When A Psychiatrist Does Philosophy

[u/Intelligent-Grass721]

This is from Joel Paris, considered a highly influential psychiatrist, in his screed against psychoanalysis. The rest of the paper is of similar quality. I come across this paper all the time, I always stop to wonder if anybody besides me has actually read it.

https://journals.sagepub.com/doi/full/10.1177/0706743717692306

[u/noriweed]

Sorry for the stupid question but can you please elaborate a little more on why you disagree with him or the article? As a psychologist I think the article has a lot of valid points even if some are a bit far fetched. Thank you!

[u/Intelligent-Grass721 → u/noriweed]

Sure. It comes down to basic academic integrity with his use of citations. for example:

For example, CBT, now the most influential form of psychotherapy, was originated by Aaron Beck, a psychoanalyst who had given up believing that Freudian methods were helpful for patients.36

I really like Beck, and therefore know that Beck continued to describe himself as a neo-freudian and publish on psychoanalysis for his entire career. He co-authored 'Biological Underpinnings of the Cognitive Model of Depression: A Prototype for Psychoanalytic Research' in 2012! (See Rachel Rosner's 'The Splendid Isolation of Aaron Beck' for a detailed account of Beck's relationship with psychoanalysis.)

Knowing this, I'm eager to understand what source Paris is citing. Beck was highly prolific, so perhaps he knows something I don't. I find my way to the citation, only to be dissapointed. Below is the only quote or mention on anything concerning psychoanalysis from the beck paper:

This conceptualization of a dual processing system has its roots in Freud’s concept of appraisal and reflective reappraisal and relates to automatic and controlled processing in cognitive psychology.

Again, this is the evidence Paris gives.

This trend continues. He cites Janet Malcolm's the impossible profession to support the claim that psychoanalysis isn't economically viable career path--but the impossible profession is an interview with a single psychoanalyst 40 years ago, and it says nothing of the sort. (the interview is with an old school MD, who is probably being over paid, if anything).

He discounts nobel prize winner Eric Kandel as 'being stuck in a time warp', and unaware of other modalities. This is strange, as Paris is in his 80s. So it doesn't seem like telling us to ignore somebody because they are old constitutes valid criticism. A simple google search would show that Kandel is well aware of other modalities. And I mean look, if somebody wants to disagree with a highly established individual, that's fine. Of course. It's the bread and butter of what we do. But one needs to come up with a better rebuttal than 'stuck in a time warp'. This is not a position in line with evidence based practice. It's an argument fit for the sandbox.

He tells us that psychoanalysis is irrelevant to MBT. This is probably the strangest claim. MBT was founded by two psychoanalyst, who met at an analytic institute, who then formulated a treatment using psychoanalytic terminology, published it in psychoanalytic journals, and teach it at the Anna Freud institute. So it would be rather strange to put forth the irrelevance of psychoanalysis here and elaborate no further. Even weirder, he simply leaves out Bateman as a co-founder of MBT. It's hard not to observe that Bateman is a psychiatrist. Specifically, an influential psychiatrist whose professional existence calls into question the position Paris takes in this paper. So... erm, why is the psychiatrist excluded in a paper about what is relevant to psychiatrists? It would seem to me to stretch the limits of charity to ascribe such an opportune omission to mere sloppy scholarship.

And then lastly we have the diatribe on the post modern neo marxists coming to destroy the truth. There is one word quoted to support this claim (his only quotation in the entire paper), and that word is.... not even in the document he is quoting. The Foucalt citation has nothing to do with anything. And it's little wonder Paris doesn't provide a genuine Foucalt citation...

"Marxism exists in nineteenth-century thought as a fish exists in water; that is, it ceases to breathe anywhere else" -- guy who uses marxism to say that all ideas are equally valid.

And of course, even if it were true that postmodern neo-marxists were coming to destroy the truth, this would not provide an argument for psychoanalysis being irrelevant to psychiatry! That's the funniest bit to me. It's so far removed from having fuck all to do with anything.

I could keep going (or go back and cite any claims i've made if you feel they aren't properly cited), but i'll leave it there. hope that helps explain my position!

[u/noriweed → u/Intelligent-Grass721]

It does help a lot. Thank you for being so thorough in your response. I don't personally like or agree with psychoanalysis but it's place in the therapeutic world can not be denied indeed (it being one of the best treatment for some disorders).

