THE FUTURE OF PSYCHOTHERAPY?



In an article that may well surprise psychoanalysts, the Freud Memorial Professor at UCL has put forward some remarkable views on the future of psychotherapy (1). Brain scanning techniques will allow us to evaluate therapeutic methods, advances in molecular biology will enable us to select target populations for intervention, and neuroscientific knowledge will help patients make use of mental strategies to cope with weaknesses in brain function.

The apparent lack of understanding of the analytic process, or indeed of the aims of analytic therapy, are so pronounced that the Freud Memorial Professor appears to present us with a parody of how an uninformed critic of psychoanalysis might see Freud's project undone by Science.

Fonagy sees three central problem areas in the field of contemporary psychotherapy: little is known about who will benefit from what type of therapy, the specificity of interventions has not been properly clarified, and there is the danger of 'guildification', a threat that Fonagy compares to "the tragedy that befell psychoanalysis".

This choice of problems poses some immediate questions. The notion of target populations and that of specific interventions suppose that therapy is a procedure that exists in its own right and that can be applied like a bandage or administered like a medicine. Rather than seeing therapy as a property of a relationship between two people, or something that might mean something quite different to different people, there is a basic assumption that there are what Fonagy calls 'users' and then the therapeutic methods themselves.

There are certainly aims of therapeutic processes, and these have been well researched by analysts for many years now, but they will always be determined in relation to the specificity of a case and the patient's voiced articulation of their situation. This is a process that the patient engages in or, in many cases, decides not to, and what makes analytic therapies specific here is precisely their refusal to map out target populations. It is up to the patient, after all, to see some behaviour pattern as pathological or not. As analysts, we cannot tell them that they have a problem, even if we can at times try to make them see some aspect of themselves as symptomatic. If they do so, and start to see this area of their lives as posing a question, then a therapy can start. But it can never be administered for that same reason: it requires the subjective involvement of the patient.

Fonagy seems completely unaware of these basic features of the therapeutic offer, and tells us that the future of research in psychotherapy lies in developmental psychopathology. He claims that pathogenic mechanisms can only really be discovered by developmental observations, despite the fact that Freud, who clearly had hardly any chance in his career to make any developmental observations, was able to come up with the most serious and still unsurpassed theory of pathogenic mechanisms: repression, splitting, denial, denegation, disavowal, to name the most celebrated.

But what is behind Fonagy's appeal to developmental observation? He must know that most of these procedures fail to take basic analytic variables into account, such as the unconscious intentions of the experimenter, and he must also know that despite some work which is of great interest, most developmental research constitutes an active avoidance of the themes and hypotheses at the heart of the psychotherapeutic enterprise. One suspects that developmental studies are invoked here to give a more solid basis to therapeutic research, as if the observation language of such studies would be more reliable than, say, the speculative framework of Freudian metapsychology.

The real problem here is nothing less than Freud's discovery of the unconscious. What this discovery meant was that no area of human activity could be deemed exempt from the effects of repression, including, as Freud pointed out, the observation language supposedly characterising science. To oppose two languages, one speculative and the other observation-based, is ultimately to foreclose the possibility that each of them may be just as prone to effects of the unconscious as the other. And the history of developmental psychology bears this out quite clearly.

The same failure to grasp what an unconscious process is guides Fonagy's elaboration of these themes. "The structured, manualised psychotherapy techniques of the future", he tells us, "will be designed to specifically address empirically established developmental dysfunctions". Once again, a dysfunction is made to exist independently of the person's experience of it, a bias that merely reinforces social, non-subjective criteria of normality. This is really psychotherapy at the service of the State, and it may well be central to Fonagy's individual project. We could also wonder here what the word 'manualised' means and why exactly it is included in the sentence.

Symptoms are no longer subjectively experienced questions or sources of satisfaction, but independent, autonomous entities, the result of developmental dysfunctions which have affected the brain. But there is still a place for the subjectivity of the patient! Fonagy advocates more 'user' input into evaluative technologies ; a user, after all, may worry about housing, employment and the presence of supportive companions rather than "symptom distress". Perhaps it hasn't occurred to him that anything can form a symptom for a human being, depending on the place it occupies in their life. And that to separate housing and employment issues, however well-intentioned, is to do exactly the same as separating observation language. What matters will be how these issues form a part of the specific life of the specific patient. To separate them off is not only untenable but deeply patronising.

This complete removal of subjectivity from psychotherapy seems to be taking us closer and closer to what resembles a dated picture of medicine, construed as a sum of external procedures to be applied to the organism to act against ill-health. Even the outcome of therapy, we now learn, urgently requires "non-biased, non-subjective measures of outcome". Now what on earth can such a statement mean? If the patient says they're happier to live, should we test this to see if they're telling the truth? And can't one person's outcome be very different from another's? How can an outcome be non-subjective?

Fonagy's sinister vision of the future becomes even more disturbing here, as he advocates the use of brain-imaging techniques to evaluate therapeutic outcome, and he cites an experiment that purports to show neural correlates of the experience of social exclusion. Whether we find fault with the experimental procedure involved or not, the same basic problem still persists: can an experience be experimentally isolated and attributed to a range of subjects as if it were, fundamentally, the same 'thing' ? The weakness of such views has long been in evidence, from the stimulus-response experiments aiming to induce a specific, isolated emotion in the 30s and 40s to the more mathematically sophisticated yet still equally naïve experiments of today. Does Fonagy really believe that there is an emotional experience called 'social exclusion' that can be objectively found in the brain?

Yet things go from bad to worse. What comes next is an encomium to molecular biology that may remind readers of the eugenics apologia of the early part of the twentieth century. Fonagy is convinced that "biological vulnerability will become increasingly detectable", with combinations of genes accounting for different types of environmental vulnerability. In the example he gives, we learn that those with the S allele of the promoter region of the serotonin transporter gene SLC6A4 may benefit from "prevention intervention" more than those with the L genotype. Enhancing the capacity of those with the S genotype to cope with adverse life situations would lower the risk of major depression, and Fonagy is all in favour of the "impeccable logic" of prevention programmes.

These advances achieved through molecular biology will allow individuals to learn that "reducing the impact of specific types of environments will protect them from the disease process". Will the infant learn to get new parents to avoid becoming ill later on? Will it learn how to best move through the depressive position or the Oedipus complex? Will it be able to tell which phantasy systems will make it happier in later life? Most worrying here is the tone of Fonagy's forecasts. Subjective problems have now become disease processes. When a patient complains of their sexual orientation, or being disappointed in love or always wanting to please other people, do we see that as a disease process?

Yet Fonagy believes that psychological 'disorders' are correlated with specific brain dysfunctions. The function of psychotherapy is then to provide " a set of techniques that the mind can use to overcome a biological deficit". Neuroscience will help patients use "mental strategies to cope with weaknesses in their brain function". And now we come to perhaps the most astonishing claim of the article. "The human mind as a system", we are told, "evolved to be able to bypass and overcome dysfunctions in the physical organ upon which it depends : the brain. It was to exploit this self-healing capacity that Freud invented psychotherapy".

Could it be true? Is this really what the Freud Memorial Professor believes? Could even the wildest flight of fancy transform the Freudian enterprise into this absurd evolutionary fulfillment? Freud had no interest in the self-healing capacities of human beings. What he did have an interest in was the capacity of human beings to provide themselves with false rationalisations of their behaviour; the facts of resistance and transference; the negative therapeutic reaction and the unconscious satisfaction found in some forms of suffering; the power of phantasy systems to provide frameworks for what we experience as our reality; and the function of human speech to transform this reality. We could certainly continue this list, but what we will not find there is Fonagy's definition of why Freud invented psychoanalysis.

Where are such distortions leading us? The real scope for future development, we now learn, is how molecular biology will open up a vista of "biologically indicated psychosocial treatments". "Knowing that in individuals with the S/S genotype severe maltreatment doubles the probability of major depressive disorder ( to over 60% from 30% for those with the genotype ) helps us to focus interventions on childhood maltreatment for the first group to a greater extent than for the L/L group"(2). Does this type of logic remind the reader of anything? Does it not aim implicitly at a segregation? Isn't biology being used as a way of separating different people? Does it all seem worryingly, perhaps terrifyingly, familiar? And can it really be the view of a psychoanalyst?

Fonagy's vision is, in the end, not that of psychoanalysis but of mental hygiene. Problems belong not to individual human beings but to scientists who will locate them at a molecular level and then set about remedying them. Of course, it is the best-interest of the patient that comes first, and so how could such a logic be faulted? Yet this is a programme for the future of psychiatry, not of psychotherapy. Fonagy's project involves a repugnant form of mental hygiene that is antithetical to the basic tenets of psychoanalysis.

DARIAN LEADER

November 2004

(1) Peter Fonagy, 'Psychotherapy meets neuroscience, A more focused future for psychotherapy research', Psychiatric Bulletin, 28, 2004, pp.357-359.

(2) The reference here is a well-known article by Caspi et al, 'Influence of Life Stress on Depression: Moderation by a Polymorphism in the 5-HTT gene', Science, 301, 2003, pp.386-9. Note that this research relies on the circular theory of the serotonin system : this is where the candidate genes lie because SSRIs remedy depression. It also relies on an uncritical use of 'stressful life events' scales, and other arbitrary techniques employed to regiment the 'data'. Fonagy doesn't have the space in his article to tell us that more than half the Caucasian population has an S allele.

 

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