Contemporary Psychiatry,Psychoanalysis,and Psychotherapy

In his Perspective, “Is Psychoanalysis Still Relevant to Psychiatry?” Paris ¹ presents a critical perspective on psychoanalysis in the context of evidence-based care. Scientific discourse demands critical dialogue, and so in this editorial, I provide alternative perspectives on some of Paris’s arguments and further thoughts on psychoanalytic training, research, and treatment. My concern is that by unnecessarily pitting psychiatry against psychoanalysis, we may throw out the baby with the bathwater.

Psychoanalysis provided the modern origin of the talking therapies. From its beginning with the works of Freud, it has evolved to incorporate intersubjectivist etiological formulations of pathology, suffering, and healing. ² Leuzinger-Bohleber, editor of a recent comprehensive review of psychoanalytic research, comments that “not only a plurality of theories has been developed but also a plurality of research procedures, which is an indicator for any mature scientific discipline” (p. VIII). ³ Paris ¹ points out how the principles of psychoanalysis and its derivative, psychodynamic psychotherapy, have progressed to incorporate infant research and to reconcile themselves with neurobiology. Beyond those influences, current psychoanalytic thought is informed by theory of mind, feminist theory, queer theory, sociology, cognitive psychology, nonlinear dynamics, evolutionary biology, political science, anthropology, Buddhism, evolutionary psychology, and ethology. Many aspects of this rich interdisciplinary landscape of influences lie outside the domain of science and its standards of evidence, but not all.

Indeed, there is no doubt about the strength of evidence supporting various modalities of psychotherapy as treatment or their place in psychiatry. Canadian position papers and working group papers on psychotherapy published over the past 4 decades highlight that psychotherapy treatments are integral, core components of psychiatric practice. ^{4 –6} In these position papers, psychoanalysis is not separately discussed; however, as Paris ¹ notes, the founding authors of numerous theories of psychopathology (e.g., Bowlby, Beck, Fonagy, and Bateman) from which psychotherapy treatments have been developed acknowledge their indebtedness to psychoanalytic ideas. The most recent Canadian Psychiatric Association (CPA) position paper on psychotherapy in psychiatry underscores “the unique contributions psychiatrists can make when they are able to integrate psychological and biological approaches within a treatment plan ⁶ .” Psychotherapies are recommended as effective treatments for many psychiatric disorders, with a strong evidentiary base of support, whether used alone, sequenced with pharmacological treatments, or combined with medication. They are thus included in international consensus treatment guidelines. ^{7 –11} In the recently updated Canadian Network for Mood and Anxiety Treatments (CanMAT) depression guidelines, cognitive behavioural therapy and interpersonal psychotherapy are first-line treatments, and psychodynamic psychotherapy is a second-line recommended treatment. ⁸ Meta-analyses and systematic reviews of psychodynamic and psychoanalytic psychotherapy research that include controlled trials have established empiric, evidence-based support, especially for short-term psychodynamic psychotherapy. ^3,12 Further evidence from randomised controlled trials (RCTs), while fraught with challenges, is indeed needed given the high intensity and high costs of psychoanalytic treatment and in light of public health needs to improve access to mental health care. ¹³ It is true that one of the hazards of the “mature science” that has produced multiple psychodynamic and psychoanalytic approaches is that it is difficult to make comparisons and to generalise findings to practice. It is reassuring, however, that the effect sizes of psychotherapies in general are equivalent to and sometimes greater than pharmacotherapy treatments, with superior results in long-term follow-up for some conditions, especially anxiety disorders. ^{8,14 –22}

As Paris ¹ points out, psychoanalysis uses intensive individual single cases for training and exposition of clinical techniques. Case reports do not test hypotheses, but neither are they intended to. Their value is substantial but is intended to support case-based education, the development of theory, and qualitative research. Case reports with close examination of the details of individual patients’ stories form a core of analytic training and discourse, grounding clinical observations within theories. It is a method that has been valuable enough to be retained in psychiatry ²³ and other forms of psychotherapy training. ^{24 –26}

Of course, sources of evidence are not confined to RCTs and cases. Experimental studies integrate anatomical, genetic, and neurophysiological observations to elucidate the roles of interpersonal and mental processes in pathological functioning, ^{27 –34} and process research examines moderators and mediators of outcome. An epistemic framework for research that integrates advances in psychoanalysis, psychotherapy, neurobiology, and psychology using multiple methods is compatible with 21st-century research agendas. ^3,35 This research need not be seen as an “attempt to rescue psychoanalysis” but merely as the natural progress of discovery that has always been a driving force in science.