[u/Intelligent-Grass721 → u/noriweed]

thanks for the civil response, always happy for the rare occasion when this contentious subject doesn't collapse the possibility for discourse on reddit. <3

you gotta recognize a miracle when you see one!

[u/kazumisakamoto → u/noriweed]

For which disorders is psychoanalysis better than any other kind of psychotherapy? I thought this was never proven

[u/Intelligent-Grass721 → u/kazumisakamoto]

I'm sad to see your very reasonable question be downvoted.

For which disorders is psychoanalysis better than any other kind of psychotherapy

This isn't personally how I would phrase it -- generally speaking we start to see equivalent efficacy amongst competent clinicians, regardless of choice of modality. In other words, adherence to a particular modality does not seem to influence outcomes, though other things certainly do.

Or you could look at it like this: Adherence to modality will get a treatment to perform better than no treatment, better than placebo, and as well as other treatments. But whatever it is that makes a treatment perform better than that (i.e. a treatment with better efficacy than treatment-as-usual) is not adherence to modality. Wampold's work elaborates on this. Clinicians with greater efficacy spend 4.5 times as much of their time engaging in what he terms 'deliberate practice', which includes things like self-study, colleagues to discuss case material with, attending lectures, and so on. It's a bit like Gladwell's 10k hours rule, only much more specifically quantified and robust. But it's the same general principle. The clinicians with the best results are the people who put in the most work, and work in such a way that they are genuinely challenging themselves and striving towards improvement. And if you scale that out a few decades, then somebody who puts in the work is doing laps around the person who stopped improving when they finished graduate school. The effect of deliberate practice on efficacy is much more demonstrable than the effect of modality choice on efficacy. There are exceptions. I don't think anything is in the running for ERP for OCD. Exposure therapy is absolutely fantastic for the problems that exposure therapy is absolutely fantastic for. When it comes to meaningful personality change, however, the secret sauce doesn't seem to be in the modality.

I'm generally skeptical of any claim of an established psychological treatment being "better" unless it's followed by a clear operalization of what "better" means. (Better at the end of treatment? What about a 5 month follow up? What about a 1 year follow up? If a treatment is better at end of treatment, the same at 5 month follow up, and worse at 1 year follow-up, which treatment is 'better'? Does 'better' mean statistically significant, or clinically significant? If so, how is clinical significance being translated into statistical terms?What about the cost, frequency and duration of treatment? Is there evidence that the efficacy literature also translates into effectiveness? What is the role of active mechanisms of treatment in determining whether or not a treatment is better or worse? What are the clinical considerations that would make a patient a more likely candidate for one treatment over the other? And so on. )

I think that when evaluating a problem this complex, it is imperative to resist the temptation for simple narratives.

However, one can find a very sturdy collation on the efficacy of psychoanalysis in the recent position paper put forth by the World Psychiatric Association, in which the evidence is presented that psychoanalysis satisfies the empirically supported treatment criteria formulated by Tolin and adopted by the American Psychological Association.

Or, I suppose to answer you question forthrightly, FBT is currently lauded as the 'best' eating disorder treatment, and FBT was largely formulated by chris dare, who wrote not one, not two, but three papers which emphasize the necessity of psychoanalysis in his formulations. The first two papers are specifically about the role of psychoanalysis in FBT, the last one is about the books which influenced his entire career the most.

So, that would be an example of a treatment with a clear psychoanalytic genesis being lauded as the 'best' treatment.

However, the literature actually only states that in randomized control trials, FBT produces a non statistically significant difference in adolescents with anorexia nervosa with a short duration of illness and parents with high rates of expressed warmth. Even amongst people who checked all of those boxes, there was still no difference at 5 year follow-up. The people selling this stuff, of course, don't say any of that. They simply say science says that it is the best, most evidence based, most gold standardest treatment.

Hopefully this underscores how claims of superiority really require the sort of careful unpacking that can only occur when the terms and criteria have been properly operationalized.

[u/wokeupabug → u/Intelligent-Grass721]

I'm generally skeptical of any claim of an established psychological treatment being "better" unless it's followed by a clear operalization of what "better" means. (Better at the end of treatment? What about a 5 month follow up? What about a 1 year follow up? If a treatment is better at end of treatment, the same at 5 month follow up, and worse at 1 year follow-up, which treatment is 'better'?...)

