The following article is from American Psychologist, Vol. 65. No.2, and is a review of a paper by Jonathan K. Shedler "The Efficacy of Psychodynamic Psychotherapy,". Jonathan K. Shedler PhD, University of Colorado Denver School of Medicine.
Psychodynamic Psychotherapy Brings Lasting Benefits through Self-Knowledge
WASHINGTON—Psychodynamic psychotherapy is effective for a wide range of mental health symptoms, including depression, anxiety, panic and stress-related physical ailments, and the benefits of the therapy grow after treatment has ended, according to new research published by the American Psychological Association.
Psychodynamic therapy focuses on the psychological roots of emotional suffering. Its hallmarks are self-reflection and self-examination, and the use of the relationship between therapist and patient as a window into problematic relationship patterns in the patient's life. Its goal is not only to alleviate the most obvious symptoms but to help people lead healthier lives.
"The American public has been told that only newer, symptom-focused treatments like cognitive behavior therapy or medication have scientific support," said study author Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine. "The actual scientific evidence shows that psychodynamic therapy is highly effective. The benefits are at least as large as those of other psychotherapies, and they last.
To reach these conclusions, Shedler reviewed eight meta-analyses comprising 160 studies of psychodynamic therapy, plus nine meta-analyses of other psychological treatments and antidepressant medications. Shedler focused on effect size, which measures the amount of change produced by each treatment. An effect size of 0.80 is considered a large effect in psychological and medical research. One major meta-analysis of psychodynamic therapy included 1,431 patients with a range of mental health problems and found an effect size of 0.97 for overall symptom improvement (the therapy was typically once per week and lasted less than a year). The effect size increased by 50 percent, to 1.51, when patients were re-evaluated nine or more months after therapy ended. The effect size for the most widely used antidepressant medications is a more modest 0.31. The findings are published in the February issue of American Psychologist, the flagship journal of the American Psychological Association.
The eight meta-analyses, representing the best available scientific evidence on psychodynamic therapy, all showed substantial treatment benefits, according to Shedler. Effect sizes were impressive even for personality disorders—deeply ingrained maladaptive traits that are notoriously difficult to treat, he said. "The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended," Shedler said. "In contrast, the benefits of other 'empirically supported' therapies tend to diminish over time for the most common conditions, like depression and generalized anxiety."
"Pharmaceutical companies and health insurance companies have a financial incentive to promote the view that mental suffering can be reduced to lists of symptoms, and that treatment means managing those symptoms and little else. For some specific psychiatric conditions, this makes sense," he added. "But more often, emotional suffering is woven into the fabric of the person's life and rooted in relationship patterns, inner contradictions and emotional blind spots. This is what psychodynamic therapy is designed to address."
Shedler acknowledged that there are many more studies of other psychological treatments (other than psychodynamic), and that the developers of other therapies took the lead in recognizing the importance of rigorous scientific evaluation. "Accountability is crucial," said Shedler. "But now that research is putting psychodynamic therapy to the test, we are not seeing evidence that the newer therapies are more effective."
Shedler also noted that existing research does not adequately capture the benefits that psychodynamic therapy aims to achieve. "It is easy to measure change in acute symptoms, harder to measure deeper personality changes. But it can be done."
The research also suggests that when other psychotherapies are effective, it may be because they include unacknowledged psychodynamic elements. "When you look past therapy 'brand names' and look at what the effective therapists are actually doing, it turns out they are doing what psychodynamic therapists have always done—facilitating self-exploration, examining emotional blind spots, understanding relationship patterns." Four studies of therapy for depression used actual recordings of therapy sessions to study what therapists said and did that was effective or ineffective. The more the therapists acted like psychodynamic therapists, the better the outcome, Shedler said. "This was true regardless of the kind of therapy the therapists believed they were providing."
Contact Jonathan Shedler, PhD, by e-mail or by phone at (303) 715-9099 and by cell at (970) 948-4576.
