Thursday, January 22, 2015

Research and Treatment Outcome: The Reluctant Psychoanalyst Continues to Report from the Convention

Psychoanalysis has a long and uneasy relationship with traditional empirical research.  Freud was quite concerned that researchers would not appreciate that the unconscious cannot be observed directly and he privileged the analytic hour as the one and only position from which we can learn about the unconscious and, indeed, the functioning of the human mind.  Taking this position hamstrung psychoanalysis.  It interfered with it joining the mainstream of scientific development that revolutionized so many fields during the twentieth century.  I suppose it is a testament to the psychoanalytic situation and to Freud’s genius that he developed something from it that still has some relevance now, more than one hundred years later.  But we are woefully behind our peers who work from other disciplines, many of which were founded within an empirical tradition, of using research techniques to both a).  Understand how well our patients “objectively” benefit from our work together and b). Understand what is taking place between ourselves and our patients.

This year, a German researcher, Marianne Leuzinger-bohleber, presented the results of research that she has done with others over the course of the past decade or so.  She is working in a country where insurance is still paying for psychoanalysis – and where the insurance companies are, like those here, asking whether longer term more intensive treatment is worth it.  Some interesting results that mollified the insurance companies – who are concerned not just with their own expenditures on treatment but on the productivity of the workforce – including noting that those with treatment had fewer sick days after the treatment than the population as a whole – and that this discrepancy increased across time – so that they had many fewer sick days six years out of treatment than they did when ending treatment and that they were bucking the trend of the comparison population which had an increasing number of sick days as time passed.  They also noted that, when compared with medications and with shorter term treatments, psychoanalysis led to fewer relapses and, as with the result above, increasing measures of health across time.

I should note that in another session, the folks who study infant's attachment to their parents were discussing their speculations about treatment.  They have shown that poor attachment style in infants is related to difficulties as an adult.  They have also shown that poor attachment styles of parents predict difficulties in the attachment of kids.  Finally they have shown that attachment styles of adults improve as a result of therapy.  The step that is left to demonstrate – the study hasn’t been done, but it will be - is that therapy can interrupt the pattern of poor attachment – so that those who were poorly attached who go through a treatment that improves their attachment style will parent children who are less likely to be poorly attached.  Wouldn’t that both make sense and be neat?

So the question gets asked, what is it that causes these changes?  Why does psychoanalysis foster improved functioning?  Psychoanalysts have long written about this subject.  They have posited many factors.  The early analysts suggested that interpretation – particularly what were called mutative interpretations – were what caused the changes.  In essence, they proposed that increased insight caused the changes that we see in treatment.  More recent analysts have argued that what changes is the quality of the relating that the analysand does, and that this is the result of engaging in a deeply satisfying relationship with the analyst.  (This, by the way, has been a tough sell to the old school psychoanalysts who see a relationship cure as temporary and only lasting as long as the therapeutic relationship – but the relational group has demonstrated that something about the relationship with the therapist sticks).  Yet a third group has proposed that the process of freely associating frees the mind up and the patient can approach difficulties with more creative enthusiasm and solve problems with greater ingenuity and verve.

Leuzinger-bohleber and her group did an interesting thing – they measured all three of these qualities before and after treatment, plotted them in a three dimensional space – and looked at how they changed from before treatment to the conclusion of treatment.  The graph, which had empty spheres for the before data points and solid for those after, looked like two clouds – one dense and compact, centered around poor insight, poor relationships, and little creativity at the beginning of treatment and a much bigger, but also more divergent cloud up, to the right and in back of the beginning of treatment that were the bubbles post treatment.  Some people improved on one dimension, some on two, and some on all three.  A few did not improve, but the majority did (enough for the insurance guys to be impressed), but the intriguing thing is that improvements look different in different people.  Overall there is a shift in the cloud, but on an individual level, some people had much more insight, though their relationships didn’t change much; others were much more creative, but not necessarily significantly more insightful – a myriad of configurations that described the arcs of particular treatments. 

One size does not fit all.  What patients walk away with differs.  When we measure symptoms, there is a reduction – but this may be occurring for different reasons with different people.  One of us may feel less stuck because we finally get how it is that we have ended up at this particular point in our lives.  We may not change things much, but we may derive comfort from knowing – coming to peace as it were – with who we are and how we got here.  Others may figure out a way out of a complicated and convoluted trap – moving away from situations that previously baffled them – and these situations may be external, internal, or some combination.  Yet others may feel more connected with others – perhaps as a result of coming to trust a particular person they may be more willing to risk trusting others in the world.  For most of the people in the study, there was at least some of each of these elements – but there may have been a strong suit among the three – though many seemed to move significantly positively on all three dimensions.

So then the question becomes, what happens that these changes are coming about.  Traditionally the theorizing and the research have focused on what the therapist does, what the patient’s characteristics are, or on the quality of the relationship between the therapist and the patient.  In the discussion within this group, an idea emerged that we may have overly focused on the activity of the therapist.  We, as analysts, are constantly thinking about our technique.  Another group in the discussion presented data that suggested that even when an analysis is going poorly, the analyst may still be doing “good” technique as we measure if formally.  What might matter most – and what might be most mysterious and difficult to assess and to effect is what is going on in the patient.  What is the patient doing in the treatment?  Wouldn’t this be the best predictor of a good outcome?  And what does analysis allow?  It allows space for the patient to work – a place for the patient, in the presence of a reasonable other, to explore.  Perhaps our emphasis on what we are doing is partly a means of helping us stay within bounds – to help prevent us from interfering with a healing process that the patient “knows” how to engage in.

This series of thoughts, which draws on the conversation in the research group but also begins to move away from it, mirrors parts of the conversation with the attachment folks.  The attachment folks were commenting on how much care it took to provide a solid attachment foundation.  They were noting that it was kind of miraculous that the human species is doing as well as it is.  In fact, they noted, if positive attachments in infants to their caregivers were necessary to the survival of the species, we would be extinct.  So how do we pull ourselves up by our bootstraps?  Despite not having gotten all that we need, we are frequently able to provide for other’s needs.  Or, more precisely, others are able to make use of our well-intentioned but not perfect efforts to do what they need to do – to get better.  Yes, the better able to be attuned, to be present, to sense what is just outside of awareness and to offer that at a moment when it can expand awareness we are able to do and be the more we can help this process along, but we might want to focus some of our efforts on the healing desires and abilities of the people with whom we work – to think, as Jonathan Lear alluded to in his plenary address, which I have written about in another blog, not just about what is wrong with our patients and their situation, but to help recognize what might be right, and what might help them make it righter.

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