I think people probably do have the intuition that a psychotherapy is "better" if its clinical results are sustained or improve, rather than declining, on follow-up -- though it's certainly worth bringing attention to this qualification so that people can think critically about it. And there has been some literature suggesting that psychodynamic therapies do better in this regard, hasn't there?

Another way to "reframe" the question of which psychotherapy is "better than any other kind" would be to measure "adherence to a particular modality" by third-party assessment of records of what's going on in the psychotherapy process, rather than by the clinician's self-identification. And this argument for the psychodynamic tradition has been made as well, hasn't it -- that therapists, independent of their self-identification, tend to be more effective whose practice looks more to third-party assessors as focusing on the things psychodynamic psychotherapy focuses on?

If these results are borne out as we continue to research this stuff, these would be some ways to argue for the efficacy of the psychodynamic tradition, as a distinct approach, I think.

Of course, as always in scholarship there are competing perspectives and researchers arguing back and forth. And the importance, which you mention, of identifying which patient population is being studied is crucial to always keep in mind -- we perhaps should not think of psychotherapy as a single, one-size-fits all approach to all mental health problems, but rather recognize different psychotherapeutic techniques as more or less appropriate to different clinical contexts. But these are some ways that researchers asking this question have tried to approach it, for what that is worth. (I know you're familiar with this stuff, but noting it may be of use to /u/kazumisakamoto, /u/noriweed, or whoever else is following this.)

[u/Intelligent-Grass721 → u/wokeupabug]

I think people probably do have the intuition that a psychotherapy is "better" if its clinical results are sustained or improve, rather than declining, on follow-up -- though it's certainly worth bringing attention to this qualification so that people can think critically about it.

Yes, I certainly would think more sustained effects would qualify a therapy as better, and I would think most people would agree as well.

However, as I'm sure you know, it's commonplace for a therapy RCT to stop at end of treatment, or with minimal follow-up. And to be fair, it's not like the researchers are just lazy or apathetic; RCT's are already so cost prohibitive that it's a small wonder they exist at all. It's simply not realistic to have lengthy follow-ups most of the time. Still, this creates a mismatch between the researcher criterion for 'best treatment' and the public perception of what these terms mean.

It also makes comparing research a nightmare. To use my own neck of the woods of eating disorders as an example: "Recovery rates varied between 6% and 83% depending on the definitions used.", and "In about 35% of the studies recovery has not been defined." (ibid).

In other words, terms like recovery, when used on their own, are essentially rendered bereft of meaning when deployed in a research context. (And so is the term 'better', if ones idea of a better eating disorder treatment is one that leads to more recovery). Only some of the time does the researcher actually bother to operationalize their terms to the extent that their claims can be comparatively evaluated with similar claims about similar treatments. None of this level of nuance makes it way to policy-makers. And I have indeed seen policy makers like UK's NICE provide endorsement of treatments which provide immediate benefit, even if the benefit begins to drop precipitously, even when other treatments show gaining improvement after end of treatment.

Welcome to 'the literature', where the terms are made up and the points don't matter.

And there has been some literature suggesting that psychodynamic therapies do better in this regard, hasn't there?

I've certainly heard Shedler say this, and I've come across it in isolated incidents in my own reading. I can't say i've ever read a really proper evaluation of the 'sleeper effect', but it would seem to me to make some kind of intuitive sense.

Another way to "reframe" the question of which psychotherapy is "better than any other kind" would be to measure "adherence to a particular modality" by third-party assessment of records of what's going on in the psychotherapy process, rather than by the clinician's self-identification.

Right, yeah this is how Wampold is measuring it. Footage of the session which is reviewed by experts in a modality in which the adherence of the clinician is rated. Due to my psychoanalytic leanings, i'm leery about the implicit premise that one can stick a camera in the corner without mucking up the transference. But perhaps it's not as big a deal as I imagine it to be.

If these results are borne out as we continue to research this stuff, these would be some ways to argue for the efficacy of the psychodynamic tradition, as a distinct approach, I think.

Definitely. However, I'd say I'm still about 70% smitten with the Wampoldian notion that modality as a primary determinant of outcome is a wild goose chase, and there are other relevant things going on in the clinical context which are not captured under the heading of theoretical orientation. And so perhaps this research paradigm of ours which emphasizes modality to the exclusion of all else carries implicit assumptions that should be more closely examined.