Barbara Tholfsen on LinkedIn alerted me to this Ella Sharpe Quotation from 1930 about the necessity of reading "three blind mice" etc. if you want to be an analyst:
"In any reading for analytical qualification I would make compulsory the following books:
Nursery Rhymes, the Alice books, Hunting of the Snark, Grimm, Andersen, the Brer Rabbit books, Water Babies, Struwelpeter, Undine, Rumpelstilzkin, Peter Ibbetson, Greek Myths and Tragedies, Shakespeare's Plays.
Were I an arbiter of training, I should set an examination on those books as a final test by which the would-be analyst should stand or fall. My final examination for qualification would run on these lines:—
1. Quote in full a verse in which 'London Bridge is falling down' occurs.
2. Give briefly the story of three blind mice.
3. If the mice were blind, how came they to run after the farmer's wife so purposely? Account for the cutting off of their tails.
Illustrate what unconscious drama is being staged when a patient thinks of himself as one of the blind mice.
What inference concerning the health of the ego do you draw from the fact that the tails were cut off instead of the mice being killed?
Somewhere in that list of immortal stories we shall all find an unconscious phantasy of our own. To understand even the tale of the three blind mice is to have a conception of what those crystallized terms id, ego and super-ego really mean in terms of the drama of life. Faced by a cross-examination on children's nursery rhymes in terms of psycho-analytical theory, with an application to the struggles going on in ourselves or in our patients, would any of us do more than scramble through it? To pass it creditably would mean that one had a good chance of being a creditable technician."
Ella Freeman Sharpe "The Technique of Psychoanalysis " 1930 http://www.linkedin.com/groups?viewMemberFeed=&gidU622&memberIDF776851
'Just as Winnicott says,
"There's no such thing as a baby",
There is no such thing as a group'.
In this post I will discuss the proposition that 'Just as Winnicott says, "There's no such thing as a baby", there is no such thing as a group', in relation to the work of Bion.
The proposition implies a connection between Winnicott's remark and there being "no such thing as a group", so I will begin by exploring what Winnicott had in mind, in order to provide a context for thinking about Bion's observations in this regard.
From within this context I will then outline some aspects of Bion's thinking about groups, and develop and explore possible links with Winnicott's thinking about infants in ways that might suggest there are no such things.
No Such Thing As An Infant
Wiinnicott's famous remark "there is no such thing as an infant" took place at a Scientific Meeting of the British Psycho-Analytical Society, circa 1940. Winnicott refers to this remark in a footnote to his 1960 paper "The Theory of the Parent-Infant Relationship", and links it in turn to a footnote of Freud's in "Formulations on the Two Principles of Mental Functioning" (Freud, 1911, p.220). In his footnote Freud suggests, when one includes the care an infant receives from its mother, the psychical system of mother-and-infant can be considered as subject only to the pleasure-principle and free of any reality-principle. Winnicott attached great importance to this idea indicating Freud was suggesting there is a stage at which infant and mother form a unit. Although Freud does not elaborate, Wiinnicott proposes at the beginnings of life the very meaning of 'dependence' comes into question as "the infant and the maternal care belong to each other and cannot be disentangled." (Winnicott, 1960, p.40).
Winnicott develops the idea that mother and infant begin by being entangled in ways that change our ordinary understanding of what it means to depend on someone. In this earliest period of life, before speech has begun to develop, an infant1 depends on maternal empathy rather than "on understanding what is or could be verbally expressed" (Ibid, p.40). The baby at this stage has no symbols and no ability to have one thing stand for another; it relies on a mother to make sense of the world, to 'mentalize' the raw data of internal and external experience and to transform it into symbols or signal affects (Mitrani, 1995, p.70).
