The following letter, criticising a self-proclaimed “ground breaking research study” on the efficacy of “long term psychoanalytic psychotherapy”, was addressed to colleagues, psychoanalysts and psychotherapists of various orientations.
A few weeks ago, I too received the message J… was kind to send, the one about the Tavistock Adults Depression Study (TADS). I read the informative note, “Psychoanalytic psychotherapy can help depressed patients where other treatments fail”, http://tavistockandportman.uk/about-us/news/psychoanalytic-psychotherapy-can-help-depressed-patients-where-other-treatments-fail, and also the research report, “Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression (TADS)”, http://onlinelibrary.wiley.com/doi/10.1002/wps.20267/pdf.
I won’t deny it: when I read such research studies, my inclination is not to be sceptical, but to be dismissive. However, I don’t think that my attitude merely reflects my prejudices or, to put it another way, I assume that we might share (at least some of) the same prejudices. I decided therefore to communicate to you some thoughts about the impact research like that can have on the way we think and practice and eventually on the fate of our profession.
I am fully aware of the fact that psychoanalysis, not to mention psychotherapy, is a vast and differentiated field and that clinicians, according to their affiliations and tastes, think and work in ways that vary, sometimes considerably. So, when in exposing my thoughts I invoke, defend or use psychoanalysis in order to develop an argument, I refer to my understanding of what psychoanalysis is, not to a psychoanalysis that would exclude politics and ethics from its field and present itself as a unified thought.
I quote the following point of the research: “In total, 308 patients were screened for eligibility. Of these, 235 attended for interview. Inclusion criteria were: age 18-65 years; current DSM-IV diagnosis of major depressive disorder as ascertained by the Structured Clinical Interview for DSM-IV (SCID-I, 26); minimum duration of two years of the current depressive episode; minimum score of 14 on the 17-item version of the Hamilton Depression Rating Scale (HDRS-17, 27) and of 21 on the BDI-II; and at least two failed treatment attempts (elicited at interview and veriﬁed from medical records), one of which must have included treatment with an antidepressant medication, and the other with either an antidepressant medication or a psychological intervention”.
What is the relationship between the language and logic of this research, on the one hand, and psychoanalytic ethos on the other? If psychoanalysis is interested in the subject, in allowing the emergence of what is absolutely particular in each subject, then what place can lists of “symptoms”, “structured clinical interviews” or “scores” on the x or z rating scales have in psychoanalytic clinical praxis? And, taking a step further, in what sense is “depression”, a catch-all term that was coined in order to cover mental states affected by the administration of antidepressants, a psychoanalytic concept?
Psychoanalysis can address the demand of the subject who speaks of his suffering in terms of depressive affects. But if psychoanalysis makes it possible for an analyst to listen to a “depressed” subject, and to patients in general, it is by distinguishing the symptom and the underlying structure (neurosis, psychosis and perversion).
The same symptom can be found in every structure and thus the symptom reveals nothing about how a subject organises their world. What matters is their relation to the symptom and that relation is determined by their response to an experience of fundamental loss, the one that Freud named castration. That comes first from a logical point of view. The structure is not a general concept emerging from a process of elimination of what is particular in each case. It is a matrix that allows the production of constructions that give each case its unique character.
Psychoanalysis deals with “depressed” patients one by one, on the basis of the specific way they are inscribed in a structure. There is an immense difference between, on the one hand, the young man who believes that “he is crap” in order not to assume his castration and is utterly tormented by this idea when the circumstances confirm his inability to amount to much; and on the other hand, the student who falls into melancholia when the ideal relationship with his professor collapses the moment he realises that the ideal (love for knowledge in this case) merely covered up the object which he has always been for him and to which he now obviously is reduced. And the difference is not only theoretical, as the researchers who believe in facts would say without any effort to hide their contempt for psychoanalysis and its theories. In the second case, if we take it as an example, the melancholic state of the subject might need to be sustained, because that gives some meaning to his life and averts him from a passage to the act. In such cases, an analyst has to work within a very narrow space, which is defined by the patient’s utter despair and their reluctant decision to talk to a clinician.
