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For an intellectual movement which has been widely dismissed as dead for the past several decades or longer, psychoanalysis is surprisingly well represented in the academic book market. Daniel Pick's Psychoanalysis: A Very Short Introduction, a recent entry in that category, is strikingly ambitious in scope, aiming to provide readers with an introduction to Freud's theoretical writings, its development by subsequent psychoanalysts, and the therapeutic practice embedded within that tradition. Given this volume's slender frame -- approximately 120 pages -- successful investigation of such broad territory would have been an impressive achievement, but it is ultimately unsatisfying for reasons which are at turns mundane and instructive. Mundane because, in the case of his discussion of Freud and subsequent psychoanalysts, Pick is clearly constrained by this volume's modest size; instructive because his discussion of psychoanalytic method betrays some enduring perplexities about the way analysts conceive of and approach their practice. I will, therefore, focus this review on the latter.
The discussion of analytic method stands to be the most useful part of this book, for a few reasons: First, psychoanalytic therapy is much less well understood, and less well represented in the current literature, than the fundamentals of Freud's own thought or its development by subsequent theorists. Second, with a number of therapeutic alternatives to psychoanalysis available to most service users, including pharmacotherapy and cognitive-behavioral therapies (CBT), it is natural to wonder what enduring value, if any, is to be found in psychoanalysis. There are then two key questions which we would want Pick's discussion of analysis to answer: What does analysis do, and how does it do it? To the first question, Pick answers, as one would expect a Freudian to do, that psychoanalysis relieves neuroses by revealing their subconscious sources the analysand and by enabling expression of the tensions and impulses which would otherwise manifest as symptoms. He also affirms the Freudian orthodoxy which says that this description is just as true for those whose subconscious conflicts lead to severe psychopathology as it is for those in whom it produces a vague feelings of malaise or ennui. With the second question, Pick is at a loss.
The trouble Pick has getting traction on the problem of explaining how psychoanalysis works is revealed in a number seemingly offhanded statements sprinkled throughout the text. He cites with approval Joyce McDougall's claim that while psychoanalysis operates on common mental structures, it demonstrates the existence of "countless possible 'theatres of mind'" (26). Suppose we take this as a serious claim; it then seems natural to ask how it is possible to determine precisely what processes underlie any particular symptom set. Pick does neither answers the question nor gives any indication that he recognizes it. Elsewhere, when discussing the tendency of analysts read unconscious intentions into apparently innocuous behaviors of their patients, he cites an anecdote in which a wartime patient of Melanie Klein's was made late for a session by a bombing raid and, upon his arrival, was nevertheless eager to assume responsibility for his tardiness. The lesson of the story, Pick says, is that analysts must be sensitive to the possibility that in such situations, "a psychical factor may -- not must -- be in play" (65). He does not, however, give any indication how the question could be settled one way or the other. Now, it's all well and good to suppose that apparently meaningless events might be subconsciously caused, but it's hard to see what use that hypothesis might be to a therapist unless she is given a sound method for determining whether or not that is the case. It is not clear that psychoanalysis can provide her with such a method. To highlight these passages may seem like nitpicking on my part, but I take them as telling because they raise the question how an analyst can know whether she has properly interpreted the patient's thoughts and behaviors. An example may help reveal the Freudian theory posits that a person might guard against realization of a repressed desire by expressing revulsion at the object of desire. But how might an analyst determine whether the patient's expressed revulsion is a defense mechanism or a phenomenon to be taken at face value and explored as such? Pick gives no answer, and so one is struck by both the leeway that the discipline affords its practitioners with respect to interpretation and the faith that it places in such acts of interpretation. That is not necessarily a vice, but one might expect a discipline with presumptions of objectivity to also have a means of evaluating the accuracy of such interpretations, but nothing of the sort exists. Thus, it seems that individual analysts have the freedom to superimpose Freudian theory on the patient's psyche as they please.
That one gets these impressions when reading Pick's volume is certainly not his fault. His subject is, after all, a tradition inaugurated by a man who considered himself a scientist of the mind while simultaneously insisting that his theories could neither be confirmed nor refuted by experimental means. There are clear ironies here, some more notorious than others, and I do not expect Pick to be able to explain them away. It would, however, be nice if he demonstrated awareness of how problematic they are. A comparison might be made with Anthony Storr, who, in his introduction to Freud from the same series as Pick's volume, treats the paradox of Freud's self-conception as a scientist in what I take to be appropriately dismissive fashion (Storr 2001, 147-150). Furthermore, this paradox is quite closely connected to Popper's infamous critique of psychoanalysis. Towards the end of the book, Pick acknowledges that criticism and responds thusly: "Analysts with appropriate integrity are open to alternatives… their interpretations are best regarded as openings to investigation, not the last word" (120). But this response is a clear non sequitur, for the charge is not that analysts dogmatically cling to their interpretations in the face of contrary evidence; it is that the structure of Freudian theory does not provide them with resources for determining what counts as evidence either for or against an interpretation. Whether Pick has misunderstood the problem or simply chosen to evade it does not really matter. Either way, his failure to directly address a critique of his topic so well known that it is virtually a cliché to repeat it produces a feeling of dissatisfaction that is hard to shake.
A similar issue is found when Pick attempts vindication of the value of psychoanalysis against the claim that CBT has a superior track record with respect to relief of psychopathological symptoms. Pick observes that "analysts…have been slower to subject their work to" empirical evaluation "and have often proved wary, even extremely critical, of the entire enterprise of outcome testing per se, pointing to its often reductive and crudely utilitarian nature" (19). Pick neither endorses this criticism nor disavows it so it is hard to tell what he thinks of it, but the criticism itself is very hard to take seriously. Recall the breadth of explanatory scope which psychoanalytic practitioners claim for themselves; the same mechanisms posited as causes of everyday, sub-pathological neuroses are also said to be behind cases of severe psychopathology. Thus, analysis is meant to provide treatment for both, a presumption which Pick affirms in his introduction (12-16). But if we understand psychopathology as true pathology -- mental illness as genuine illness -- then the criticism that therapeutic alternatives to psychoanalysis are "crudely utilitarian" is almost absurd. One would not tell a victim of some bodily pathology that the urgency of her desire to be cured is the product of a crudely utilitarian impulse at that she really ought to be examine what her disease means for her. Now, of course, a psychoanalyst will suggest a fundamental disanalogy between these two cases, arguing that mental illnesses are diseases of rationality rather than of the body and, because meanings are the currency of rationality, mental illnesses can only be treated through exploration of the meanings the subject finds within herself and imposes upon her environment. That may be true, but even so it does not justify deriding the value of CBT. It is a fact that psychopathology produces considerable suffering, and relief of that suffering ought to be seen as a just aim in itself and one imbued with considerable moral urgency. If the psychoanalytic approach does better at producing long-term results than CBT, then that is both a different claim than that "outcome testing" is "reductive and crudely utilitarian" and a suggestion that CBT, with its empirically testable methodology, is a natural ally of psychoanalysis, rather than an opponent. It is probably true that advocates of CBT have been just as insensitive to the possibility of such an alliance as psychoanalysts, but that does not make Pick's discussion of the matter any more adequate.
There is something both unfortunate and ironic about the tone Pick takes with respect to these matters. On a few occasions he mentions studies -- he cites Fonagy (2010b) -- that seem to show that psychoanalysis is at least as effective at symptom reduction as CBT (69-70). This is an interesting and potentially useful fact but Pick does not make it the fulcrum of his defense of psychoanalysis, instead treating it as somehow beside the point. This is, from an objective point of view, quite curious, for it would seem that results such as these would be embraced by the psychoanalytic community and replicated with an eye toward achieving greater understanding of the mechanisms which underlie successful analysis. That the psychoanalytic community still lacks such an understanding (Fonagy 2010a) is unsurprising given its history of hostility to empirical study. Instead, toward the end of the book, after having dismissed Popper's criticism, Pick suggests that the success of psychoanalysis does not rest on its status as a science. Viewed from a certain aspect, this is undoubtedly true; Freudian thought may live on as an intriguing way of understanding art, culture, politics, and the mind. But if it is not science, then it cannot be medicine; if it is not medicine, then it is not an endeavor well suited to the treatment of genuine psychopathology. Thus, to reject scientific scrutiny of psychoanalysis as some kind of a category mistake is to acknowledge that its primary value is found in what it offers to individuals afflicted by sub-pathological character tics who can afford the cost of weekly analysis for an indeterminate span of time. In weighing the relative values of psychoanalysis and CBT, Pick refers to the latter's practitioners as "'life coaches'" (17) and "gurus of modern 'happiness'" (123), but he is also comfortable asserting that "a personal 'journey of discovery' cannot be 'trialled'" (69). Fair enough on the latter point, but I have to wonder what use people who are genuinely, severely ill have for personal journeys of discovery. As long as psychoanalysts see themselves as above such utilitarian matters as theory confirmation -- and they do have theories -- they will be the ones to whom appellations such as "life coach" and "happiness guru" are most applicable.
I do not know the extent to which Pick's conception of psychoanalytic practice reflects that of the general psychoanalytic community, but it is frustrating to think that it might be. The existence of some studies of its efficacy suggests that some psychoanalysts are open to empirical evaluation, but it is far less investigated than CBT. Nevertheless, Pick is right when he says that psychoanalysis can be an effective treatment for psychopathology; the data is unambiguous on this matter (e.g. Bateman and Fonagy 2008, Fonagy et al. 2015, Leichsenring, Rabung, and Leibing 2004). The question yet to be answered is one I posed above: Precisely how does it work? Uncovering the mechanisms by which analysis operates would be a breakthrough of considerable therapeutic value, providing insight into the situations in which it stands to be successful and those in which it does not. Mental health services will surely be strengthened by proliferating the methods of treatment available to its users, each with unique strengths and scopes of applicability. If psychoanalysts hope to be a part of such a movement, then they will have to change their general attitude toward empirical evaluation. That may, for reasons articulated above, require reevaluation of the structure of Freudian thought, but whatever changes follow may ultimately be for the benefit of psychoanalysis. It should, therefore, be hoped that the view of psychoanalytic practice that Pick presents in this volume lies outside the mainstream of the discipline.
Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. The American Journal of Psychiatry, 165(5), 631--638.
Fonagy, P. (2010a). Psychotherapy research: do we know what works for whom? The British Journal of Psychiatry, 197(2), 83--85.
Fonagy, P. (2010b). The changing shape of clinical practice: Driven by science or by pragmatics? Psychoanalytic Psychotherapy, 24(1), 22--43.
Fonagy, P., Rost, F., Carlyle, J., McPherson, S., Thomas, R., Pasco Fearon, R. m., … Taylor, D. (2015). Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS). World Psychiatry, 14(3), 312--321.
Leichsenring, F., Rabung, S., & Leibing, E. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Archives of General Psychiatry, 61(12), 1208--1216.
Pick, D. (2015). Psychoanalysis: A Very Short Introduction. New York, NY: Oxford University Press.
Storr, A. (2001). Freud: A Very Short Introduction. New York: Oxford University Press.
© 2016 Christopher Parker
Christopher Parker is a PhD student in philosophy at University of Cincinnati whose research primarily focuses on the history of psychiatry and the concept of mental disorder.