Thursday, 20 February 2014

Psychoanalysis and the Scientific Imagination

This post is about the part of psychology that has maybe caused more disagreement than any other. Doomed and tragic, dogmatic and sometimes foolish, psychoanalysis has been derided and "killed off" multiple times over. Like a religion it inspires dogged loyalty among followers which embarrasses people of a more skeptical mindset. Nonetheless, I retain an ongoing fascination with psychoanalysis as a way of thinking.

As an undergraduate I was discouraged from even thinking about picking up a book by Freud. His work was taken as the paradigmatic example of how NOT to do psychological science. The prototypical psychology undergraduate who makes assured statements of the form "Freud has all been disproven" has not really got it right (could they even say what it would mean to disprove such a huge body of work?), but they are not wrong either. How can I be both empirically minded and interested in the metaphysical suppositions of a patrician doctor from fin de si├Ęcle Vienna?

The privilege of "Sciencey-ness":

Here's the source of one potential form of mistaken thinking about the science of therapy. Contrary to intuitions, psychoanalytic theory is no less capable than cognitive theory of leading to treatments that can be manualised and tested. We may assume Cognitive Behavioural Therapies are more appropriate for modern clinical settings because the language of "cognition"; "schema" and so forth lends an additional superficial "sciencey-ness". However, the real litmus test of a therapy is neither its sciencey-ness nor its poetic intuitive appeal, but its ability in clinical trials to effect the sort of changes it claims to be able to make.

Unfortunately, it is a shabby truth that psychoanalytically inclined clinicians have resisted seeing RCTs as a legitimate way to validate their insights. Where they have (Fonagy and Bateman's Mentalisation Based Therapy and Clarkin and colleagues Transference Focused Psychotherapy-both interventions in the field of "Borderline Personality Disorder") they have produced some promising results. Some service users have reported that DBT, with its talk of "emotion regulation" can feel infantalising and restrictive. If alternative approaches can avoid these complaints then that would seem an important advance in the direction of greater choice for a group of people who are often otherwise offered very little.

Psychoanalysis and Science:

"Basic" psychological science isn't just a set of methods for verifying theoretical statements. Although such tools for verification are the main subject matter for philosophers of science, we also need a way to generate theories and new ideas to test. This requires creativity, imaginative flair and some familiarity with what you are trying to study. Einstein's creative thought experiments are lauded by the popular imagination because they challenged the conventional wisdom about how energy worked. If we view psychoanalysis as a rich field of imagination-stimulating ideas about the mind, its utility to science comes more to the fore. Nobel prize winning brain physiologist Eric Kandel has called psychoanalysis "the most coherent and intellectually satisfying view of the mind", albeit in the context of a plea to its practitioners that they up their game in terms of scientific theory development. Another Nobel winner Daniel Kahneman tells a fascinating story here about the value of reading Freud closely to generate new ideas for experimental testing:

In thinking scientifically about the way the world works we perhaps need to start with a proliferation of theories and ideas which we only later cut down to size through empirical investigation. If nothing else, psychoanalysis has been provocative and stimulating in developing detailed ideas about what sort of things minds are.

Psychoanalysis and "the ecstasy of truth":

Somewhere beyond the deliberately limited and precise technical vocabulary of scientific psychology there lies an explanatory and expansive language of mind to which we aspire. Novelists and poets have the ultimate privilege in this domain, they deal in fiction and verse, which provides the ultimate disclaimer for saying whatever you want and sometimes landing upon something that feels deeply and wonderfully true. 

Werner Herzog explains the distinction between two different views of truth

Psychologists have a duty to write and think in a different way if they have any hope of saying things which are verifiably and usefully accurate. We are-nobly I think-purveyors of what Werner Herzog would call the "accountants' truth". The price we pay for this is that we limit our capacity to get at the fullness of "the ecstacy of truth"; the truth of what it is and means to be human. Nonetheless we all surely want, at least in some part of ourselves, to go beyond cautious psychometrics and deploy words that really get at what it is like to feel and think. Why otherwise would we have become psychologists?