Winnicott describes how in the "ordinary way" a mother provides a "holding environment" within which the infant can build up a "continuity of being" (Winnicott, 1960, p.47) by identifying with her baby and shifting some of her sense of self onto it. This early primitive relationship between mother and baby, which is not really a relationship between two things in the ordinary manner of things, or even something that happens between two things, but is rather a kind of agglomeration of bits attempting to obtain some sense of themselves:
On the one hand we have 'baby', a word we use to describe a physical entity observed from the outside as a something that is attended to. From the outside this something has projected onto it a fantasy of a psychological entity, which is really a bundle of raw sensory perceptions, sensations, unexperienced experiences, or "beta-elements" (Bion, 1962b, p.7). We can say as a physical entity the baby will not survive without a caregiver, but we can also say as a psychological entity the baby does not exist without a caregiver, in the ordinary course of things, a mother.
On the other hand we have 'mother', a word we use to describe a physical entity observed from the outside as a something that attends to the physical needs of something we call a baby. We tend to assume this mother has a psychological reality: However this cannot be taken for granted and only comes into being when she is able to allow herself, and is allowed, to participate in the undifferentiated bundle of psychological stuff that is mother-and-baby by entering a state of receptivity, or what Bion called "maternal reverie" (Bion, 1962a, p.309) where the mother contributes "alpha-function" (Bion, 1962b, p.2) to the mass of "beta-elements" (Ibid, p.7) that is mother-and-baby.
From the point of view of mother-and-baby, 'mothering' in this primitive psychological sense, cannot be thought of as something brought to the baby. If it is 'brought to', in a literal sense, something about the baby's experience of going-on-being will be lost. The baby needs to believe it is bringing alpha-function as mother. For this to be true it must be able to take itself as mother-and-baby for granted.
This is why Winnicott suggests:
"The newly integrated infant is … in the first group. Before this stage there is only a primitive pre-group formation, in which unintegrated elements are held together by an environment from which they are not yet differentiated. This environment is the holding mother." (Winnicott, 1965, p.219, emphasis in original).
Before this integration "the individual is unorganised, a mere collection of sensory-motor phenomena, collected by the holding environment. After integration … the infant human being has achieved unit status, can say I AM" (Ibid, p.217).
Winnicott uses the word "integration" for this moment in development where a baby becomes a person with an inside and an outside (Ibid, p.217).
No Such Thing As A Group
"… the basis of group psychology is the psychology of the individual, and especially of the individual's personal integration" (Winnicott, 1965, p.215)
"The apparent difference between group psychology and individual psychology is an illusion produced by the fact that the group brings into prominence phenomena that appear alien to an observer unaccustomed to using the group." (Bion, 1961, p.169)
Focussing now on Bion's observations about groups, I will proceed by referencing three aspects of group psychology he articulated to the discussion above. The three aspects of group experience are:
1) The work group;
2) Basic assumptions, and;
3) Proto-mental phenomena.
Bion observed activity in groups where the group seems "capable of establishing contact with reality and recognises the need to evolve, and to work together towards a common aim." (Lopez-Corvo, 2003, p.310) Bion called this a "work group" (Bion, 1961, p.98), but it is not really a group, rather it is a way of describing an aspect of mental states operating within a group. Learning, in these mental states, is by experience: There is a need for truth, and an awareness of the painful consequences of acting without an adequate grasp of reality. (Ibid, p.100)
Work group activity demonstrates a level of maturity such that the group undertakes mental work to achieve a task, containing and speaking about feelings rather than discharging them (Symington, 1996, p.126). I suggest this is linked to a 'capacity to be alone' which Winnicott proposed was vital to development. (Winnicott, 1958, pp.416-420). The work group may be thought of as a psychological environment where "ego-relatedness" is primary and "id-relationships" within the group strengthen the work of the group rather than disrupt it. (Ibid, p.418). Individuals in work group mentality are able to experience being alone in the presence of others. (Ibid, p.417) Although there is no such thing as a "work group", there will be aspects of this mentality in any group that is orientated towards work.
