Canadian

Psychiatric Association

Association des psychiatres

Perspective du Canada

The Canadian Journal of Psychiatry /

La Revue Canadienne de Psychiatrie
Is Psychoanalysis Still Relevant to Psychiatry? 2017, Vol. 62(5) 308-312
ª The Author(s) 2017
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DOI: 10.1177/0706743717692306
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Joel Paris, MD1

Keywords
psychoanalysis, neuropsychoanalysis, attachment theory

Psychoanalysis is a theory of psychopathology and a treat- virtually all attempts to carry out revisions have fallen into
ment for mental disorders. Fifty years ago, this paradigm the same trap as afflicted Freud, that is, basing theory on
had great influence on the teaching and practice of psychia- clinical experience rather on replicable scientific evidence.12
try. Today, psychoanalysis has been marginalized and is Moreover, as acknowledged by one leader in the field,13
struggling to survive in a hostile academic and clinical training in psychoanalysis has not encouraged research,
environment.1,2 This raises the question as to whether the while articles describing empirical findings remain a rarity
paradigm is still relevant in psychiatric science and in psychoanalytic journals
practice. Attachment theory is a notable exception.14 This model
In a difficult climate for the theory and practice of psy- now has an extensive scientific literature.4 Its originator,
choanalysis, several responses have emerged, either by John Bowlby, unlike other analytic theorists, gave priority
attempting to bridge the gap with science or by redefining to research findings. 2 An American psychologist who
the field as lying outside of science. Thus, some analysts worked with Bowlby, Mary Ainsworth, developed the
have supported revised paradigms, such as attachment the- “strange situation,” a method of evaluating attachment styles
ory, that are better supported by evidence.3,4 Others have in children.15 These styles can also be measured in adults
taken the view that Freud’s ideas concerning the uncon- using interview or self-report measures.4 There are now
scious mind are compatible with modern neuroscience.5,6 thousands of studies showing a relationship between attach-
Still others have moved in the opposite direction, arguing ment styles and mental health.4 For many psychoanalysts,
that it is sufficient to offer a coherent interpretation of psy- attachment theory, in one form or another, has become their
chological phenomena.7 This review will briefly examine all primary model.14
these attempts to revive psychoanalysis. However, as pointed out years ago by the British child
psychiatrist Michael Rutter,16 the attachment model has
limitations. Like previous models derived from psychoana-
Revising the Paradigm lysis, attachment theory does not take into account the
Almost no scientific theory or medical treatment that is a temperamental and biological vulnerabilities that make
century old can be expected to survive without major mental disorders more likely to develop.17,18 Nor does the
changes. In fact, one of the main reasons for the decline model, in its present form, take full account of gene-
of psychoanalysis is that the ideas of Freud and his environment interactions in development.19 These prob-
followers have gained little empirical support.8 Freud’s lems are, of course, by no means specific to attachment
theoretical model of the mind and of child development theory. More specifically, the attachment model also tends
has been challenged and refuted by a wide range of not to consider that children can benefit as much from
evidence.9 multiple attachment figures (“alloparenting”) as from a
The absence of solid and persuasive evidence for the mother.20 Finally, attachment theory runs the risk of being
theory may be the consequence of its self-imposed isolation
from the empirical sciences. The philosopher Karl Popper
1
considered psychoanalysis to be a pseudo-science because it McGill University, Montreal, Québec
has produced so many hypotheses that cannot be refuted
Corresponding Author:
empirically.10 Joel Paris, MD, McGill University, 1033 Pine Avenue West, Montréal, QC
Several psychoanalysts have attempted to update theory H3A 1A1, Canada.
and practice in the light of current knowledge.11 However, Email: [email protected]
La Revue Canadienne de Psychiatrie 62(5) 309

