BMJ 2012;344:e1211 doi: 10.1136/bmj.

e1211 (Published 20 February 2012) Page 1 of 2

Head to Head

HEAD TO HEAD

Does psychoanalysis have a valuable place in modern

1 2
Peter Fonagy Freud memorial professor and head of research chief executive , Alessandra
3 4
Lemma unit director clinical director
1
Department of Clinical, Educational and Health Psychology, University College London, London WC1E 6BT, UK; 2 Anna Freud Centre, London;
Psychological Therapies Development Unit, Tavistock and Portman NHS Foundation Trust, London; 4Psychological Interventions Research Centre,
3

University College London

Psychoanalysis is under greater attack than ever before. An with somatoform disorders.6 Ultimately these investigations
unprecedented decommissioning of psychoanalytic services has will enable us to better understand the therapeutic mechanisms
taken place across the United Kingdom’s National Health of a range of approaches and provide badly needed
Service (for example, Forest House NHS Psychotherapy Clinic), improvements in our treatments of complex disorders.
justified by cost savings. What are the reasons for this attack The psychoanalytic approach makes three valuable and unique
and what can be said in psychoanalysis’s defence? contributions to a modern healthcare economy. First, in their
It has been claimed, perhaps fairly, that psychoanalysis and applied form, psychoanalytic ideas can support mental health
psychodynamic psychotherapies have failed to promote a culture staff to provide high quality services despite the interpersonal
of systematic evaluation and that the outcomes are difficult to pressures to which they are inevitably exposed when working
measure and demonstrate. Relative to the number of studies on with disturbed and disturbing patients. Psychoanalytic
the effectiveness of cognitive behavioural therapy, few adequate understanding helps us to respond in humane ways when anxiety
studies are available of psychodynamic therapy outcomes. A and stress threaten our ability to contemplate behaviour in terms
growing body of studies, however, report that psychodynamic of underlying mental states. The framework psychoanalysis
therapy is effective in the treatment of both mild and complex provides for understanding why things go wrong in therapeutic
mental health problems. For example, a meta-analysis found relationships draws on a well-developed theory of interactional
substantial effect sizes in randomised controlled trials of long process.7 There are few viable alternative models for how a
term psychodynamic psychotherapy, larger than those for short disturbed individual or community can affect the thinking and
term therapies.1 Positive correlations were also seen between behaviour of those engaged with them.
outcome and duration or dosage of therapy. Another Secondly, there are increasingly strong indications that adult
meta-analysis found that psychotherapy in addition to mental health problems are developmental in nature; three
antidepressants significantly reduced depressive symptoms quarters can be traced back to mental health difficulties in
compared with antidepressants alone.2 A third meta-analysis childhood, and 50% arise before age 14 years.8 The
found that short term psychodynamic psychotherapy may be psychoanalytic model is unique in proposing a developmental
more effective than other therapies for somatic disorders.3 So theory (of attachment relationships) that is now firmly supported
evidence is on its way. by evidence.9 It therefore allows us to understand the relationship
Convergent support for psychoanalytic approaches comes from between early experience, genetic inheritance, and adult
20 studies of brain function changes after a range of psychopathology. This developmental framework emphasises
psychotherapeutic treatments, including psychodynamic ones, early intervention and has been critical in shaping positive
for several mental disorders.4 Brain changes that have been mental health policy, including the UK government’s “No
shown include a substantial increase in 5-HT1A receptor density Health Without Mental Health” strategy.10 Acknowledging the
in patients with major depressive disorder after psychodynamic developmental, relational foundations of mental health also has
therapy—this was not the case in patients who received important implications for prevention.
fluoxetine5—and normalisation of neuronal activity in patients

[email protected]

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2012;344:e1211 doi: 10.1136/bmj.e1211 (Published 20 February 2012) Page 2 of 2