By altering his focus (Bion, 1961, p.48) Bion observed activity in groups which focussed on the group preserving itself, as if it had "a natural tendency to disintegrate" (Symington, 1996, p.128). The wellbeing of individuals becomes secondary to a basic assumption there is a need to maintain the group, even though there is no effort to make the group worthwhile; "adherence to the group is an end in itself." (Bion, 1961, p.63). Bion called the mental states associated with this activity "basic assumption" mentality, connecting it with "powerful emotional drives" (Ibid, p.146). This mental activity requires no training, experience, or mental development and makes use of "valency", or an individual's readiness to engage in this way. (Ibid, p.116) It is "instantaneous, inevitable, and instinctive" (Ibid, p.153).
Bion observed groups expressing basic assumption mentality through one of three mutually exclusive patterns: Dependency (baD), Pairing (baP), and Fight/Flight (baF). I suggest these patterns may be compared to three focusses a newly integrated infant might find refuge in2, on the edge between integration and unintegration: baD – Orienting centre and reference point (breast, phallus etc.); baP – Order, structure and hierarchy (sexual union, primal scene); baF – Boundary, edge and covering (skin, womb, container).
Like an infant held together by its mother's skin, a group experiences a sense of integration due to the unifying state of mind of the active basic assumption. However that this is "a dangerous achievement" since the "repudiated external world comes back at the new phenomenon and attacks from all quarters and in every conceivable way" (Winnicott, 1965, p.219). Perhaps this explains why a group becomes so preoccupied with its own survival as an end in itself. Although there is no such thing as a "basic assumption group", there will be aspects of this mentality in any group, an orientation towards survival of the group and avoiding learning by experience.
Bion was led to propose proto-mental phenomena through wondering what happens to the inactive basic assumptions. He visualised the the two inactive basic assumptions existing as a matrix of proto-mental states where "physical and psychological or mental are undifferentiated" (Bion, 1961, p.102), a system containing precursors for the emotions which are present in other aspects of the group. (Lopez-Corvo, 2003, p.222) Meltzer suggests "It is not intended to describe a cause and effect series", rather refer to a level "at which physical and psychological events are not differentiated, where the emotional components are fused because incipient as observable psychological phenomena." (Meltzer, 1998, p.279)
I suggest we may compare the 'proto-mental' aspect of a group to an unintegrated infant, or "primitive pre-group formation", of mother-and-infant (Winnicott, 1965, p.219), in a state of invisible oneness. Both refer to a state that is not physical or mental, rather the two are undifferentiated, what Bion refers to as beta-elements (Bion, 1962b, p.7) "which may manifest themselves as accident, illness, or vocal utterance." (Symington, 1996, p.138) Just as there is no such thing as an unintegrated infant without a mother, there is no such thing as a "proto-mental group"; since these aspects only exist in relation to the mental states of 'work' and 'basic assumption' as a pre-symbolic and pre-psychological matrix of possibility.
Bion offers us these three "vertices" (Bion, 1970, p.21) from which to understand groups , and suggests it is useful to find ways that bring the basic assumption aspect (ba) and the work group aspect (W) into contact (Bion, 1961, p.126). I believe any group which is endeavouring to be creative needs to bring the ba-activity and the W-activity into relationship: Emotional states associated with the active basic assumption and mental states associated with the work group can then enter a dialectical relation where "each creates, informs, preserves, and negates the other" in the realm of transitional phenomena and potential space (Winnicott, 1971, p.107).
Employing the thinking of Ogden (1985) to develop this, I suggest in establishing contact between ba-group-activity and W-group-activity the exclusive unities of 'group' and 'individual' are transformed into a three-ness of individual, group, and individual-as-group as three distinct entities. 'Oneness' (the invisible group-individual existing as a proto-mental soup) becomes 'three-ness', since at the moment of differentiation within the group-individual unit, not only are the group and individuals created as objects; in addition, individuals are created as subjects. Individual as subject is an observer of group and individual as (symbolic) objects; each individual becomes the creator and interpreter of his symbols. (cf. Ogden, 1985, p.133)
There is no such thing as a group without these moments where the group is created as a symbolic object in the mind of participating subjects.
