Friday, August 23, 2013

Where the Analysts Went Wrong: Introduction

Cognitive Behavioral Therapy (CBT) is currently the predominant psychotherapy treatment paradigm taught to clinicians-in-training in psychology graduate schools. However, when I first received psychotherapy training in the mid 1970’s, by far the predominant school of psychotherapy was psychoanalysis. We did receive a smattering of behavior therapy training, and we were even assigned one book about family systems ideas by Virginia Satir. Our training program was a bit unusual in that regard. 

Just like the CBT industry does now, analysts exaggerated the validity of the scientific evidence for psychoanalytic theory, and made grossly inflated claims about the effectiveness of psychoanalytic treatment. Its theory was applied to everything, even to schizophrenia, although by then it was pretty clear to most of us that they were completely wrong about that condition. I’m surprised analysts did not try to treat ingrown toenails with psychoanalysis.

Just as now, economics played a huge part. (That’s why I just called it the CBT industry).  When I made some rather mild criticisms of one aspect of CBT theory and practice on my Psychology Today blog, a CBT therapist wrote a rebuttal, and several people wrote in to say how unethical I was because I was not practicing a “scientifically validated” form of psychotherapy, and was therefore by implication a snake oil salesman. 

Readers of my book, How Family Dysfunction Spurs Mental Disorders, know that the “evidence base” in all of psychotherapy is actually quite weak, and that CBT controls the funding of research and denies it to practitioners from other schools – although nonetheless there are still many studies from other schools that are every bit as strong (or should I say as weak) as the CBT studies. That includes analytically-oriented therapies, as a meta-analysis by Jonathan Shedler in the February-March 2010 issue of the American Psychologist clearly showed.

Not to mention that most psychotherapy outcome studies rely on so-called treatment manuals that spell out what therapists are supposed to do, so that all the therapists in the study are doing the same thing – regardless of how the patient is reacting to what they are doing.  NO competent practicing clinician does that. 

Psychotherapy involves science of course, but in many ways it is an art form as well. People are complicated, and each patient is unique in many ways, and can always choose to respond positively, negatively, or not at all to any intervention made by a therapist.

Additionally, each treatment manual is comprised of multiple ingredients – some of which may help or be the primary active ingredient, some of which may do nothing, and others of which may actually be counterproductive. And yet many CBT proponents argue as if everything they do has been scientifically proven.

It is clear to me that CBT practitioners say this stuff for the same reason that Big Pharma controls and distorts the practice of doing, and the dissemination of results from, studies of medication effectiveness: They want to “sell” their goods and stamp out the competition. (BTW, that does not mean that therefore a pharma-sponsered study has NO validity - only that bias must be taken into account).

Analysts also protected their turf back in the day, very arrogantly, although ultimately they failed. As a trainee, if you criticized any aspect of analytic theory, you were told in no uncertain terms that you needed to go into psychoanalysis yourself, so you could find out why you were “resistant” to analytic theory. In other words, the only reason you were questioning the theory was because you were neurotic!  

This recommendation involved the use of not one, but three logical fallacies, all wrapped up in a single statement. It was a non sequitur, since someone might be questioning the theory for any number of other reasons besides their own psychological issues. It was an ad hominem attack, since it was going after the questioner and not the question. And of course it was begging the question.  The accusation of being neurotic might be true if analytic theory is true, but that is the very issue in doubt and under debate.

Another trick that different economic interests in mental health use to denigrate the competition also involves the issue that all of the so called schools of therapy do not consist of single ideas, but consist of a large number and a wide variety of different ideas and techniques that are tied together by some common threads. Anyone who bothers to think about it has to know that some of these ideas could be wrong while others could still be right, or that an idea may have validity for some situations and for some phenomena while being inappropriate for explaining or addressing others.

For instance, people in the field may try to argue against all the ideas of a particular school, even though many are obviously quite valid, by throwing up a few incidences of when the school had something clearly wrong. They will of course pick the most egregious examples they can find. To criticize psychoanalysis, they might bring up such discredited - and now fairly much discarded - analytic ideas such as "penis envy," or the wild overemphasis on the Oedipus Complex.