Let us go back to the research. Under the headline “assessments” we read the following paragraph: “The primary outcome measure was the HDRS-17, modiﬁed to include increases in sleep, appetite and weight (35). Trained interviewers blinded to treatment condition conducted the evaluations. All evaluations were recorded, and all interviews were double-rated by an independent blinded coder to establish inter-rater reliability. An ICC of 0.89 was obtained for the total HDRS-17 score with the following severity bands: 0-7 not depressed, 8-13 mild depression, 14-18 moderate depression, 19-22 severe depression, 23 very severe depression. Full remission was deﬁned as an HDRS17 score of 8 or less (36). Following Hollon et al. (14), HDRS-17 scores 12 were considered to meet criteria for partial remission”.
Do we, as psychoanalysts or psychotherapists, really believe that the states covered by the term “depression” can be allocated to bands on a scale from 0 to 23 according to their severity? Is this a measure or – let us remember Stephen Jay Gould – a mismeasure of man? Is this mechanistic fragmentation of the human experience in tune with a psychoanalytic approach?
If there is a multitude of manifestations of “depression”, and if each one of them should be defined against an experience of fundamental loss, for the conceptualisation of which Freud used or invented myths, then neither what is therapy nor what is therapeutic result is self-evident; these depend not only on the specificity of the case but, essentially, on the character of the depressive state the clinician treats. And since the depressive state can only be defined in terms of theory, the nature of therapy and also the therapeutic effect can only be defined and assessed with relation to the clinical field and the theory that structures it. The therapeutic result is not external to the clinical framework; it is to be found on this side of its horizon.
The research, very differently, asks the question “what is the right therapy for depression”, not only without constructing a concept for the problem that psychoanalysis presumably treats better than other forms of therapy, but also assuming that it is possible to introduce a diagnostic category irrespectively from the clinic that deals with the person who suffers. The psychoanalytic clinic, or every other clinic for that matter, is supposed to deal with the “depression” that this research takes as a given.
But if, as I claim, the research sets a therapeutic aim that is external to the theory and clinical practice of psychoanalysis, then what is this aim? I’ll answer the question in terms of psychoanalysis, in order to show the abysmal distance that separates psychoanalysis itself from the logic that governs the research under discussion and the likes of it. The aim of such research is the restoration of the pleasure principle: a life without “depression”, since “depression” is a form of malaise, and life—for reasons that the research does not make an effort to explain, maybe because this point is supposed to be an obvious one—should be “depression” free.
The imperative that is implied by the research, namely to be positive and lead a life in which depressive affects don’t have a place, can take superegoic dimensions, increasing the pressure to reach ideal standards and pushing subjects towards guilt or the perseverance of chimeric enjoyment.
In psychoanalysis we don’t want to see the patient “increasing their sleep, appetite or weight”, criteria by which the research evaluates the experience of psychoanalysis. Not because we get some kind of pleasure when we encounter an emaciated figure or a person exhausted by sleepless nights, but because we believe that desire is the only way to address depressive affects, and desire has no object. A patient is not expected to become a good citizen, achieve harmony or experience happiness, because these ideals, instead of liberating desire and allowing a subject to deal with depressive affects or anxiety, introduce obligations and can increase suffering. The imperative that psychoanalysis opposes transforms human beings into prisoners of well-being.
Psychoanalysis encourages the subject not to give up on their desire. And yet desire, by its nature, traverses the boundaries of pleasure and well-being. Maybe we need psychoanalysis in order to stay with this inevitable paradox.
In my opinion, this research reinforces intolerance towards suffering as a structural part of human life and induces us to adapt to the norm. If its outcome, prima facie, supports psychoanalysis, its logic undermines psychoanalysis’ fundamental premises. And since the path we follow in order to reach a conclusion is at least as important as the conclusion itself, I cannot agree that the research is on the right track.Alex Ilias