Can a psychoanalyst understand a patient?

Discomfortness about pyschoanalytic theories

As a third-year resident psychiatrist, I am currently providing psychoanalytic psychotherapy to four of my patients. I have little experience with psychotherapy and knowledge of psychotherapy theories, but ever since I began learning about psychoanalysis, one question has continued to exist: do we truly know or understand how the mind works? As some might have guessed, well known papers by Yuri Lazebnik¹ and Eric Jonas² motivated me to think about this question further.

Before I dive into the deep, dark side of current psychoanalytic theories, let’s get one thing straight: I’m not aiming to be that overeager young resident who sounds like they’re auditioning for the role of “Most Pessimistic Grumbler” in the annual hospital play. Yes, I confess - contemporary psychotherapies aren’t just therapeutic brain tickles; they indeed offer real benefits to some patients.^3,4

However, evidience of pyshotherpy’s effectiveness need not necessarily validate the underlying theories. Psychoanalytic thought encompasses a variety of perspectives from numerous analysts, including Freud, Klein, Winnicott, and Kohut. While some analysts are grouped together under the same umbrella - object relations theorists, for example - many psychoanalytic theories differ signficiantly from one another. Yet, among these diverse viewpoints, few possess robust scientific support for their foundational claims about individual drives or the mechanisms of mental functioning.

‘Why’ we need scientific psychoanalysis

Freud, a Helmholzian, sought to understand the mind through neurophysiology. Freud acknowledged the limitations of scientific knowledge about the mind, but he believed we could eventually understand it:

This is merely due to our being obliged to operate with scientific terms, that is to say with figurative language, peculiar to psychology. We could not otherwise describe the processes in question at all, and indeed we could not even become aware of them. The deficiencies in our description would probably vanish if we were already in a position to replace the psychological terms by physiological and chemical ones.⁵

Although interesting theories have been presented over the decades, we still lack a comprehensive framework for explaining how the mind works. In fact, some might argue that we don’t even know the right questions to ask, though I consider this an overly pessimistic view. Since Freud’s time, numerous brilliant psychoanalysts have proposed new theories about mental processes, yet it seems we are drifting away from a scientific understanding of the mind. The gap between what we’ve discovered in neuroscience and psychoanalysis has grown wider, and neither psychoanalysts nor neuroscientists are interested in understanding the biological foundations of psychoanalysis. Indeed, some psychoanalysts might even contend that discussing the biological basis of psychoanalysis is beyond the scope of their field. I respectfully disagree with them.

So, is this lack of scientific grounding a problem? If psychoanalysts are achieving good outcomes with their patients, does this not suggest that psychoanalysis is advancing appropriately? Should we be pushing for more scientifically rigorous theories? My answer to that final question is a resounding ‘Yes.’

To convince you, let me refer to Eric Kandel, a psychiatrist and Nobel laureate, who shared insightful thoughts in an interview:

There’s absolutely room for psychoanalysis, but I don’t want anyone to think of me as representing a last-ditch attempt to save it. That’s not my view at all. I think psychoanalysis has real problems. When I was a resident in psychiatry—that would be 1960—you couldn’t be considered committed to proper psychiatry unless you were psychoanalytical. And everyone was in analysis. Now very few people are, because psychoanalysis failed in a number of ways. It didn’t provide outcome studies to show that it worked; it didn’t produce mechanistic studies to show how it worked. So people who are critical began to reject it, and that’s still the state of things right now. It needs to be completely revised if it’s going to be effective—and I have reason to believe that it might be—but we need those studies.⁶

Moreover, we have to note that both the amount spent on private health insurance and government health spending are steadily rising.

public-health-expenditure-share-gdp

Health spending in the U.S. increased by 4.1% in 2022, reaching $4.4 trillion, which equals to $13,493 per capita.⁷ Hospital care constituted the largest portion of this expenditure, accounting for 30.4% of the total spending. In response to these rising costs, numerous countries are implementing strategies to reduce healthcare spending. These include setting caps on the number of covered sessions for long-term psychotherapy or limiting insurance coverage to short-term psychotherapies.⁸

To persuade others of the importance of psychoanalysis, merely stating that its effectiveness can’t be conclusively proven by research is like trying to sell a car by saying, “Well, it might work.” Sure, proving the effectiveness of psychoanalysis is one of psychology’s millennium questions, but that doesn’t mean we can just shrug and move on. We still have an obligation to tackle this issue, ensuring that even those outside the field can see the value in investing time and money into therapy.

