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Monday, October 5, 2009

Is Freud Back in Fashion? No.

Freudian psychoanalysis is the key to treating depression, especially the post-natal kind (depression after childbirth). That's according to a Guardian article by popular British psychologist and author Oliver James. He says that recent research has proven Freud right about the mind, and that psychoanalysis works better than other treatments, like cognitive-behavioural therapy (CBT).

Neuroskeptic readers have encountered James before. He's the person who thinks that Britain is the most mentally-ill country in Europe. I disagree, but that's at least a debatable point. This time around, James's claims are just plain wrong.

So, some corrections. We've got a lot to cover, so I'll keep it brief:

"10% [of new mothers] develop a full-blown depression...which therapy should you opt for? [antidepressants] rule out breastfeeding" - No, they don't. Breast-feeding mothers are able to use antidepressants when necessary, according to the British medical guidelines and others:
Limited data on effects of SSRI exposure via breast milk on weight gain and infant development are encouraging. If a woman has been successfully treated with a SSRI in pregnancy and needs to continue therapy after delivery, there is no need to change the drug, provided the infant is full term, healthy and can be adequately monitored...
James's statement is a dangerous mistake, which could lead to new mothers worrying unduly, or even stopping their medication.

"People given chalk pills but told they are antidepressants are almost as likely to claim to feel better as people given the real thing."
- This is true in many cases, although it's a little bit more complicated than that, but this refers to trials on general adult clinical depression, not post-natal depression, which might be completely different.

There's actually only one trial comparing an antidepressant to chalk placebo pills in post-natal depression. The antidepressant, Prozac, worked remarkably well, much better than in most general adult trials. This was a small study, and we really need more research, but it's encouraging.

"Regarding the talking therapies, in one study depressed new mothers were randomly assigned to eight sessions of CBT, counselling, or to psychodynamic psychotherapy. Eighteen weeks later, the ones given dynamic therapy were most likely to have recovered (71%, versus 57% for CBT, 54% counselling)."

This is cherry-picking. In the trial in question the dynamic (psychoanalytic) therapy was slightly better than the other two when depression was assessed in one way, which is what James quotes. The difference was not statistically significant. And using another depression measurement scale, it was no better at all. Take a look, it's hardly impressive:

Plus, after 18 weeks, none of the three psychotherapies was any better to the control, which consisted of doing precisely nothing at all.

"Studies done in the last 15 years have largely confirmed Freud's basic theories. Dreams have been proven to contain meaning." - Nope. Freud believed that dreams exist to fulfil our fantasies, often although not always sexual ones. We dream about what we'd like to do. Except we don't actually dream about it, because we'd find much of it shameful, so our minds hide the true meaning behind layers of metaphor and so forth. "Steep inclines, ladders and stairs, and going up or down them, are symbolic representations of the sexual act..."

If you believe that, good for you, and some people still do, but there has been no research over the past 15 years supporting this (although this is quite interesting). There was never any research really, just anecdotes

"Early childhood experience has been shown to be a major determinant of adult character." Nope. The big story over the past decade is that contra Freud, "shared environment", i.e. family life and child rearing make almost no contribution to adult personality, which is determined by a combination of genes and "individual environment" unrelated to family background. One could argue about the merits of this research but to say that modern psychology is moving towards a Freudian view is absurd. The opposite is true.

"And it is now accepted by almost all psychologists that we do have an unconscious and that it can contain material that has been repressed because it is unacceptable to the conscious mind." Nope. Some psychologists do still believe in "repressed memory" theory, but it's highly controversial. Many consider it a dangerous myth associated with "recovered memory therapy" which has led to false accusations of sexual abuse, Satanic rituals, etc. Again, they may be wrong, but to assert that "almost all" psychologists accept it is bizarre.

"Although slow to be tested, the clinical technique [of Freudian psychoanalysis] has now also been demonstrated to work. The strongest evidence for its superiority over cognitive, short-term treatments was published last year..."

First off, the trial referred to was not about post-natal depression, and it didn't test cognitive therapy at all. It compared long-term psychodynamic therapy, vs. short-term psychodynamic therapy, vs. "solution-focused therapy" in the treatment of various chronic emotional problems. No CBT was harmed in the making of this study.

After 1 year, long-term dynamic therapy was the worst of the three. At 2 years, they were the same. At 3 years, long-term dynamic therapy was the best. Although all these differences were small. Short-term dynamic therapy was no better than solution-focused therapy, which is rather a point against psychoanalysis since solution-focused therapy is firmly non-Freudian. And amusingly, the "short-term" dynamic therapy was actually twice as long as the dynamic therapy in the first study discussed above, which James praised! (20 weekly sessions vs 10). (Edit 23.10.09)

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James ends by slagging off CBT and its practitioners, and suggesting that we need a "Campaign for Real Therapy", i.e. not CBT, something he has suggested before. This is the key to understanding why James wrote his muddled piece.

The British government is currently pouring hundreds of millions into the IAPT campaign which aims to "implement National Institute for Health and Clinical Excellence (NICE) guidelines for people suffering from depression and anxiety disorders". NICE guidelines essentially only recommend CBT, so this is effectively a campaign to massively expand CBT services. CBT is widely seen as the only psychotherapy which has been proven to work, in Britain and increasingly elsewhere too.

Oliver James, like quite a lot of people, doesn't like this. And in that, he has a point. There are serious debates to be had over whether CBT is really better than other therapies, and whether we really need lots more of it. There are also serious debates to be had over whether antidepressants are really effective and whether they are over-used. But these are all extremely complex questions. There are no easy answers, no short cuts, no panaceas, and James's brand of sectarian polemic is exactly what we don't need.

[BPSDB]

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