Minding the gap between positivism and hermeneutics in psychoanalytic research

The Research-Practice Psychotherapy Wars: The Case of Group Psychotherapy in the Treatment of PTSD

In light of two recent meta-analyses of the efficacy of group psychotherapy in treating posttraumatic stress disorder (PTSD), this article critically reviews the randomized control trial (RCT) generated findings as well as two of its outgrowths-the production of a variety of clinical practice guidelines for treating PTSD and the dissemination efforts to transfer laboratory findings to clinical practice. All three of these activities have received considerable pushback from experienced clinicians and Boulder-identified scientist practitioners, creating an ongoing and entrenched gap or split between researcher and clinician. The article also reviews the various suggestions that have been offered to heal this gap and ending the hegemony of RCT outcome research as the only game in town for declaring what constitutes evidence. Specifically, the literature suggests two primary strategies for helping to realize the scientist-practitioner model and thus advancing the cause of psychotherapy, in general, and group psychotherapy, in particular: (a) leveling the playing field so that both researcher and practitioner have real authority and voices for shaping the field; and (b) shifting the research priority away from a purely outcome focus, asking only does it work, and moving to a more sophisticated, theoretically guided empirical study of process-outcome, examining the how, why, when, and for whom it works.

Bias Toward Psychodynamic Therapy: Framing the Problem and Working Toward a Solution

Although psychodynamic therapy (PDT) is an evidence-based intervention for a broad spectrum of psychiatric conditions, there is often notable bias in the way PDT is depicted both in the popular media and in the scientific literature. This has contributed to a negative view of PDT, which hampers both patient access to this treatment and researcher access to funding for further research on PDT. The adverse effects of these distortions and biases are detrimental not only to PDT but also to the overall field of psychotherapy, raising questions about its credibility. Here we summarize current evidence for PDT, describe existing biases, and formulate a set of recommendations to foster a more balanced perspective on PDT.

Interpreting the inner world of ADHD children: psychoanalytic perspectives

ADHD is increasingly seen as associated with cerebral dysfunction and caused by it. This development is concomitant with an emphasis on medication, behavioural treatments, and parent training programmes. In contrast, psychoanalytic therapy has receded into the background and is often viewed as inefficient or even noxious. This paper argues that such views are based on a misunderstanding of the scope of psychotherapy. Though much more systematic research is needed to establish its efficacy, it can inform on the ADHD child's emotional experiences. It can shed light on the connections between his/her inner world and symptoms, such as attention deficits, hyperactivity, and impulsivity. On the other hand, it cannot establish causality in the individual or general case. If we recall that the diagnosis is based on a list of symptoms, not of etiology, we realize that this limitation applies to any scientific perspective on ADHD. Psychoanalytic treatment is one of several approaches to understanding ADHD and helping the child cope with it. This is achieved by the psychoanalytic method, a hermeneutic approach with which the analyst interprets the child's behaviours and communications as they emerge in the session. The implications of such an approach are discussed.​​​​.

Clinical Case Studies in Psychoanalytic and Psychodynamic Treatment

This manuscript provides a review of the clinical case study within the field of psychoanalytic and psychodynamic treatment. The method has been contested for methodological reasons and because it would contribute to theoretical pluralism in the field. We summarize how the case study method is being applied in different schools of psychoanalysis, and we clarify the unique strengths of this method and areas for improvement. Finally, based on the literature and on our own experience with case study research, we come to formulate nine guidelines for future case study authors: (1) basic information to include, (2) clarification of the motivation to select a particular patient, (3) information about informed consent and disguise, (4) patient background and context of referral or self-referral, (5) patient's narrative, therapist's observations and interpretations, (6) interpretative heuristics, (7) reflexivity and counter-transference, (8) leaving room for interpretation, and (9) answering the research question, and comparison with other cases.

Treatment notes: objective measures of language style point to clinical insights

Application of a computerized text analysis procedure is proposed that has the potential for use by psychoanalytic and psychodynamic clinicians: the systematic examination of linguistic style as reflected by clinicians in their ongoing process and case notes, which are ubiquitous in the mental health field. The studies reported here are, as far as is known, the first attempts to study treatment notes systematically using such procedures. Linguistic measures are used to track the trajectory of the clinical process throughout the treatment in two contrasting cases, one rated successful, the other not. The computerized linguistic analysis used here focuses on two analytically relevant linguistic variables: Mean High Referential Activity (MHW), a measure of the degree to which language is connected to emotional processing, and Reflection (REF), the use of words referring to logical functions. Changes in the relative position of these measures indicate nodal points in the treatment that might be analytically or therapeutically problematic, and that might be overlooked in a solely clinical reading. The analyst's activity as reported in notes during such nodal periods is clinically examined to see how it may have affected the course of the analysis. This method has the potential for use in ongoing treatments, and may help clinicians refine their interventions.