another psychodynamic model that, by emphasizing prob- Given its cost, the lack of good evidence for the effi-
lems in early childhood, can be used to blame parents for cacy of psychoanalysis has reduced its market share. Con-
psychopathology in their children. sumers are now less likely to seek this lengthy and
expensive form of treatment; for some time, it has been
difficult to make a living as a full-time analyst.34 Modern
Is Psychoanalytic Treatment Evidence-
psychotherapists practice in a competitive market that
Based? includes a very large number of treatment methods. Psy-
Modern medicine and psychiatry expect all forms of ther- chotherapies of all kinds now tend to follow other para-
apy to be supported by evidence.21 Peter Fonagy,11(p77) a digms and to be relatively brief.35
psychoanalyst who is also a respected researcher, has Some analysts who rejected the classical model became
acknowledged that “the evidence base for psychoanalytic prominent in the development of different approaches to
therapy remains thin.” treatment. For example, CBT, now the most influential form
In a recent research update, Fonagy22 found support for of psychotherapy, was originated by Aaron Beck, a psycho-
psychodynamic therapy in a variety of conditions. How- analyst who had given up believing that Freudian methods
ever, almost all the studies he reviewed concerned short- were helpful for patients.36 A new generation of clinicians,
term psychodynamic psychotherapy. This type of treatment particularly those trained in clinical psychology, have tended
has a good evidence base23,24 and its efficacy is comparable to adopt this perspective.
to that of cognitive behavioral therapy (CBT).24 But con-
flation of brief therapy with classical psychoanalysis is
misleading.
Neuropsychoanalysis
Time-limited dynamic psychotherapies, the only treat- In an era in which psychiatry is dominated by neuroscience-
ments derived from analytic theory that have been widely based models, psychological constructs tend to be neglected
tested in research, may be efficacious independent of and may be taken seriously only when they have neural
their theoretical position or brand name. This “dodo bird correlates.37 Some psychoanalysts have sought to link their
verdict” has been supported by a wide body of research model with neurobiological research and to claim that newer
and applies to all forms of psychotherapy.25 Moreover, methods of studying the brain can validate their theories.5,6
while meta-analyses of briefer psychodynamic treatments Mark Solms, a South African neuropsychologist, is the
provide good evidence of efficacy,23,24 these results can- founder of “neuropsychoanalysis.” This new field, with its
not be generalized to long-term psychodynamic therapy, own society and its own journal, proposes to use neuroima-
in which virtually no controlled trials have been ging to confirm analytic theories. Its key idea is that subjec-
conducted. tive experience and the unconscious mind can be observed
A few reports have attempted to examine the outcome of through neuroimaging.5 It is known that brain processes can
classical psychoanalysis.26 However, a meta-analysis of 14 be seen on brain imaging even before they have entered
studies27(p107) concluded, “A limited number of mainly pre/ consciousness.38 However, claims that neuroimaging vali-
post studies, presenting mostly completers analyses, provide date Freud’s model of the unconscious can be based only
empirical evidence for pre/post changes in psychoanalysis on “cherry-picking” the literature. The observed correspon-
patients with complex mental disorders, but the lack of com- dences are superficial and hardly support the complex edi-
parisons with control treatments is a serious limitation in fice of psychoanalytic theory.
interpreting the results.” Solms39 has also suggested that Freud’s ideas about
Fonagy22 claims efficacy for long-term psychodynamic dreams are consistent with neuroscience research based on
therapy for personality disorders. However, the therapies rapid eye movement (REM) activity. This attempt to rescue
that have been tested, such as his own “mentalization- a century-old theory met with opposition from dream
based treatment,”28 are not psychoanalysis but mixtures of researchers who consider Freud’s clinical speculations to
psychodyamic and cognitive-behavioral interventions be incompatible with empirical data.40,41
adapted for the treatment of severely ill patients. The proposal to establish a discipline of neuropsychoana-
The German psychoanalyst Falk Leichsenring has pub- lysis also met with a mixed reception from traditional psy-
lished meta-analyses of extended forms of psychoanalytic choanalysts, who did not want to dilute Freud’s wine with
treatment,29,30 claiming that there is sufficient evidence to neuroscientific water.42 Neuroscientists, who are more likely
support this treatment in complex mental disorders, and to see links to psychology as lying in cognitive science,43
other recent reviews of this literature have made a similar have ignored this idea. In summary, neuropsychoanalysis is
argument.31,32 However, these conclusions are not justified being used a way to justify long-standing models, without
because of heterogeneous clinical presentations, small sam- attempting to find something new or to develop an integra-
ples, and small effect sizes.33 It would be possible, in prin- tion of perspectives on psychology.
ciple, to conduct better studies that address all these issues. However, Eric Kandel,44 influential in the light of his
However, the cost of that kind of investigation would prob- Nobel Prize for the study of the neurochemistry of memory,
ably be prohibitive. has taken a sympathetic view of the use of biological
310 The Canadian Journal of Psychiatry 62(5)

methods to study psychoanalytic theory. Kandel had wanted of professionals and academics with no training in science
to be an analyst before becoming a neuroscientist.45 But could lead to an increasing isolation of the discipline.
Kandel, who does not actively practice psychiatry, may be While only a few contemporary psychoanalysts have
caught in a time warp, unaware that psychoanalysis has been embraced postmodernism, the humanities have made use
overtaken by competitors in the field of psychotherapy. of psychoanalytical concepts for their own purposes as a
Another attempt to reconcile psychoanalysis with science way of understanding literature and history.
has come from the literature on neuroplasticity.46 It is now
known that neurogenesis occurs in some brain regions (par-
ticularly the hippocampus) during adulthood and that neural Conclusions
connections undergo modification in all parts of the brain. In 2009, the British Journal of Psychiatry published a debate
There is also evidence that CBT can produce brain changes about whether the journal should accept psychoanalytic case
that are visible using imaging.47 These findings have not reports.54 The debate pitted a biologist, Lewis Wolpert,
been confirmed in psychoanalytic therapies. However, Nor- against a psychoanalyst-researcher, Peter Fonagy. Wolpert
man Doidge, a Canadian psychoanalyst, has argued that psy- argued that psychoanalytic case reports should be excluded
choanalysis can change the brain.48 This may be the case for because they are in no way scientific. Fonagy, while con-
all psychotherapies. However, more recently, Doidge49 has ceding some of his opponent’s points, defended analysis by
claimed that mental exercises can reverse the course of pointing out that research is possible and is now beginning to
severe neurological and psychiatric problems, including be conducted. But while Fonagy himself is committed to
chronic pain, stroke, multiple sclerosis, Parkinson’s disease, empiricism, he represents a very small minority in a field
and autism. While these books have been best-sellers, most that lacks that commitment.
of their ideas in the second volume,49 based on anecdotes Unfortunately, the modern revisions of psychoanalysis do
rather than on clinical trials, have had little impact in med- not offer a coherent response to critics. It is difficult to see
icine. This story underscores the difficulty of reconciling the how any of the current responses to criticism can save psy-
perspectives and methods of psychoanalysis with scientific choanalysis from a continued and lingering decline. Analysis
methods based on empirical testing. has separated itself from psychiatry and psychology by
teaching its method in stand-alone institutes. The field may
Psychoanalysis and the Humanities only survive if it is prepared to dismantle its structure as a
separate discipline and rejoin academia and clinical science.
Psychoanalysis claimed to be a science but did not function Whatever its limitations, psychoanalysis left an impor-
like one. It failed to operationalize its hypotheses, to test tant legacy to psychiatry. It taught a generation of psychia-
them with empirical methods, or to remove constructs that trists how to understand life histories and to listen
failed to gain scientific support.1 In this way, the intellectual attentively to what patients say. In an era dominated by
world of psychoanalysis more closely resembles the huma- neuroscience, diagnostic checklists, and psychopharmacol-
nities. Today, with few psychiatrists or clinical psychologists ogy, we need to find a way to retain psychotherapy, whose
entering psychoanalytic training, the door has been opened basic concepts can be traced back to the work of Freud, as
to practitioners with backgrounds in other disciplines, part of psychiatry.55
including the humanities.
This trend is related to a hermeneutic mode of thought,50 Declaration of Conflicting Interests
which focuses on meaningful interpretations of phenomena,
The author(s) declared no potential conflicts of interest with respect
rather than on empirical testing of hypotheses and observa- to the research, authorship, and/or publication of this article.
tions. Since the time of Freud, the typical psychoanalytic
paper has consisted of speculations backed up with illustra-
Funding
tions, similar to the methods of literary theory and criticism.
One model currently popular in the humanities is “critical The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
theory.”51 This postmodernist approach uses Marxist con-
cepts to explain phenomena ranging from literature to poli-
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