Successful and Schizophrenic

A moving account by Elyn R. Saks of building a successful and creative life while experiencing schizophrenia. After a hospitalisation at the age of 28 she was advised that because of her diagnosis she would never lead an independent life. She has since become Associate Dean and Orrin B. Evans Professor of Law, Psychology, and Psychiatry and the Behavioral Sciences at the University of Southern California Gould Law School.

Psychoanalysis and research

An editorial piece for the December 2010 edition of the journal Psychoanalytic Psychotherapy makes for challenging reading. The authors strenuously criticise the indifference and resistance towards research that they see amongst many psychoanalysts.

Given the time, cost, and intensity of the demands placed on patients and therapists who enter into psychoanalysis, the fact that the field has neglected to perform appropriate assessments of whether or not the treatments we routinely recommend and deliver actually work is shocking.

The authors are not anti-psychoanalysis, both are staff members of the Columbia University Center for Psychoanalytic Training and Research. Part of their concern is for the diminishing prevalence and influence of psychoanalytic treatment, which they relate to the absence of sound evidence for its effectiveness. They dismiss those forms of evidence that are most often used by psychoanalysts and psychodynamic psychotherapists.

…clinical lore, collegial interaction, and direct observations by sole practitioners can appear superficially rational as a basis for determining the effectiveness of a treatment….
Psychoanalysts pride themselves on their awareness of the impact of fantasy and wishful thinking during their treatments, but minimize the impact of such factors on their subjective assessment of their own clinical outcomes.

In place of such subjectivity, the effectiveness of these treatments should be evaluated using randomised controlled trials based upon treatment manuals, so that the practitioner’s adherence to the treatment protocol can be assessed. Although some effectiveness studies have been published, it is claimed that many are flawed.

As I say, a challenging article, and one that leaves me with contradictory thoughts.

On the one hand I do feel the lack of a widely-accepted evidence base for the effectiveness of psychoanalytic psychotherapy. I do think that such a body of evidence is growing and I appreciate those studies that I see that add to this evidence.

However, I’m uneasy about the the insistence that randomised controlled trials provide the only trustworthy evidence of effectiveness. The work of John Ioannidis, for example, brings the reliability of such trials into question. In a study of 49 of the most highly regarded and frequently cited medical papers published in the last 13 years, his team found that 11 had not received independent verification, while of those that were retested, 14 or 41% ‘had been convincingly shown to be wrong or significantly exaggerated’. Two fifths of these key papers, when retested, were shown to be misleading, papers that were widely cited and referred to by physicians for guidance. (see my earlier post)

I’m also sceptical about the prospect of manualised treatment. For me psychotherapy is about an encounter between two people, with an attempt by the therapist to leave behind preconceptions and to see what use of him or her the patient or client wishes to make. Can a manual allow me to enter into that encounter without memory or desire? Although, I have to admit my ignorance of such manuals and how they are utilised.

And so I’m left with dilemmas that for now I cannot resolve. I want, for myself and for our profession, proof that this practice is effective, both for ethical reasons and to secure our place amongst recommended treatments. But I’m also not sure that the concept of treatment is the best way to describe this journey that I take with my patients. Certainly they come to me in distress and hoping for change. And, given the investment noted above, they deserve to find that our encounter is worthwhile and helps to bring about change. But I have doubts that this is best described in terms of a DSM diagnosis or the relief of a symptom.

Mother-infant psychoanalysis

A Swedish study, involving mothers with troubled infants, showed improvements in mother’s depression and her relationship with her baby following a two-month course of two or three times a week psychoanalytic treatment for both mother and infant.

I recently came across a link to this interesting study, reported in Science Daily last year. The study followed 80 mothers who had sought help at Child Health Centres, nursing centres or  parenting internet sites. All of the mother-infant pairs received support from the centres, but half were also assigned to joint psychoanalytic treatment at the Mother-Infant Psychoanalytic Project of Stockholm. The treatment lasted about two months, with two to three sessions a week.

The treatment provided a safe environment in which the mother and her baby could  express how they felt. With the help of the analyst the mother could come to understand her baby’s ‘difficult’ behaviour as a form of communication, rather than as an attack upon her or a result of her failure. In this safe place the mother and baby could finally find each other.

In follow-ups six months later, mothers who had received the psychoanalytic treatment showed improvements in their depression, better relationships with their babies and a greater sensitivity to their baby’s signals, as compared to mothers who had only received the support of the Child Health Centres.

Morality and empathy in babies

Recent research is throwing more light on the moral understanding that young infants have of the world. Paul Bloom, a professor of psychology at Yale, has written a New York Times article about research at the Infant Cognition Center into the moral life of babies. As well as showing how even very young infants start to develop an understanding of how the world functions, the research also demonstrates the early existence of empathy and identification.

Bloom’s article begins by describing the baby’s early understanding of physics and psychology, and the techniques used to investigate this understanding. Rather than living in a completely chaotic world, eye tracking techniques show that even very young babies have realistic expectations about such things as the operation of gravity and the movement of objects through space and time. For example, babies show surprise when objects appear not to conform to these laws. While their expectation of the external world may be relatively naive, these babies nonetheless show an early understanding of how the world is structured.

As well as this understanding of the external physical world, toddlers also show some early understanding of the existence of internal world within others. Bloom quotes a study which shows that 15 month-old toddlers are able to conceive of the mental life of other people. The toddlers are shown an adult watching an object being placed inside a box. The object is then removed from the box without the adult’s knowledge. However, the infants still expect the adult to look for the object in the now empty box. For this to be the case the toddlers must understand how the adult mistakenly views the world, the infant must have an idea of the adult’s internal world.

The researchers at the Infant Cognition Centre have gone on to use these techniques to explore what moral understanding babies have of the world. Their investigations involve showing babies puppets or geometrical shapes as characters in situations in which they helped or hindered someone else. Babies who were as young as 5 months old showed a preference for the helpful shapes or puppets over the unhelpful ones. To get closer to ideas of justice, the investigators then introduced situations of reward or punishment. Helpful characters were rewarded or punished by another puppet, and unhelpful characters were treated likewise. When the character was helpful, the babies preferred the puppet that was rewarding it rather than the puppet which punished. However, with the hindering characters the preference was reversed, with the babies preferring the puppet who punished the character. The babies demonstrated a sense of fairness.

In Bloom’s discussion he argues that these experiments show the early existence of a naive moral understanding held by infants, similar to their naive understanding of the physical and psychological worlds. At an early stage we have the tools with which to judge the actions of others and to respond to kindness and meanness. However, Bloom points out that this understanding is still very undeveloped and unmodified by culture and rationality.

These are interesting findings which show the infant’s early understanding of the world, including the internal worlds of other people. The findings join a growing body of evidence for our early capacity for empathy and identification. In their preferences for ‘nice’ characters it is likely that these babies were identifying with the characters in these vignettes. As well as understanding the internal worlds of others, these babies were internalising the external world, becoming involved in these dramas and making judgements about the participants. These are processes which lie at the heart of a psychoanalytic understanding of human development.

Encounters Through Generations

Film from the British Psychoanalytic Society with eminent older psychoanalysts discussing their trade and the future of analysis.

I was impressed by the humanity shown by these elder analysts. It was also interesting to hear Betty Joseph and others talk about similar themes to those that we hear every day in the psychoanalytic psychotherapy world. Themes that includes a pessimism caused by the swing of fashion against psychoanalysis. Nonetheless the depth of perception and humanity evidenced by these analysts makes me think that psychoanalysis has enough truth to outlive these changes of fashion.

Go to Encounters Through Generations