Is Psychoanalysis Making a Comeback?

Cognitive-behavioral therapy has been the de facto therapy modality of the last two decades. Even The Coddling of the American Mind authors Greg Lukianoff and Jonathan Haidt based the entire thesis for their book on the tenants of CBT. Every Better Help advertisement you hear on a podcast will invariably contain “CBT” or “CBT therapists”. CBT became the de facto therapy because of it’s promising efficacy demonstrated in thousands of studies as well as its huge appeal to insurance companies, since CBT is usually time-bound, prescriptive, and structured.

CBT has shown promising results for anxiety and depression as researchers have shown in a slew of meta analyses. Meta analytic research is essentially research on research, where thousands of articles about a topic are analyzed to reveal if pattern exists. There is certainly a pattern with CBT. It reduces acute symptoms including depressive episodes, worrying, and panic attacks, along with many other uncomfortable psychiatric symptoms. Cognitive behavioral therapy is also used for disorders that are more ego-syntonic, and don’t cause as much subjective distress for the client in question, like anti-social personality disorder.

Interestingly, almost all of that can also said be said about psychoanalysis, though it does not get nearly as much attention. In fact, one of the most cited and important meta analyses on treatment efficacy published in the last 10 years found that therapeutic modality did not matter nearly as much as the relationship itself between client and therapist. This idea is actually germane to both psychoanalysis and CBT but as the modality has developed and evolved, psychotherapy became less about the relationship between client and therapist and more about results, technique, and outcomes. This is in part why companies like Talk Space and Better Help were able to emerge and why they chose CBT as the therapy they advertise. If your therapist is actually just a faceless person texting you, the relationship becomes much less relevant and becomes more about the “services” they provide which are supposed to be quick, efficient, and useful. While not convenient, good outcomes from therapy rarely come from simply teaching someone a tip.

Cognitive-behavioral therapy as its core hedges on the assertion that most dysfunction arises from beliefs and negative thought patterns. There is certainly much more to the theory, but put succinctly, CBT therapists believe that if they can teach you how to think and speak to yourself in ways that are more realistic, adaptive, and positive, you will begin to feel and behave more positively. For example, a common question a therapist will use when utilizing CBT is “when x happened, what was going through your mind?” or “what was the thought you had before you had the panic attack? During? After?” This type of technique is actually much more difficult than it sounds, and a good example of why CBT actually requires more training than simply going to graduate school. Most therapists who say they practice CBT are not certified, and while CBT is a major facet of the counseling skills we learn in graduate school, it is rare that students graduate knowing the ins and outs of cognitive behavioral theory and practice which, as it was originally was intended, is complex and requires structured homework assignments after every session.

The reason why these questions don’t always work in of themselves is that it is actually very hard to remember what you were thinking exactly when you felt anxious. And as soon as your therapist asks you to do this, your attention immediately leaves the room and it is harder to attune to how you’re feeling in the moment, which is almost always necessary for any kind of progress in psychotherapy. The theory behind the question is that in order to reduce depression or anxiety, the client must isolate whatever negative thought occurred, and link it to a belief they have about themselves. For example, the thought may be “I don’t want to get out of bed because doing anything is pointless” and the core belief attached to that thought may be “I’m bad, or I’m lazy.” The therapist then challenges the core belief after doing some investigation of where it came from (a critical parent or an early shameful experience) and asks the client to challenge it with them. The usual script goes something like “Tell me all the reasons why you aren’t lazy (looking for evidence to counter-act the belief) and why you’re good.” In actuality Aaron Beck who founded CBT was quite direct, provocative, and pragmatic. He did not actually argue that negative core beliefs are always wrong, but he did argue that repeating them or dwelling on them, was futile and furthered distress. Furthermore he argued, it is just as important that one focuses on the positive about themselves while ignoring or putting less emphasis on, the negative. The problem is that as CBT as evolved, it has become less confrontational and more validating. What if someone who also experiences depression has learned lazy habits and struggles to counteract them? Does this person need to be told they are in fact not lazy, or do they need to be encouraged to value their time more, and challenged to try different habits? For psychoanalysts of course, the question would not be “how do I help this client be less lazy or depressed” but “what does laziness or depression mean for this client?” and “why are they behaving this way?”. “What conflicts are present for this client that render them paralyzed from time to time?”.

In the years I have spent practicing psychotherapy I have found that almost every time someone is in distress, the why is more important to discuss than the how. For one, with the proliferation of information online, most clients can find psycho-education materials quickly and easily, which they do. A therapist who simply offers information or suggests solutions is likely wasting time. Of course, there are instances when this approach is appropriate, and I use psycho-education as a technique often, in conjunction with other techniques. Furthermore, the risk in solely taking this approach early on is that invariably when it fails, the onus of failure is placed on the client. Likely the client in the first place did not just need a suggestion that he or she start journaling, or a circumscript analysis of his or her thoughts, but a therapist who is genuinely interested in understanding them and the source of whatever issue they are coming in with. It is not rare that I meet clients who are simply interested in personal development and improvement, but it is rare that these clients stay in therapy for more than a few sessions. For those clients, coaching may be a better overall fit than psychotherapy.

So is it at all that surprising that psychoanalysis seems to be a making comeback? The practice has received heavy criticism over the years for its exclusionary history and high costs. Sessions can cost hundreds of dollars and are recommended multiple times a week, at least for traditional Freudian analysis. The therapist is a ‘blank slate’ and usually only asks questions, with the patient facing away from the therapist (a la the famous couch). Psychoanalysis as a discipline is historically European and upper class—everything about it seemed to, and perhaps still does, scream white, bourgeois, and self-indulgent. However, traditional Freudian psychoanalysis is only one form of psychoanalysis. Others, like Lacanian analysis, feature a more active and engaged psychotherapist. And of course there is psychodynamic psychotherapy, which in practice can resemble a sort of mish-mash of psychoanalytic theory and CBT.

Many of the tenants of psychoanalytic theory hold up today—the power of the unconscious, the importance of discussing transference and counter transference in therapy, the function of defense mechanisms. These ideas, at least for me, have helped me understand people so much more than simply asking them what thoughts make them feel anxious. This is perhaps why students still study psychoanalysis and why there seems to be an uptick in practices that offer it. More therapists are now describing themselves as “psychodynamic” which as described, combines modalities and theories.

CBT isn’t going anywhere anytime soon and will likely remain one of the most popular therapeutic modalities in the history of psychiatry and psychotherapy and it is not the only effective form of psychotherapy. Perhaps we were too anxious to write off psychoanalysis—dare we forget the invaluable impact Freud had just in our linguistics and arguably our collective consciousness. The Freudian slip, the Oedipal/Electra complex, defense mechanisms, the subconscious; these constructs are used in every day conversation. They have arguably shaped, at least in the West, how we think about ourselves and others. Perhaps it is time we return to the source of those ideas, and see what other worthwhile lessons we can find.