‘How’ to have a more scientific approach

To adopt a more scientific approach in psychoanalysis, we must rely on scientific realism and reductionism, as is done in all medical fields. Scientific realism posits that diseases and their treatments have objective, observable realities that can be systematically studied and understood. In psychoanalysis, however, we often use ambiguous terms such as ‘libido’, ‘paranoid-schizoid position’, ‘self-object’, and ‘alpha function’. While psychoanalysts might argue against the ambiguity of these terms, I confidently claim their lack of clarity. These terms do not have a biological basis that anchors them in reality, nor do they possess definitions universally agreed upon across different theories.

To advance psychoanalysis scientifically, we need to refine these concepts, grounding them in observable and measurable phenomena that align with the principles of scientific realism. Computational neuroscience, which leverages mathematics—one of the most objective languages humankind uses—holds potential for refining and redefining the vague concepts discussed in psychoanalysis.

One good example of understanding projective identification through the lens of active inference is as follows. According to the theory of active inference, the brain’s primary goal is to minimize its surprise, either by updating its internal world model or by selecting actions that achieve this goal. Projective identification can be viewed as an action chosen to influence external reality (in this case, the therapist) so that the therapist behaves in ways that align with the patient’s expectations. Therefore, projective identification serves as a strategy to reinforce the patient’s confidence in their own internal world model. Below is a demonstration case illustrating that projective identification results in lower expected free energy compared to not engaging in it. (Adapted figure from GitHub.)

free_energy

This perspective not only clarifies why it is crucial for therapists to avoid embodying the projected qualities, but also provides a framework for understanding why some borderline patients can temporarily exhibit psychotic-level symptoms. Both psychotic beliefs and projective identification can be understood through the same theoretical lens and may lie on a continuous spectrum, with the primary difference being the severity of the phenomena.

Likewise, applying neuroscientific knowledge and computational frameworks to psychoanalytic terms would not only provide clearer definitions but also allow us to relate these concepts to psychopathology terms with more established biological meanings. By integrating these scientific approaches, we can enhance our understanding of psychoanalytic constructs, making them more precise and empirically grounded. This integration facilitates the translation of psychoanalytic ideas into the language of modern neuroscience and psychiatry, bridging the gap between psychological theories and biological evidence.

Reductionism, on the other hand, is another crucial philosophical concept for advancing the medical field. By understanding the mechanisms of treatment, we can eliminate unnecessary components, thereby making the treatment more efficient. In psychoanalysis, the lack of a crystal-clear criterion or measurement for defining when a patient is ‘cured’ complicates our ability to discern which elements of the treatment are essential.

Returning to the concept of projective identification, we can reasonably argue that a patient with a high dependence on projective identification is likely to experience problematic relationships. If we could measure an individual’s tendency to use projective identification versus updating their internal model through computational models and cognitive tasks, a drop in the patient’s reliance on projective identification to a normal range could serve as a valuable prognostic or predictive marker for psychoanalysis.

By integrating these objective measurements with the therapist’s and patient’s subjective assessments of progress in psychoanalytic psychotherapy, therapists can make more confident decisions about when to terminate therapy. Furthermore, conducting research to correlate the subjective outcomes of psychotherapy with objective measurements can provide a stronger scientific foundation for the necessity of psychotherapy. This approach underscores the importance of psychotherapy and supports its efficacy with empirical evidence, as emphasized in the previous section.

Coexistence of ‘subjective’ and ‘objective’ science is the key

In wrapping up this essay, I want to clarify that I am not arguing against the importance of the therapist’s and patient’s subjective experiences and feelings. I cannot more strongly agree that the relationship between the therapist and patient is the most crucial part of therapy. Additionally, I acknowledge that subjective experiences cannot always be reduced to objective, scientific terms.

Many contemporary psychotherapists advocate for setting aside theoretical considerations during therapy sessions to focus on what the patient says. This approach represents the ‘subjective’ aspect of psychoanalysis. However, once the session ends, therapists often reflect on theories, consider transference and countertransference, and evaluate the direction of the therapy. This represents the ‘objective’ aspect of psychoanalysis.

What I am emphasizing is that if we do not acknowledge the current gaps in the scientific foundation of psychoanalysis, we risk relegating the field to the realm of literature or art, rather than science or medicine. As a psychiatrist who firmly believes in the necessity of psychoanalysis for some patients, I do not want this outcome. It is crucial to incorporate objective measurements and scientific rigor into psychoanalysis to maintain its credibility and effectiveness as a therapeutic approach.