Is Psychoanalysis Mounting a New Challenge to Cognitive Behavioral Therapy?

Photo: Max Halberstadt

If you ask the average right-thinking person who follows psychological research what forms of therapy do and don’t work, here’s a likely answer: Cognitive behavioral therapy, which focuses on getting patients to recognize and disrupt certain types of harmful thought patterns, works. Freudian psychoanalysis, which tends to be a longer-term explanation of how patients’ reactions to life and their behavior in relationships are shaped by roiling unconscious forces, many of them stemming from childhood events, is mostly bunk.

Writing in The Guardian, Oliver Burkeman has a long article that complicates this view in intelligent, provocative ways, and it’s very much worth reading for anyone interested in practical questions about the effectiveness of therapy, the trickiness of studying behavioral science, or both. The basic gist: Though the CBT-beats-psychoanalysis line has, in some quarters, solidified as settled fact (or close enough), there’s at least some research that should make us question it. Those in the psychoanalysis camp, Burkeman notes, can point to recent studies that both show CBT to be less effective than previously trumpeted, and psychoanalysis more so — especially when it comes to how patients do in the long term.

There’s no way to fully capture the nuances of Burkeman’s article in a blog post — you really should read it. But here are a few scattered observations that I think should be part of the follow-up conversations his piece will hopefully spark:

1. Let’s not lump together a therapy and the way it might be administered.
At one point, Burkeman relays a story that feels ripped from a dystopian Terry Gilliam film:

A few years ago, after CBT had started to dominate taxpayer-funded therapy in Britain, a woman I’ll call Rachel, from Oxfordshire, sought therapy on the NHS for depression, following the birth of her first child. She was sent first to sit through a group PowerPoint presentation, promising five steps to “improve your mood”; then she received CBT from a therapist and, in between sessions, via computer. “I don’t think anything has ever made me feel as lonely and isolated as having a computer program ask me how I felt on a scale of one to five, and – after I’d clicked the sad emoticon on the screen – telling me it was ‘sorry to hear that’ in a prerecorded voice,” Rachel recalled. Completing CBT worksheets under a human therapist’s guidance wasn’t much better. “With postnatal depression,” she said, “you’ve gone from a situation in which you’ve been working, earning your own money, doing interesting things – and suddenly you’re at home on your own, mostly covered in sick, with no adult to talk to.” What she needed, she sees now, was real connection: that fundamental if hard-to-express sense of being held in the mind of another person, even if only for a short period each week.

I may be mentally ill,” Rachel said, “but I do know that a computer does not feel bad for me.”

Throughout the article, Burkeman highlights the various ways CBT can seem a bit mechanistic or robotic, especially as compared to the sometimes-years-long relationships psychoanalysis patients develop with their analysts.

And yes, in its most boiled-down and streamlined forms, CBT can consist of workbooks, PowerPoints, and the like, but as Burkeman acknowledges, there are also versions of CBT that do, for example, encourage patients to look at possible root causes of their behavior and problems — many talk therapists, in fact, have a CBT focus.

2. We can’t talk about psychological treatment without talking about resource constraints.
When you address mental illness as a public-health problem requiring public-health funding, which it is, you quickly get into somewhat uncomfortable territory. Which therapies should get funding? What are the criteria for saying a therapy “works” enough to be useful on a large scale? To what extent will you accept outcomes that aren’t perfect but do seem to be net-positive?

For instance, let’s say the aforementioned computer-assisted delivery of CBT skills does make a few patients feel uncomfortable, but that it can significantly reduce anxiety and depression symptoms among, say, 40 percent of those who complete the curriculum (I’m pulling a number at random for the sake of this hypothetical). And let’s say that, given the size of the group of people you can offer treatment to, to make the same number of people feel better through psychoanalysis, you’d need to spend five times as much money (again, just an example).

It may well be the case that you can afford to fund one but not the other. At that point, is it moral, or smart from a policy perspective, to reject an intervention simply because it feels creepy or less personalized or whatever else? In the world of public health, lots of things don’t feel great but are good policy, or better than any plausible alternatives.

3. It’s hard to separate out the benefits of psychoanalysis from the benefits of just having someone to talk to.
Simply because Burkeman’s piece is long and contains lots of fascinating stuff, one particular point gets a bit relegated to the end, but it’s really important:

[M]any scholars have been drawn to what has become known as the “dodo-bird verdict”: the idea, supported by some studies, that the specific kind of therapy makes little difference. (The name comes from the Dodo’s pronouncement in Alice in Wonderland: “Everybody has won, and all must have prizes.”) What seems to matter much more is the presence of a compassionate, dedicated therapist, and a patient committed to change; if one therapy is better than all others for all or even most problems, it has yet to be discovered. [Psychoanalyst] David Pollens, in his Upper East Side consulting room, said he had some sympathy for that verdict, despite his passion for psychoanalysis. “There was a wonderful British analyst, Michael Balint, who was very involved in medical training, and he had a question he liked to pose [to doctors],” Pollens said. It was: “‘What do you think is the most powerful medication you prescribe?’ And people would try to answer that, and then eventually he’d say: ‘the relationship’.”

In some of the studies cited as supporting psychoanalysis, it’s not entirely clear what’s going on — whether the patient is benefiting from the quirky specifics of the psychoanalytical approach, or benefiting from having regular access to a space where they can unload their most personal, troubling problems on a trusted confidant. As this debate continues, it’s really important to keep this distinction in mind.

Freud Fights Back Against the CBT Consensus