I was listening to a Tolin lecture the other day -- the guy who formulated the current EST guidelines endorsed by the APA. I was mildly apprehensive, because at that point I knew him only from a CBT meta-analysis that was (I thought rightly) criticized for being partisan. Later on in the lecture, he took a very interesting position on these matters:

He says: "I'm not a fan of any treatment that has a name. Especially if the name is in all capital letters. Because I suspect that that's a package that's being sold -- and by the way I will put cognitive behavioral therapy on that list --because I think that those names mostly obscure what we're doing."

In other words, there's an emerging paradigm that de-emphasizes the role of treatment package in favor active mechanisms, and the active mechanisms themselves do not necessarily have to be beholden to any one theoretical approach.

This sort of stuff is very much in its infancy, still totally undercooked. But I think it's very healthy that there be some alternative perspectives to infuse the landscape of psychotherapy research, especially in light of how disappointing efficacy research has ultimately been for improving patient outcomes. I have no idea yet if this new paradigm will hold water, but I do know that if it reduces the amount of modality bickering that I am subjected to then I am enthusiastically for it.

[u/wokeupabug → u/Intelligent-Grass721]

I'm inclined to the view that our handling of psychotherapy remains in the stage of -- without getting into some of the details of what I mean by this -- a pre-scientific folk practice. And that in some ways we have backtracked in this, since the decline of the dominance of psychoanalysis -- though in other ways we have improved. I see the future of the field as being in its establishment as a distinct profession, since it's only then that we'll have the institutional framework for really training a psychotherapist per se (as opposed to a clinician of whatever background who picks up CBT or whatever) from the foundations up. And while legislation and education has taken some important steps in this direction, I think it's stalling as there's too much institutional inertia -- there's too much institutional authority in someone being a "psychiatrist" or "clinical psychologist", with the "psychotherapists" or "mental health counsellors" not having the same cultural or institutional cache. This really has to change, though I don't know how that change is to happen.

And -- on the topic of the preceding comments -- one of the virtues that I perceive in the psychoanalytic tradition is that if we wanted a broad theoretical-clinical background to train psychotherapists in, that covered the different aspects of psychotherapy, and had the resources to be adapted to serve different populations, I don't see that there's really any question or competition. It's psychoanalytic training. And this makes perfect sense historically -- almost all the psychotherapy we have, the behaviorists being the notable exception, is literally some modification of psychoanalysis. And almost always this has been done by picking one or two features of psychoanalysis and emphasizing them, while setting aside the rest. Usually in the context of treating a very select population, and facilitating the training of clinicians for that special application.

That's part of what I mean in wondering if there's been some "backtracking" here. Historically, it rather looks like we had a theoretical foundation rich enough to train clinicians in a breadth of psychotherapeutic understanding which could then be modified in this way, and it's like we have -- at the institutional level -- forgotten about it now.

Of course, a not insignificant factor in things having developed in this way has been a certain dogmatism among psychoanalysts -- particularly in America, which is perhaps part of why we see so many schisms from the psychoanalytic tradition coming out of that country, but not only in America. But I think the psychoanalysts are increasingly -- if begrudgingly and under coercion -- coming around. The psychoanalytic tradition is, at this point, rather far from a monolith. Even IPA trained psychoanalysts in America, the top population for psychoanalytic dogmatism, say and do things these days that would have gotten them excommunicated generations ago -- giving up drive theory for relational theory (I think a mistake, but that's a different conversation!), doing counter-transference disclosures, and stuff like this. And of course we have "psychodynamic psychotherapy", whose practitioners -- if not all the IPA trained analysts, even while they concede that this is mostly what they actually do in their practices -- often see as not clearly distinguishable from psychoanalysis, we have short-term protocols with a psychodynamic orientation, and so on. The analysts aren't quite there yet -- there was a conversation on an IPA list where hardly anyone thought there was any clear difference between the experience of a 4x/wk versus a 3x/wk therapy, but the question of why the former should be insisted on for training analysis is still met with a kind of embarrassed silence -- but things have changed a lot since the heyday of analytic dogmatism. Hell, American institutes even teach Klein and occasionally Lacan these days.

For reasons we have already noted, I don't really see any strict barriers to regarding things like cognitive therapy or client-centered therapy the same way -- i.e., and so, in this sense, not categorically different than various psychodynamic psychotherapies. So we're already so close to being able to think in this systematic way about a general psychotherapy. There's just so much institutional inertia in the way, so that I'm not hopeful in the short- to medium-term.