The proposition that "there is no such thing as a group" has been examined in the light of Bion's thinking about groups informed by Winnicott's thinking about early infant experience and later developments by other psychoanalytic thinkers. An attempt is made to develop a vertex from which contact between the mental states of basic-assumption and work-group can be understood as marking a threshold where a group can begin to exist.
*1* As Winnicott points out the meaning of 'infant' is derived from the Latin 'infans' meaning 'not talking' (Winnicott, 1960, p.40); similarly the lack of speech is inferred in the derivation of 'baby' which derives from 'babble', an imitation of a baby's making of noise before it has words.
*2* I have discussed the idea of 'refuge' elsewhere in an unpublished undergraduate thesis "Going For Refuge" submitted in 1987 (Balfour, 1987).
Balfour, C. J. A. (1987). Going For Refuge. Bachelor of Architecture. Auckland University.
Bion, W. R. (1961). Experiences In Groups and other papers. London: Tavistock Publications Limited.
Bion, W. R. (1962a). The Psycho-Analytic Study of Thinking. International Journal of Psycho-Analysis, 43, 306-310.
Bion, W. R. (1962b). Learning From Experience. London: William Heinemann Medical Books Ltd.
Bion, W. R. (1970). Attention and Interpretation. London: Tavistock Publications Ltd.
Freud, S. (1911). Formulations on the Two Principles of Mental Functioning (Strachey, Trans. XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works).
Lopez-Corvo, R. E. (2003). The Dictionary of the Work of W.R. Bion. London: H. Karnac (Books) Ltd.
Meltzer, D. (1998). The Kleinian Development. London: Karnac Books.
Mitrani, J. L. (1995). Toward An Understanding Of Unmentalized Experience. The Psychoanalytic Quarterly, 64, 68-112.
Ogden, T. H. (1985). On Potential Space. The International Journal of Psychoanalysis, 66, 129-141.
Symington, J. & N. (1996). The Clinical Thinking of Wilfred Bion. London: Routledge.
Winnicott, D. W. (1958). The Capacity To Be Alone. International Journal of Psychoanalysis, 39(5), 416-420.
Winnicott, D. W. (1960). The Theory of the Parent-Infant Relationship. International Journal of Psycho-Analysis, 41, 585-595.
Winnicott, D. W. (1965). The Family and Individual Development. Tavistock Publications Limited.
Winnicott, D. W. (1971). Playing and Reality. Hove, E.Sussex: Brunner-Routledge.
Recently the thought occurred to me that we have antidepressants back-to-front, as it were.
The listed side-effects of these drugs (mostly SSRI’s) is really the main action, and the advertised effect is the real side effect.
In other words antidepressants reduce anxiety and depression as a side effect of reducing libido – in the more inclusive sense of ‘life force’. Perhaps the relief of depression occurs because anxiety and depression are symptoms of libido or life energy hitting up against an obstacle or difficulty either in the internal or external world. This obstruction interferes with the ability of libido to express itself.
Reduce libido and the unpleasant effects (depression and anxiety) of libido encountering an “obstruction” are correspondingly also reduced.
As I drive back from analysis several times a week I pass a billboard advertising plastic surgery. "The Six-Pack Redefined" it proclaims, and shows a 'before' and 'after' picture of a man who has been given a sexy "six-pack body". Even at the darkest moments of my analysis I have not been tempted. I think the 'before' picture looks more like my cup of tea so to speak, apart from not being able to afford what I imagine is expensive surgery. But I am very curious about the red slash across one corner of the billboard which says "As seen on TV".
The red slash 'As seen on TV' seems to be some sort of recommendation or validation of the procedure. I don't have a television myself and willingly miss out on this important aspect of popular culture. I prefer to listen to the radio (the pictures are better I find) and I am an avid collector of podcasts. So I have no idea how this procedure can be seen on tv, but I imagine perhaps as a commercial, or docuvert I think they are called. What interests me is how it seems to imply if something is 'seen on TV' it is more credible, or somehow more 'real'.
