Colin Brewer. 4 June. 2011.
Published in the newsletter of ‘HealthWatch’ June 2011.
There was a little flurry of criticism among the usual suspects (ie people like HealthWatch members) about a recent Science Museum exhibition that implied support for psychoanalytical treatment, as opposed to simply noting its place in the history of psychotherapy, much as one might note the once-flourishing arts of trepanning or phrenology. Though crammed into a rather small space, it was prominently positioned at the entrance to the main exhibition hall. Brisk debates in The Guardian and New Scientist followed its opening.
Anti-Freudians argued that since psychoanalysis was based on theories that were either immune to disconfirmation (and thus fundamentally unscientific) or had been tested and mostly disconfirmed, the museum shouldn’t have given it space or should have made clear that its popularity in some quarters (as with homoeopathy) didn’t mean that there was good evidence for its effectiveness. Freudians countered that psychoanalysis was still clinically relevant and could match the results of other talking treatments in some conditions. The museum were unhelpful when I contacted them, needing several reminders before replying (rather oddly) that: “The Science Museum has never set itself up as a gate-keeper deciding what is or isn’t ‘science’. As a museum, we have a wide ranging interest in many forms of scientific culture…”.
Like all interventions, psychotherapies can be compared and evaluated. Blinding is more of a problem than with tablets but less than when comparing, say, medical with surgical treatments. However, psychoanalysis is a relic from the days before routine RCTs. Its continued existence is reminiscent of the continued presence of bishops in Parliament, a symbol of something once powerful and influential but now much less so. Naturally, like the bishops, psychoanalysts (including the numerous schismatic sects) insist that they are still vital for the health of the nation.
It is true that in some comparative studies, psychoanalytical treatment gives similar results to those of its main competitor, cognitive-behavioural therapy (CBT). However, all psychotherapies have enormous placebo/non-specific components which (as with antidepressants) greatly exceed the specific effects of treatment. Most psychiatrists have encountered patients who thank you profusely at the end of a session during which they describe the problem as they see it and you do nothing except encourage them to talk. Patients respond non-specifically to being the subject of therapeutic attention and psychotherapy is one of the more obvious (and often gratifying) forms of attention. One of the best comparative studies of ‘Freudian’ psychotherapy vs CBT (Sloane et al 1975) actually found a modest superiority for CBT but for me, the more important finding was that many patients in both groups experienced much of their subsequent improvement following the initial session, which was essentially diagnostic in focus rather than therapeutic.
Two RCTs of psychotherapies in alcoholism – one old and British, one recent and American – had very similar outcomes. In Edwards et al’s (insufficiently) famous trial of ‘treatment’ vs a single session of simple ‘advice’ to cut down or stop drinking, there were similar and quite positive 12-month outcomes in both groups. ‘Project MATCH’ was a very expensive multi-centre RCT of three conventional psychological interventions for various types of problem-drinker. The results were awaited with great anxiety by the partisans of AA, CBT and motivational interviewing but in the end, it was a case of ‘all have won and all shall have prizes’. It was significant that when MATCH was designed in the 1990s, nobody thought that Freud-based therapies deserved a place. It’s also worth noting that 10% of the subjects deteriorated during treatment. A later review of the results concluded that: “Untreated alcoholics in clinical trials [also] show significant improvement. Most of the improvement which is interpreted [in MATCH] as treatment effect is not due to treatment. Part of the remainder appears to be due to selection effects.” Other studies repeatedly show that, with the possible exception of CBT, which involves specific and quantifiable techniques, there is no difference in outcomes between trained and untrained counsellors or therapists.
Psychoanalysis involves many assumptions (mostly untestable) about human nature and the ‘structure’ of the psyche: CBT makes relatively few, mostly testable. If Freudianism’s venerability is supposed to be a plus-factor, perhaps we should go back even further to Occam, whose trusty Razor warns us against complex, assumption-rich theories like Freud’s. Another problem of evaluating psychotherapies is that inter-therapist variability is a major confounder. To some extent, this is true of all treatments (experienced surgeons are better than tyros) but in psychotherapies, the therapist largely is the treatment. Unsurprisingly, four-fold inter-therapist variations in outcome for the same therapy are not uncommon, whereas myxoedema responds to thyroxine regardless of the prescriber’s bedside manner.
The exhibition was called ‘Psychoanalysis. The unconscious in everyday life’. The museum wouldn’t give me contact details for the curator but she wasn’t difficult to find and was happy to talk with me. Dr Caterina Albano is a cultural historian at St Martins College of Art and the exhibition was the museum’s idea, not hers. She disclaims any particular views about psychoanalysis as a treatment, regarding it rather as one way of looking at life and art. She thus displayed items by trendy ceramicist Grayson Perry but also included toys devised by psychoanalysts for ‘play therapy’ with children. This gave a distinctly therapeutic air to the exhibition that was arguably unfortunate. I doubt very much that psychoanalysis would have entered and influenced Western thought as much as it did (and clearly still does in non-scientific circles) if it hadn’t done so by using Freud’s status as a physician who claimed powerful individual and social curative properties for his invention. That claim has no serious evidence-base.
Psychoanalysis began life as a psychological treatment, once so prominent that Baroness Wootton famously claimed in the 1960s that Freud might outlive Jesus. That now seems doubtful. Freud’s Collected Works have been discreetly moved by their publisher from ‘psychology’ to ‘philosophy’. Philosophers don’t do RCTs. The worst of them just try to impose their philosophy on the rest of us. People who disagreed with Freud were accused of showing ‘resistance’. Communists called it ‘false consciousness’ or ‘counter-revolutionary thought’. Thank goodness both philosophies have been put in their place.
None of this should induce therapeutic nihilism. People usually feel better after talking (and listening) therapies but that is mainly because all clinicians – even insensitive ones – are walking placebos, whether we like it or not. Nothing wrong with that, as long as we remember that placebos are supposed to help patients feel better. They are not supposed to help doctors feel that they have developed a specifically effective treatment when they haven’t.