Attachment and other theories used in formulation need not be seen as “another theory to blame parents” but rather as useful paradigms to understand early life adaptation and current difficulties such as affect regulation or maladaptive adult patterns of relating. Contemporary attachment theorists and developmental psychologists are taking into account temperament, early life experiences, social environments, and epigenetics in the etiology and treatment of psychiatric problems. ^{36 –38} With respect to the consideration of alloparenting, the very first question of the gold standard of assessing adult attachment, the Adult Attachment Interview, is “who raised you?” assuming that early life primary care providers are biological or adoptive parents, but this can also be interpreted more broadly. ³⁹ Every argument can be undermined by cherry-picking.

Paris ¹ raises questions about the role of psychoanalysis in psychiatry, which are similarly important for many kinds of medical therapeutics. Insufficient numbers of RCTs, publication bias, training requirements, nonstandardised applications of guidelines, and the high-intensity, costly treatments require scrutiny.

Psychiatry residency training does not prepare psychiatrists to practice psychoanalysis; however, its theories are taught—theories that have evolved over time to inform contemporary psychodynamic psychotherapy practices and remain core aspects of various time-limited psychotherapy models. These dynamically informed constructs include the importance of the therapeutic alliance, the establishment of shared goals, and the need to actively listen to our patients with empathy and attentive presence. Some key concepts of psychoanalysis have endured and form the basis of psychodynamic psychotherapy: some of mental life is unconscious; past experiences influence our present ones; trauma and neglect are sources of pathology; transference to the therapist and others is a primary source of data for understanding; countertransference can provide information about the patient’s impact upon others; unpleasant or threatening thoughts, memories, feelings, desires, or perceptions are sometimes kept out of awareness, resulting in difficulties, symptoms, and problematic behaviours; and psychopathology is determined by the interaction of complex biological and psychological forces. We can retain the fruits of the psychoanalytic thought without retaining the historical methods of psychoanalysts, but psychiatry would be much poorer without these insights.

Although there are fewer controlled studies of psychoanalytic treatment, there is in fact evidence for the efficacy of both short- and long-term psychodynamic psychotherapy (LTPP). ¹² Leichsenring and Rabung’s systematic review ⁴⁰ of 23 studies conducted between 1984 and 2008 identified 11 prospective RCTs and 12 observational studies of >1000 patients receiving LTPP in which there was a large within-group effect size of 0.96 (95% confidence interval, 0.87-1.05) for pre- to posttreatment overall outcomes, and for the 8 studies that included a comparison group, the overall between-group effect size was even larger at 1.8 (95% CI, 0.70-3.4). There is no question that more research is needed and that the plurarity of analytic models along with the feasibility challenges of studying long-term models makes this difficult. Although dismantling studies have been suggested, it may be that the unique combination of elements in affect-focused psychotherapies accounts for their effectiveness. ⁴¹

Psychiatrists in particular need to possess both knowledge and skills in evidence-supported psychotherapies, including psychodynamics, to act as medical experts, consultants, stewards of clinical service teams, shared care collaborators, and trainers of future generations of mental health professionals. Psychotherapy expertise enhances the psychiatrist’s capacity to use a biopsychosocial formulation to guide assessment and treatment decisions, form and sustain therapeutic alliances, motivate patients to engage in treatment and health-promoting behaviours, and ethically manage the complicated dynamics of clinician-patient relationships. ⁴²

The next decade will no doubt generate innovations to further improve psychotherapy’s effectiveness and access for individuals with mental illness. Our prime minister, Justin Trudeau, and national health minister, the Honourable Jane Philpot, along with many of the provincial ministries of health are to be commended for their increased support of mental health access that includes psychological treatments. Psychotherapy treatments can effectively address suffering and enhance outcomes and the quality of care of mental illnesses across a spectrum of health care settings. As evidence-based practitioners and psychiatrists, we must use what is best for our patients and be trained in a broad range of effective treatments, including psychotherapies and psychoanalytic principles. Based on 40 years of outcome and process research, it is clear that psychotherapy treatments are helpful for patients with psychiatric disorders and therefore a critical component to be preserved in the training and practice of psychiatrists of the 21st century.