Many years ago I read a book I remember as "The Private Future". I have not been able to find this book since, but I recall a chapter on television and culture. The author suggested one of the difficulties with television is it brings the most public of arenas into our most private realm. Where once families would gather around the hearth or its equivalent, increasingly we sit around a television. This turns the private inside out, blurring the distinction between public and private in ways that reality tv shows have further exploited. In addition the distinction between what is 'significant' and what is less 'significant' is further blurred: Thus we watch a news item about a human disaster somewhere in the world in the same breath as we watch an advertisement for underarm deodorant or the latest washing powder. Even worse to my mind news has become 'entertainment' and the newsreaders have become celebrities.
This reminds me of Donald Meltzer's paper on Adhesive Identification (1975) where he writes of research he participated in with autistic children. They noticed there was no inside or outside in these childrens' minds, no interior and exterior. They would draw a picture of a house and turn it over and draw another house on the other side of the page but the two doors lined up exactly, as if stepping into the house meant stepping out at one and the same time. I wonder if we are encountering a form of cultural autism where there is no distinction between inside and outside, public and private, friends on Facebook and actual intimacy.
But I digress, I was wanting to think about neuroscience. This 'As seen on TV' slash on the six-pack plastic surgery advertisement reminds me of the impact of contemporary neuroscience on psychoanalysis. I think 'As seen on functional MRI' has become somewhat equivalent in the field of the mind to 'As seen on TV' in the field of cosmetic surgery. Whilst increasingly the discoveries of modern technology confirm much that Freud observed, started us thinking about, and we now observe ourselves in our practice, 'As seen on MRI' seems to make these observations and thoughts more credible, as if we could never quite believe ourselves. At times neuroscience's almost obsessive attempts to explain who we are through functional MRI scanning and the anatomy of the brain is reminiscent of the craze for phrenology that occupied the 18th century where it was thought we could tell something useful about a person by mapping the bumps on their head.
I am not suggesting that we should reject the technology to help us understand ourselves or that we ought to dismiss the findings of technology – that would be silly – but I do think there is something disturbing in the way something is not quite 'real' until a machine tells us so! Perhaps we are more willing to believe in Higgs Boson than the the existence of an unconscious because the former is mathematical, and because it does not seem to shape our lives in the same way! We may only 'know' the Higgs boson directly through a very big machine, the Large Hadron Collider, currently looking for it. I wonder if the best device for detecting the traces of the unconscious is a mind that is attuned, or a machine.
The unconscious is more awkward than the Higgs boson in an everyday kind of way for most of us and that has always made it unpopular. I believe Freud who began as a neurologist would have been delighted with the abilities of neuroscience to further investigate the mind, but I don't think he would have stopped observing how people behaved, what they said and dreamed! He was anxious to ensure psychoanalysis was accepted as a scientific endeavour because science gave it some measure of acceptability. As Heidegger has suggested, science has become the arbiter of what is real and has replaced religion as the arbiter of 'human-beingness'.
There is some connection (I am not sure what yet) to a conversation I listened to as a podcast on "All In The Mind' (Australian Broadcasting Corporation with Natasha Mitchell) where the topic under discussion was the amount of culpability that can be attached to criminal acts committed by someone subject to an addictive substance. This had me thinking about the chain of events leading to the act committed under the influence. Assuming the addiction usually starts with a decision to try the addictive substance, could one work back up the line from the offence to the decision to become addicted and make an inference of responsibility?
However that in turn had me thinking about 'community' and how some people seem doomed to become addicts by virtue of the environment they grow up in. Are we all ultimately responsible for a criminal act committed by someone? When we lived in villages perhaps this link would have been easier to make. Now we are faced with global warming we are having to revisit the interconnectedness of things in a way that may force us to rethink everything.