Psychoanalysis an endangered species?

(Elsenberg, 1995). But In less than a generation there has been a remarkable change In the face of psychotherapy. Psychotheraples have prolifer ated: there are more than 400 at the latest count. Psychotherapy Is established as mainstream treatment for many psychiatric disorders: family intervention in schizophrenia, cognitive-beha vioural therapy and interpersonal therapy for depression, behavioural treatments for phobic disorders among others. Research In psychother apy has blossomed, and many psychotherapeutic treatments can convincingly claim to be part of 'evidence-based medicine' (Roth & Fonagy, 1996).


Jeremy Holmes
There was a time when to be a psychotherapist was virtually synonymous with being an analyst, 'psychoanalysis was the only game in town' (Elsenberg, 1995). But In less than a generation there has been a remarkable change In the face of psychotherapy. Psychotheraples have prolifer ated: there are more than 400 at the latest count. Psychotherapy Is established as mainstream treatment for many psychiatric disorders: family intervention in schizophrenia, cognitive-beha vioural therapy and interpersonal therapy for depression, behavioural treatments for phobic disorders among others. Research In psychother apy has blossomed, and many psychotherapeutic treatments can convincingly claim to be part of 'evidence-based medicine' (Roth & Fonagy, 1996).
But amidst the burgeoning importance of psychiatric psychotherapy, psychoanalysis ap pears conspicuous by its absence. This Is particularly curious since In non-psychiatric academic circles, interest in Freud and in psycho analysis has never been greater. Moreover, rallying calls to 'bury Freud' fTallls, 1996) or explanations of "whyFreud was wrong' (Webster, 1995), appear to underpin this increasing mar ginalisation. What then is the place of psycho analysis in contemporary psychiatry and psychotherapy? Can psychoanalysis be justified as a discipline and a therapy without special pleading or tendentiousness?
One tack Is to suggest that psychoanalysis is not ailing at all, but has simply changed its name; what was formerly called psychoanalysis appears now In a different guise. Despite decades of debate, psychoanalysts have failed convincingly to make a sharp distinction in technique, objectives or outcome between their discipline and 'lesser' derivatives such as psychoanalytic psychotherapy, psychodynamic psychotherapy, or even supportive psychoanalytic psychother apy. Within this wider definition, psychoanalysis Is alive and well: a recent survey of American psychologists showed that nearly 70% described themselves as psychodynamic in orientation (Garfield & Bergin, 1994).
Another important factor, conveniently ignored by its critics, has been a quiet shift In the theoretical basis of psychoanalysis -the Aunt Sally of classical Freudianlsm is simply not relevant to present day psychoanalysis. The cornerstones of early Freudian metapsychology were repression, the unconscious, and Infantile sexuality. Contemporary psychoanalysis views all three in a very different light (Bateman & Holmes, 1995), and in ways that enable cross-fertilisation with cognltlvely based therapies. Splitting rather than repression is now seen as a key defence: the aim of treatment is not so much to undo repression but to work towards greater integra tion and coherence. The unconscious is no longer conceived as an inaccessible 'seething cauldron' of drives and impulses, but in terms of an inner representational world, populated by significant others, that acts as a template for intimate relationships and can explain recurrent patterns of relationship difficulty. The early years of life, while still seen as laying the foundations of character development, are now understood in terms of patterns of attachment, rather than primarily oedipally or pre-oedlpally.
Notions of how psychoanalysis produces change have similarly been transformed. Insight alone is no longer seen as sufficient to overcome neurosis. The 'present transference' -the feelings and thoughts evoked by the here-and-now of the analytic situation -have become the focus, rather than hypothetical reconstructions of the past. Transference Interpretations, while they still have their place, have been shown to be neither necessary nor sufficient for good outcomes. Therapy is seen as a developmental process In which the analyst, through boundaries and holding, provides the conditions for growth to take place. The emergence of pattern, meaning and coherent narrative is an aim and a mark of successful therapy.
Psychodynamic therapy continues to make a significant contribution to the psychotherapy literature. Fonagy (1995) has shown that the capacity to form secure attachments despite childhood trauma is related to what he calls 'reflexive self function' (the ability to reflect, disidentlfy, or adopt a 'meta' position in relation to one's own thought processes), surely a central aim for most forms of therapy. The notion of the 'therapeutic alliance' and its relationship to transference Is one of the key technical issues in psychoanalysis. The Vandebilt studies (Henry et al, 1994) have shown that a positive therapeutic alliance by session three is a highly robust predictor of long-term outcome in therapy, again of all types.
Good outcome sustained at follow-up is the ultimate goal of therapy and of psychotherapy research. The high relapse rates in brief therapies of all types when patients are followed up for long periods is a source of concern for psychothera pists of whatever persuasion (Roth & Fonagy, 1996), and tends to suggest that longer-term therapies which incorporate understanding of negative transference are needed, especially for the highly disturbed patients presenting to psychiatric services. Modern health services seem always to be in a hurry; time is money; but the cost of major cardiac surgery is still far greater than, say, the 100-200 hours of psychotherapy that are needed to make a significant impact on borderline personality disorder. An emphasis on sufficient time is a central psychoanalytic dimen sion that should be preserved at all costs.
Psychoanalytic psychotherapy remains a vital 'spawning ground' (Henry et al 1994) for psy chotherapy research. It uniquely provides a language both for inner experience, and for the minutae of interpersonal relationships. Psycho analysis needs to be valued, not as a relic, but in a living form that has much to contribute to the emerging integrated paradigms that will form the psychotherapies of the next century.