A Psychoanalytic Perspective from Psych Practice Blogger

FruitcakeYou know, I’ve been thinking about psychotherapy lately after reading the Psych Practice blog post about psychoanalysis training.

I’ve read the post more than once and I’ll likely reread it in the future. I think it’s a riveting little story and I find it difficult to compare it with regular psychiatry residency training.

There’s probably no comparison. Even the interview process sounded grueling.

When I was in residency, my psychotherapy education didn’t include personal psychotherapy as it does for psychoanalysis training. I think that’s what’s so intriguing for me and leads me to wonder why it is not required in non-psychoanalysis residency programs.

Because we’re too busy teaching psychiatry residents about psychopharmacology, for one thing; not that it’s bad to do that, but I wonder how differently I’d relate to patients if I had undergone personal psychotherapy myself.

Sitting in a lecture room listening to somebody talk about transference and countertransference is not the same as experiencing it in real time with an analyst, not by a long shot, I’m quite sure.

Psych Practice is also brutally frank about the feeling of being discounted as a psychoanalyst nowadays. I can’t help thinking it must take a great deal of courage to follow such a path in the days of managed care, collaborative care, and by the way, how on earth do psychoanalysts fit into the straitjacket of Maintenance of Certification (MOC)? They have to participate in it somehow, though I’m not sure how MOC could be relevant to psychoanalytic practice. It’s not even relevant to my practice.

I could not find a Performance in Practice (PIP) product on the American Board of Psychiatry and Neurology (ABPN) web site which accommodated psychoanalytic practice.

And I can only imagine how frustrating it can be sometimes to see the ups and downs in the literature about the efficacy studies of psychoanalytic therapy–which is not even the same as psychoanalysis. We discussed this in September when we were just getting started with the online journal club. And I just saw a new study comparing psychoanalytic psychotherapy with cognitive behavioral therapy (CBT) for patients with bulimia in which patients improved much faster and at higher rates with CBT [1].

One of the several moving passages in the post described her own analysis experience:

The truth is, this is the hardest part of the process. One well-published senior analyst likes to say that an analysis is like getting a PhD in yourself. It forces you to look at all the things about yourself you’ve been trying to hide from since childhood-shame, guilt, anger, aggression, sadness, longing, sexuality, tenderness, competition, cruelty, to name a few. It forces you to question your assumptions about yourself, the people in your life, and the world around you. It asks you to give up your accustomed ways of interacting with the world, defenses that have protected you most of your life, and move on to other ways to be that don’t cause as much pain. And it asks you to establish an intimate bond with someone you can never truly get to know.

I  can’t think of who would know more about self-reflective improvement than a psychoanalyst.

Reference:

1. Poulsen, S., et al. (2013). “A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa.” Am J Psychiatry.
OBJECTIVE The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. METHOD A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis. RESULTS Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT. CONCLUSIONS Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.

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Comments

  1. I had the old fashion three and a half years of four times a week, free associating, dream work analysis. At the end, I complained that while I had grown up in my dreams, and knew myself better, I had not met the goal that pushed me into analysis. My beloved shrink, said I had the tools needed to reach that goal, but applying them was my job. Not the purpose of analysis.

    Besides the gains in self-awareness, two things feel right to me about analysis. The first and I think the most important was finally sharing all that you tried to keep hidden and realizing the sky didn’t come crashing done on you. The second was the power of having someone listen to you intently and focus only on you. I think it is this caring witness aspect that keeps some people in analysis forever. Not necessarily bad, but expensive and friends or spouses fill that need less intensively, but also leave you money for other things that are also valuable.

    I found cognitive behavior worked better for reaching specific goals and like coaching for its non-pathologising ways.

    Thank you for this one and happy holidays.

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  2. I’m really touched that you wrote this. Thank you.
    I wonder what most people think analysis is. In the CBT vs. Psychoanalysis for Bulimia paper, the “Psychoanalysis” they did was once a week. So I’m not sure what they intended.
    Oh, and by the way, cute reindog!

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