Psychoanalysis is not just a theory, it is a different way of having theories; a different way of writing about people. It is also a phenomenology. When Freud differentiates mourning and melancholia by saying that in the former it is the world which has become "poor and empty" while in the latter it  is the Ego itself; when Winnicott speaks of "annihilation anxiety" or of "holding" as a metaphor for the way that a clinician can help bear disorganising feelings of dread, these sorts of descriptions would seem to bring us close to lived experience in a way that technical scientific writing cannot.

Psychoanalysis is surely a dying art, surrounded by obfuscation, obscured by shroud waving, but for me it retains a valuable intellectual core. Freud was a staggeringly good writer (arguably too good; his capacity to convince and convert people can be viewed as intellectually problematic) and he developed a beautiful and detailed view of the psyche. Unfortunately for us, the truths that are contained in the enormous corpus of psychoanalytic writing are fleeting and hard to pin down. Some might suggest that analysis and analytic training can help you grasp them more firmly. I dislike the hierarchy and authoritarian nature of psychoanalytic "received" truths, but many of its texts are poetic, imagination expanding and enriching nonetheless.

Tuesday, 11 February 2014

Agendas and Anxieties: CBT for Psychosis

I have been watching discussion about the latest CBTp trial with interest and some weariness. If you haven't kept up, at least 3 expert blogs have painstakingly critiqued the results and reporting of a new study in the Lancet. Their work may have led the BBC to water down initially highly enthusiastic but inaccurate coverage:

Before and after: The BBC's shifting versions of the same study

I remain a fairly novice methodologist so I have nothing of value to add to this dispute. However, one striking and familiar pattern has emerged, apparently driven by particular anxieties upon which it is interesting to speculate.

Defenders of CBTp have emerged in the comments of these blogs angrily seeking to discredit its critics without providing much substantive defence of the data. Among the more striking things about these comments is their tone; irritable and impatient, levelling accusations of personal agendas and talk of "cabals". Perhaps for the most part, this can be attributed to the familiar fact of modality-affiliation-bias on the part of defenders. People want CBT to be effective for psychosis because they have invested time and energy in it as a cause. The same bias of course motivates overly-enthusiastic defences of any treatment. 

I think there is another anxiety present too however, one which, however misguided, is perhaps more noble. This other anxiety arises out of the current topography of the mental health debate, which appears to pit "medical"/"evidence-based" interventions against "intangiable"/"humanistic" interventions. With these binary goggles on it can look as though CBT is just about the only "humanistic" intervention that has any chance of passing the stringent hi-tech tests of an atomistic neoliberal psychiatry. Discrediting CBT is not just about one intervention; it entails a further discrediting of any provision of psychological care in this field. 

This reasoning doesn't follow, and I am not trying to motivate a case in favour of CBTp of the back of it. Why then have I said it is "noble"? Well, whatever the evidence for different specific interventions in psychosis, we would seem to want to provide in addition to them  "old-fashioned" "holistic" "person-centred" (call it what you will) care. Care, as it were, in the straightforward "folk" sense of the word rather than in the jargony bureaucratic sense. One person I interact with on Twitter has suggested calling it "psychiatric palliative care". Although I can anticipate some protests at this idea ("palliative" implies pessimism; a degenerative, fatal trajectory) I understand where she is coming from and think it's a neat coinage. Care is about a sort of ethical responsibility and it draws on a certain instinctual sense that people ought to look after and love one other. It is the sort of care which Jenni Diski recently eulogised in the LRB, sad to realise that the loss of Victorian asylums (good riddance) had also entailed the loss of "asylum" in contemporary society's treatment of mental health.

It would be misguided to rally to a therapy that cannot substantiate its claims to efficacy. We should be advocating treatments that really help people, and it is a strange thing when we don't. We need to understand why we get into such ruts if the debate is to progress. At least some of the problem is an unspoken fear: that if we see all of our caring efforts simply as testable technologies, we might lose them altogether.