And even while I think that the psychoanalytic tradition clearly provides the breadth and depth needed for a foundational training in general psychotherapy, I also think there's been a wealth of useful discoveries in the more specialized modalities. I found phenomenological approaches I picked up from Rogerians ridiculously easy to integrate into a psychodynamic approach -- some way to convey "describe what you are feeling right now" fits perfectly into resistance analysis or whatever your psychoanalytic framing is. Don't tell my psychoanalytic friends, but after learning CBT I started giving homework to long-term psychodynamic cases. Super easy way to extend the work of the sessions out through the week, without insisting on 4x/wk therapy, and very conducive to the the whole "internalizing the reflective habits of the therapeutic session so that they become tools of affect regulation in daily life" thing -- or however you would phrase that based on your own experience and readings -- which people who have gone through their own psychodynamic therapy seem generally to be familiar with.

[u/wokeupabug → u/Intelligent-Grass721]

I really like Beck, and therefore know that Beck continued to describe himself as a neo-freudian and publish on psychoanalysis for his entire career.

This issue is such a great illustration of the power of marketing. I know PhD psychologists who insist that Beck's therapy is based on cognitive psychology, because it has the word 'cognitive' in its name. You talk to Beck, and he's like, "Huh? This is modified ego psychology."

[u/Intelligent-Grass721 → u/wokeupabug]

Yes, well it also seems to me to be symptomatic of something within CBT, which is that there seems to be much less cultural injunction to read.

Coming from a psychoanalytic background, it's generally just accepted that one establishes engagement with the foundational texts of psychoanalysis, with the output of the specific psychoanalysts that one is interested in, with the relevant research to one's area, as well as a general education in the humanities.

And of course, it's not only psychoanalysis that is like this. I don't meet humanistic therapists who refuse to read Rogers. The existential therapists don't cross their arms and stomp their feet when they are told to read Yalom and Frankl. But whenever I try to talk about Beck with a CBT therapist it's just.... glassy stares in response. It's unfathomable to me that somebody would consider themselves trained in a modality and be so incurious as to what the founder of that modality actually said.

I hardly even try to talk about Beck to the people who purport to follow in his footsteps. For it is unlikely that they'd believe me if I told them what Beck said, and more unlikely still that they'd open up a book and make up their own damn mind.

[u/wokeupabug → u/Intelligent-Grass721]

Ha, I hadn't thought of that! But yes, I think you're right; this has been my experience as well.

[u/Intelligent-Grass721 → u/[deleted]]

Both Joel Paris and Jordan Peterson worked at Uni of Toronto for many many years... it's actually pretty conceivable that he got this perspective straight from the lobster man himself.

[u/OkCreme8338 → u/noriweed]

Foucault never denied objective truth, neither was he anti science. Structuralism was a big movement and every structuralist did not think the same. Saying truth is socially constructed doesn't mean it doesn't have value. Being critical of science, especially as an institution, does not mean you're rejecting it.

This is clearly the work of someone not in philosophy, who read bids, if not, bad commentators of philosophy, and thinks entitled to say factually false information based on his status.

[u/Intelligent-Grass721 → u/[deleted]]

My issue with the paper on the whole is really more related to academic integrity in the use of citations than disagreeing with the claims themselves (though some of the claims, by virtue of being unsourced or contradicted by their source, are obviously questionable). I made a comment elaborating on that below.

[u/diaenimaia → u/Intelligent-Grass721]

Anyone who publishes the claim, or paraphrases thereof, that "post modernist neo Marxists believe that truth is relative", is immediately suspect in my book. There are certainly derivations and bastardisations of post structuralist and post modernist thought in the social sciences, but in my experience there are few serious philosophers who genuinely maintain that 'truth' is simply relative.

[u/narex456]

Your first link, to me, reads like a pretty reasonable summary of postmodernism. It also reads like that's all it's trying to be.

Could you elaborate what problem you have with it?

[u/shake_appeal → u/narex456]

For someone highly concerned with the erosion of objective truth, Paris sure is fast and loose with the intent of the texts he refers to throughout.

[u/Intelligent-Grass721 → u/narex456]

no

[u/OkCreme8338 → u/narex456]

Postmodernism doesn't designates anything, there is no such philosophical movement. Critical Theory refers to a lot of things but at first it was maxsist theory. And finally this guy is living everything and it is clearly he never read anything he's talking about