode
emotional meaning. Psychoanalytic training is
essential so that we can become what our patients need us to be, yet
retain our ability to help them to see what it is happening emotionally
in the dialogue. Our interpretations may have less therapeutic
importance than what we are able to communicate with our emotional
presence. On the whole, when cognitive therapy is compared to
psychodynamic treatment, it fares no better, even on the crude measures
of outcome which are currently available to us. For example, Marsha
Linehan has made a considerable reputation for herself with a cognitive
therapy which appeared to reduce parasuicidal and self-harming behaviour
in borderline patients. She has achieved this notwithstanding the
failure of the therapy to address the severe depression manifested by
these patients or indeed show any effectiveness at all one year after
termination. By contrast, Anthony Bateman, another brilliant young
British psychoanalyst, in his studies in a psychoanalytically oriented
day hospital, showed that not only did the psychoanalytic approach
reduce parasuicidal behaviour as well as depression, but the effects
remained marked and even increased in extent 18 months after the end of
treatment. Thus we have something to
learn from the cognitive revolution but also something to teach
cognitive therapists. PW: What are the key research tasks facing psychoanalysis,
in your view? PF: I see the task of psychoanalytic research as fourfold.
First, and most immediate, we need to convince third party payers, the
academic and mental health community and potential candidates (young
doctors, psychologists and other mental health professionals) that
psychoanalysis is an effective method of therapy with unique and
powerful effects. You may feel that this is not an exciting scientific
question and I would agree. Nevertheless, it is an essential
demonstration that may be key to the future development of our field.
The IPA is rising to this challenge and is offering financial and
intellectual assistance to a number of international studies focused on
the outcome of psychoanalysis. Second, and most important, research is needed to address the
conceptual problems of our discipline. Work on psychoanalytic theory
requires more systematic investigation than may be compatible with the
average clinician’s workload. All other medical specialties have a
cadre of professionals whose designated task is the advancement of the
discipline on behalf of all its practitioners. Here empirical research
methods may or may not be helpful. The key must be a systematic approach
to the study of issues of concern to psychoanalysts, the integration of
advances within our discipline as well as other disciplines and a firm
root in psychoanalytic clinical work. The key criteria for such research
are sound methodology, serious scholarship and a significant personal
commitment. Third, research should aim to
improve the public image of psychoanalysis. For example, the university
represents a key interface between psychoanalysis and the outside world
and research is, and has always been, the lingua franca of all higher
educational institutions. Again, this requirement contains no
methodological constraints. Qualitative research is increasingly
accepted within most universities and does not conflict with the
epistemological precepts of traditional psychoanalytic inquiry.
Qualitative research is, however, extremely time consuming and demands
commitment in the same way as other approaches to the advancement of
knowledge. Finally, researchers need to
address the scepticism within their own psychoanalytic communities. The
key issue is the place of so-called clinical research. And it is here
that researchers encounter the strongest opposition. The bald statement
that all psychoanalytic treatment is research is unsustainable by
current standards of research methodology in any discipline. A surgeon
is not a researcher just because he operates. One does not become an
English scholar simply by reading Henry James. The claim that
psychoanalysis has its own unique research methods, which happen to be
perfectly compatible with private practice, is naturally attractive
because it makes researchers of all of us. Traditional clinical research
has its place in hypothesis generation and theory elaboration. Without
an effective method for integrating and testing these theories the
psychoanalytic movement will inevitably fragment further. The long-term
goal of psychoanalytic research must be the elaboration and the
integration of a knowledge base which will sustain our field for the
next Millennium. The IPA’s Research Committee,
with the support of three consecutive administrations, has tried hard to
contribute to the process of evolving a psychoanalytic research
methodology through conferences, the provision of research training,
writing research reviews and, most recently, through the distribution of
pump-priming funds to psychoanalytic researchers (the work of the
Research Advisory Board under Dr Wallerstein’s leadership). The
Committee has succeeded in mobilising a significant minority of
psychoanalysts around the world whose commitment to the advancement of
psychoanalysis in diverse fields is inspirational and will undoubtedly
bear fruit for the discipline in the century to come. PW: Peter, thank you very much indeed for these thoughtful
responses.
PETER FONAGY - BIBLIOGRAFIA (2002) The place of psychoanalytic
treatments within psychiatry (with G.O. Gabbard & J.G. Gunderson) Archives
of General Psychiatry, 59(6), 505-510. (2002) Attachment research in psychoanalysis: The next
generation (with M. Target). The American Psychoanalyst ,
36(1), 12-13. (2002) Early intervention and the development of
self-regulation (with M. Target). Psychoanalytic Inquiry
, 22(3), 307-335. 2003) Genetics, developmental psychopathology and
psychoanalytic theory: The case for ending our (not so) splendid
isolation. Psychoanalytic Inquiry, 23 (2), 218-247 (2003) Attachment theory and psychoanalysis. Journal
of Child Psychotherapy, 29 (1), 109-120. (2003) The development of psychopathology from infancy
to adulthood: the mysterious unfolding of disturbance in time. Infant
Mental Health Journal, 24 (3), 212-239. |
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