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Introduction
Psychoanalysis, psychodynamic therapy, and cognitive-behavioral therapy are all forms of talk therapy. In
the broadest terms, talk therapy is a psychological procedure by which a skilled practitioner uses
language and active listening skills to assist patients with their difficulties in living.
Victorians labeled as hysterics and obsessives -- perhaps in our modern times, we might just use the
words "neurotic", "depressed", "anxious", "attachment disordered" or "somatizing" to describe these types
of patients. Freud stumbled upon two crucially important aspects of human mentation.
1. One is the concept of psychic determinism. This means that all thoughts, feelings, and actions
arise from previous thoughts, feelings, and actions we've had and that have been recorded at
various topographic "layers" in our memory. An example of psychic determinism: a woman
inadvertently burns bread she's preparing for her family's dinner. Earlier in the day, she may have
had the brief but disturbing thought that she resented how lazy her husband is, how much
domestic work was expected of her despite the fact that they both work full-time jobs. It could be
said that her burning of the bread was psychically determined and symbolically represented her
anger and resentment towards her husband for hiding his laziness and ineptitude behind
stereotypical gender roles . Psychic determinism is responsible for many such Freudian slips.
2. The second and perhaps greater discovery made by Sigmund Freud was the existence of the
unconscious. This is the part of our mind that assists us in making dreams at nighttime, largely
determines our emotional states in relationships (especially with bosses, parents, lovers, and
children!), and can harbor ideas unknown to us that still have an impact on our mood. Because
conscious thought is such a powerful lived experience, it's hard for us to come to terms with how
little we know about ourselves and how much of our thought is buried beneath that lived
conscious experience. We think consciousness is 99% of our thought, but it is just the tip of a
very large iceberg, most of which is composed of the unconscious mind. An example of how the
unconscious can affect us is: a woman presents for treatment because she is unreasonably
jealous of her boyfriend. Whenever he spends time with his female friends, she becomes
obsessed with thoughts of how he is cheating on her with women she thinks are more desirable
than she is. After talking to the therapist, the woman begins to understand that she has some
sexual desires for women that she was unconscious of. Because these sexual wishes were
unacceptable to her, she used the defense mechanism of projection to deny them and attributed
them instead to her boyfriend (he becomes the desiring one, not her!). Rather than
acknowledging her same sex desire, she represses these wishes and developed a symptom of
pathological jealousy for her boyfriend. Once these repressed thoughts and feelings became less
threatening to her (the process is known as the unconscious becoming conscious), her symptom
of pathological jealousy vanished and her relationship with her boyfriend improved. She also
became more comfortable with the plasticity of her sexuality and fantasy life.
Western science. There are many papers written about this subject so I won't spend much time on the
issue here. Instead, I will try to make my point through an example and be as brief as possible.
There are other issues with conducting research on psychotherapy outcomes. For example, there is the
issue of how to measure whether the verbal intervention has had an effect on a subject's mood, or
whether a life change (for example, let's say a subject wins the lottery or less dramatically, gets a new
and more lucrative job) has resulted in an increase in mood. This concept refers to internal validity, the
measure of how accurately an experiment actually measures what it intends to measure.
Finally, and perhaps most salient for psychoanalytic and psychodynamic therapists, there is the reliability
of a patient's self-reported mood. Reliability refers to the confidence one can have about the instrument
one is using to measure something. For example, when you measure water temperature, you can feel
confident that your thermometer is a reliable instrument. However, when you measure mood in
psychotherapy research, it is almost always based on either the subject's self-report or the therapist's
assessment of the subject's mood, both of which are questionably reliable instruments. We humans have
a particular talent for lying to ourselves and denying our feelings. Our conscious feeling states have a
tendency to obscure how we really feel. In an interview in Contemporary Psychoanalysis (2011) the
esteemed Lacanian analyst Bruce Fink said of psychotherapy research:
"I would suggest that psychoanalysis --genuine psychoanalysis--could survive only by refusing to
engage in such research. There is a movement afoot in the American psychoanalytic community to
attempt to reduce psychoanalytic practice to something that can be quantified so as to try to satisfy
the American demand for outcome studies....A certain number of analysts are preparing outcome
studies for psychoanalysis and psychodynamic therapy in Germany, the U.S., and elsewhere.
They implicitly assume that (1) the infinitely complex psychoanalytic process can be reduced to a
set of variables that can be easily explicated and quantified, and (2) that people consciously
know whether they have been helped or haven't been helped by a certain process. The
unconscious is immediately ruled out in the very construction of such studies because in most
outcome studies I've heard of, you give a survey to people or interview people about what they
believe has happened in their therapy. Freud indicates that a big transformation often takes place
over the course of the first few weeks for months after patients end psychoanalytic treatment...so
when should you administer outcome surveys or conduct interviews? If you do so at some
predetermined period while treatment is ongoing, you may end up catching people in the midst of a
negative transference [this means when the patient experiences the therapist as unhelpful or
menacing], leading them to give very negative responses, and yet that rough patch may have been
a very necessary step along the way to a successful outcome. There's no particular time of the
unconscious..." -- Bruce Fink
anger, anxiety, remorse) and what behaviors the patient tends to engage in when she has the thought (for
example, drinking alcohol heavily, rummaging through her boyfriend's belongings looking for evidence of
his infidelity, etc.). The therapist would then try to reduce the symptom's destructiveness by identifying
other thoughts and behaviors the patient could engage in when she has the feelings of jealousy,
depression, anger, and anxiety. For example, the therapist suggests she could replace the pathological
thought with calming cognitions like ("My boyfriend loves me and has assured me he wouldn't cheat on
me."). Also, the therapist may assign the patient homework to brainstorm three alternate behaviors when
she is feelings jealous that may alleviate her negative feelings. The patient might return the following
week with this list and then start engaging in these new behaviors when she feels jealous: taking a walk,
calling a friend, or listening to relaxing music. The patient then rates on a scale of 0-10 how helpful it was
to engage in these therapeutic behaviors when distressing feelings arose in conjunction with her
problematic cognition, "I'm afraid that my boyfriend is cheating on me when he hangs out with his female
friends, who I worry are sexier than I am."