Psychoanalysis and empirical research: the example of alexithymia

An extensive body of research on the alexithymia construct is reviewed to show how various empirical methodologies can be used to evaluate the validity and increase our understanding of theoretical and clinically derived psychoanalytic concepts. The historical background of alexithymia and the theoretical framework in which the construct was formulated are presented, after which measurement- and experiment-based approaches to construct validation are described. This is followed by a review of empirical investigations that have yielded evidence that alexithymia is a dimensional personality trait associated with several illnesses of interest to psychoanalysts. Empirical research also supports clinical observations and impressions that individuals with high degrees of alexithymia principally employ primitive defenses, have a limited capacity for empathy, exhibit deficits in mentalization, and do not respond well to traditional interpretive psychotherapies. Also reviewed is empirical research that implicates genetic and environmental/developmental factors in the etiology of alexithymia, in particular childhood trauma and insecure attachments, factors generally associated with deficits in affect development and affect regulation. The clinical relevance of the empirical research findings is discussed in the final section.

Mixed methods research design for pragmatic psychoanalytic studies

Calls for more rigorous psychoanalytic studies have increased over the past decade. The field has been divided by those who assert that psychoanalysis is properly a hermeneutic endeavor and those who see it as a science. A comparable debate is found in research methodology, where qualitative and quantitative methods have often been seen as occupying orthogonal positions. Recently, Mixed Methods Research (MMR) has emerged as a viable "third community" of research, pursuing a pragmatic approach to research endeavors through integrating qualitative and quantitative procedures in a single study design. Mixed Methods Research designs and the terminology associated with this emerging approach are explained, after which the methodology is explored as a potential integrative approach to a psychoanalytic human science. Both qualitative and quantitative research methods are reviewed, as well as how they may be used in Mixed Methods Research to study complex human phenomena.

One hundred years after Sigmund Freud's lectures in America: towards an integration of psychoanalytic theories and techniques within psychiatry

The impact of Sigmund Freud's lectures in America in 1909 is discussed. Some of the roots of psychoanalysis and their contemporary relevance are addressed: neurological ideas, the discussions of the sexologists, and the degeneration theories at the turn of the twentieth century. Factors which led to the dominance of psychoanalysis in psychiatry included, in particular, its arguments against the hopelessness of degeneracy theories;yet,by isolating itself from mainstream academic psychiatry and psychology,organized psychoanalysis itself contributed to its own subsequent marginalization. In order to re-integrate itself with mainstream psychiatry, psychoanalysis needs to appreciate the importance of systematic demonstrations of the therapeutic power of psychodynamic/psychoanalytic concepts and techniques when caring for individuals.

Defensive projection, superimposed on simplistic object relations, erodes patient-provider relationships in high-risk pregnancy: an empirical investigation

In an attempt to illustrate the relevance of psychoanalytic theory and research to behavior medicine, an empirical investigation was conducted of females treated at a high-risk pregnancy specialty clinic (N = 58). Drawing from psychoanalytic object relations theory, it was hypothesized and confirmed that use of projection as a defense mechanism during pregnancy, superimposed on simplistic object relations, predicted an erosion of patient-provider relationships during the pregnancy/postdelivery period. Findings are interpreted through the perspective of mentalization, pertaining to individuals' ability to understand the mental states of self and others, specifically under significant stress. Implications for psychoanalytically oriented assessment and treatment, and for the rift between psychoanalysis and research, are discussed.

There is no place for the psychoanalytic case report in the British Journal of Psychiatry

As evidence-based mental health and the randomised controlled trial come to dominate the content of major psychiatric journals, the status and clinical utility of single case reports have been increasingly questioned. Arguably, owing to their subjective, anecdotal nature and unsuitability for rigorous scientific testing, this is particularly true of psychoanalytic case studies. Professor Peter Fonagy and Professor Lewis Wolpert debate here whether or not there is a place for such case reports in the British Journal of Psychiatry.

Equifinality, multifinality, and the rediscovery of the importance of early experiences: pathways from early adversity to psychiatric and (functional) somatic disorders

Most current mainstream research, diagnostic assessment, and treatment strategies focus on specific psychiatric disorders--on diagnoses that are based on manifest symptoms within a categorical, atheoretical approach. This disorder-centered approach has been antithetical to psychoanalytic views, which are fundamentally person centered, focusing on the dynamics of individual lives. Growing realization of the high comorbidity among psychiatric disorders has led to the need to include developmental considerations and hierarchical models in the classification and treatment of psychopathology. In addition, this realization has led to a renewed interest in the principles of equifinality and multifinality--that a given end state can be the result of different developmental paths and that similar developmental factors may lead to dissimilar outcomes. In this chapter these developments are illustrated by research on the impact of early adversity, a central domain in psychoanalytic thought. Findings from various strands of research in the neurosciences and genetic research, in particular, suggest that early adversity leads to vulnerability for a wide variety of both psychiatric and (functional) somatic disorders. These findings have contributed to the rediscovery of the importance of early experiences more generally and to the need for a broad developmental perspective. In this context, we also discuss the danger of reductionism associated with the growing influence and popularity of affective neuroscience and genetics as well as the vital role a psychoanalytic perspective might play in countering this reductionism by reestablishing the importance of meaning and meaning making in understanding and treating patients with a history of early adversity. In particular, we focus on the importance of narrative and mental representations in the development of the capacity for mentalization in these patients.