Psychoanalysis is under attack

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does it have a
valuable place
in modern
mental health

sizes in randomised controlled trials of long term
psychodynamic psychotherapy, larger than those
for short term therapies.1 Positive correlations were
also seen between outcome and duration or dosage of therapy. Another meta-analysis found that
psychotherapy in addition to antidepressantssignificantly reduced depressive symptoms compared
with antidepressants alone.2 A third meta-analysis
found that short term psychodynamic psychotherapy may be more effective than other therapies for
somatic disorders.3 So evidence is on its way.
Convergent support for psychoanalytical
approaches comes from 20 studies of brain function changes after a range of psychotherapeutic
treatments,including psychodynamic ones, for
several mental disorders.4 Brain changes that
have been shown include a substantial increase
in 5-HT1A receptor density in patients with
major depressive disorder after psychodynamic
therapy—this was not the case in patients who
received fluoxetine5—and normalisation of neuronal activity in patients with somatoform disorders.6 Ultimately these investigationswill enable
us to better understand the therapeutic mechanisms of a range of approaches and provide badly
needed improvements in our treatments of complex disorders.

Paul Salkovskis professor of clinical psychology and
applied science, Department of Psychology, University of
Bath, Bath BA2 7AY, UK
Lewis Wolpert emeritus professor of biology as applied to
medicine,Department of Cell and Developmental Biology,
University College London, London, UK

Peter Fonagy and
Alessandra Lemma say that
the psychoanalytical approach
can provide a useful and
unique contribution to modern
healthcare, but Paul Salkovskis
and Lewis Wolpert argue that it
has no place there at all

Peter Fonagy Freud memorial professor and head of
research, Department ofClinical, Educational and Health
Psychology, University College, London WC1E 6BT
Alessandra Lemma unit director, Psychological Therapies
Development Unit, Tavistock and Portman NHS Foundation
Trust, London

evidence, they are often ineffective, even relative
to being on a waiting list.3
Clearly, true paradigm shifts have occurred
in terms of the understanding of humanpsychology and of the ways in which people
experiencing psychological problems and
distress can be helped. Freud himself deserves
credit for establishing psychoanalysis as a new
paradigm over a century ago. There is, however,
an inevitability in the subsequent shift away
from psychoanalysis, which began 50 years
ago and which was de facto completed in the
1980s. Paradigm shifts are a form ofaccelerated
intellectual evolution, where the explanatory
and heuristic power of a particular theory are
supplanted by another that better explains and
predicts the key phenomena under investigation.
Sometimes a supplanted idea is kept alive in
some form; there is something charming and at
times amusing about the continued existence
of a flat earth society or the psychoanalytical
approach toliterary criticism. However, we
propose that it is no longer defensible to
continue ideas whose time has come and
gone and which have been succeeded by more

P sychoanalysis is under
greater attack than ever before.
An unprecedented decommissioning of psychoanalytical services has
taken place across the United Kingdom’s NHS
(for example, Forest House NHS Psychotherapy
Clinic, London),justified by cost savings. What
are the reasons for this attack and what can be
said in psychoanalysis’s defence?
It has been claimed, perhaps fairly, that psychoanalysis and psychodynamic psychotherapies have failed to promote a culture of systematic
evaluation and that the outcomes are difficult to
measure and demonstrate. Relative to the number
of studies on the effectiveness of cognitive...