Hyper-biological psychiatrists love to bring up the awful effects of the fallacious psychoanalytic theory of the “schizophrenogenic mother” to argue against all of psychotherapy, not even just psychoanalysis! I tell biological reductionists that if they don’t hold the theory of schizophrenogenic mothers against psychotherapists, then I will not hold the theory of eugenics against them.

I even hear Pharma-sponsored speakers indirectly and implicitly attack therapy by posing really, really stupid questions such as “What is better for depression –medication or psychotherapy?”  Well, first of all, that’s like asking, “What’s better for patients with coronary artery disease, taking nitroglycerin when they feel chest pain, or losing weight?” Those two interventions target two completely different aspects of the problem. 

Second, the question lumps together all types of psychotherapy. What type of therapy are we talking about? Which interventions? It would be like me arguing against the use of medication by pointing out how ineffective penicillin is for treating clinical depression.

Just as with many aspects of CBT (CBT'ers please take note that I am saying that), many aspects of psychoanalytic theory retain much explanatory power. They are so widely accepted that they have even become part of the cultural conventional wisdom in industrialized countries.

Who doesn’t believe that people sometimes take their anger out about something on someone or something else?  Mad at your boss, come home and kick the dog? That’s the defense mechanism of displacement. Yeah, like that never happens.

Intrapsychic conflict creating emotional and interpersonal problems because people want something really bad but feel guilty about it? Check. Conversations have unspoken subtexts?  Check. Acting towards authority figures in a certain way because they remind you of your father? That’s transference. Check. CBT folks may prefer to call the phenomenon schemas instead, but it's still transference. 

People wanting to avoid unpleasant subjects and in response changing the subject or explaining away inconvenient facts? That's resistance. Check.

Forgetting about unpleasant memories? Well, whether that’s unconscious or subconscious may be debatable, but the fact that repression exists? The whole Catholic Church child molestation scandal started with a case of "recovered" memory. Check.

The analysts are even right about personality problems stemming from childhood experiences within the family. The attachment literature is extremely powerful, and we all know that one of the biggest risks for just about every psychiatric condition in the DSM is a history of childhood abuse and/or neglect.

Ah, but there is where the psychoanalysts started to go wrong. They seemed to assume that childhood experiences completely determined what psychological problems a patient has and that subsequent experiences were somehow inconsequential. Orthodox analysts believe that your personality is fixed by the time you are five years old. Some go back even further than that.

Of course, if subsequent experiences could not affect personality, it would do a person no good at all to go into psychoanalysis, because the experience of psychotherapy would have absolutely no effect - according to the orthodox analysts’ own assumptions about personality formation.

The thing is, family experiences that start to create problems for children do not magically disappear when a child reaches a certain age.  In fact, they often go on and on and on in sometimes somewhat different forms until the parents die. And the human brain is structured to be highly responsive to what parents do, even in adults.  That will be the subject of Part II of this post.


  1. Sure had a nice little war here in france, between folks criticising the dominance of psychanalyts in france, brought out a book no less. Psychanalysts fought back with a book of their own. Then some philospher god knows the french love these often self important pricks, brought out an anti freud book. On my bi-polar forum, it is true they are anti psychanalyst very much so to the point of obsession. The cbt therapies of course are the best damn thing since sliced bread. Also there is often commentarys to say "Stay and the present and future no point looking backwards" It is the party line, one way and only our way.

    1. That bit about not talking about the past is pretty crazy. As if moments in time were entirely disconnected from those that came before, and that people's memories had no effect on them. As they say, those who are ignorant of history are doomed to repeat it.

  2. Thanks for saying what I've been thinking since the first time I heard the State Clinicians talk about "evidence-based practices" as they decided what therapies Medicaid would cover. These people hadn't provided any therapy, evidence-based or not, in decades, but the state government thought them qualified to decide what therapy the rest of the licensed clinicians in our state should use for our clients. CBT became the "one size fits all" intervention. Some research actually shows that CBT works for about 9-12 months, and then those benefits basically wear off. Insight-oriented therapies, which take longer to provide and thus cost insurance companies more, tend to have much longer-lasting results.