HEAD TO HEAD

Thirdly, psychoanalytical ideas continue to provide the the previous three years; no other relationships or activities that could
foundations for a wide range of applied interventions. Research appear to have influenced the submitted work.
and clinical observation show that other modalities— Does psychoanalysis have a valuable place in modern mental health
particularly cognitive behavioural therapy—have made use of services? is the subject of a Maudsley debate at the Institute of
theoretical and clinical features of the psychoanalytic approach Psychiatry, King’s College London on 7 March 2012 (www.iop.kcl.ac.
and incorporated these into their techniques. This may well uk/events/?id=1106).
enhance the overall effectiveness of these modalities; for Provenance and peer review: Commissioned, not externally peer
example, some evidence suggests that the good outcomes reviewed.
achieved by other therapies correlate with the extent to which
those therapies use psychodynamic techniques.11 1 Leichsenring F, Rabung S. Long-term psychodynamic psychotherapy in complex mental
disorders: update of a meta-analysis. Br J Psychiatry 2011;199:15-22.
Research clearly shows that there is no one size fits all approach 2 Jakobsen JC, Hansen JL, Simonsen E, Gluud C. The effect of adding psychodynamic
to the treatment of mental health problems; irrespective of brand, therapy to antidepressants in patients with major depressive disorder. A systematic review
psychotherapy only substantially helps around 50% of referred of randomized clinical trials with meta-analyses and trial sequential analyses. J Affect
Disord 2011, published online 16 Apr.
patients who complete treatment12 and medication fares no 3 Abbass A, Kisely S, Kroenke K. Short-term psychodynamic psychotherapy for somatic
better.13 Rationally designed services should therefore provide disorders. Systematic review and meta-analysis of clinical trials. Psychother Psychosom
2009;78:265-74.
a range of approaches for which some evidence of effectiveness 4 Karlsson H. How psychotherapy changes the brain. Psychiat Times 2011;28:8.
exists, and should continue to broaden the research base to 5 Karlsson H, Hirvonen J, Kajander J, Markkula J, Rasi-Hakala H, Salminen JK, et al.
Research letter: psychotherapy increases brain serotonin 5-HT1A receptors in patients
ensure monitoring and improvement of the effectiveness of with major depressive disorder. Psychol Med 2010;40:523-8.
these services. More comprehensively, perhaps, than any other 6 De Greck M, Scheidt L, Bölter AF, Frommer J, Ulrich C, Stockum E, et al. Multimodal

theory of the mind, psychoanalysis points to key psychological psychodynamic psychotherapy induces normalization of reward related activity in
somatoform disorder. World J Biol Psychiatry 2011 Jun;12:296-308.
phenomena and processes (such as the limitations of 7 Lemma A, Target M, Fonagy P. Dynamic interpersonal therapy: a clinician’s guide. Oxford
consciousness, defences, resistance to treatment, transference 8
University Press, 2011.
Kim-Cohen J, Caspi A, Moffitt TE, Harrington H-L, Milne BJPR. Prior juvenile diagnoses
and countertransference). These have to be integrated into our in adults with mental disorder: developmental follow-back of a prospective longitudinal
understanding of clinical work if adequate and effective cohort. Arch Gen Psychiatry 2003;60:709-17.
9 Cassidy J, Shaver PR, eds. Handbook of attachment: theory, research, and clinical
psychological treatment is to be offered. If psychoanalysis is applications. 2nd ed. Guilford, 2008.
thrown out, these aspects of the mind will have to be 10 Department of Health. No health without mental health: a cross-government mental health
outcomes strategy for people of all ages. 2011. www.dh.gov.uk/en/
rediscovered—just like Greco-Roman culture was rediscovered Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766.
after the dark ages. 11 Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychologist
2010;65:98-109.
12 Fonagy P. The changing shape of clinical practice: a comprehensive narrative review.
Competing interests: All authors have completed the ICMJE uniform Psychoanalytic Psychother 2010;24:22-43.
13 Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al.
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA
request from the corresponding author) and declare: no support from 2010;303:47-53.
any organisation for the submitted work; no financial relationships with
any organisations that might have an interest in the submitted work in Cite this as: BMJ 2012;344:e1211
© BMJ Publishing Group Ltd 2012

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe