The psychoanalytic and psychodynamic tradition of counselling, psychotherapy and psychoanalysis now has a relatively long history in the private sector but also in health, education and other sectors. It has an element of respectability and durability about it, in spite of many serious criticisms over the past few decades.
As with other traditions, many theoretical and institutional developments have taken place, some schisms remain sore points, and yet most practitioners probably feel secure in their clinical foundations and with mounting empirical research support. This article poses some well-known questions designed to review psychodynamic practice and theory as found in higher education institutions. Many of the points below also apply to non-psychodynamic therapy in these settings.
1. Durability of core theoretical principles
Central to psychodynamic practice has always been the concept of the unconscious, and with it the necessary concepts of defence mechanisms, transference and countertransference. Attachment, uncovering, interpretation, insight and other concepts are also central to the psychodynamic canon. Relatively new concepts of mirroring, mentalisation and so on are also influential.
Views regarding differences between Freudian and Jungian schools can vary enormously or in some cases converge non-problematically. The most challenging critique has perhaps been to the concept of the unconscious and its components. Without unconscious conflict defences against it, and the trained competency of the therapist to recognise and interpret these mechanisms, there is in effect no psychoanalytic tradition. Critics have of course for many years argued that unconscious processes – to which only an in-group of believer-practitioners are privy – are highly speculative and open to doubt. Insofar as psychodynamic work rests on the ‘reality’ of the unconscious, it would be an extremely fragile construct if it could be shown to be a shaky, unverifiable, or even non-existent entity.1 Psychologists and philosophers have suggested that concepts of self-deception and non-conscious processes are better ways of understanding what psychoanalytic theorists have framed as the unconscious. While psychodynamic advocates warm to any sign of rapprochement between psychoanalysis and neuroscience, a majority of academic psychologists continue to spurn psychoanalysis as a valid 21st century subject, even if it is well received in many programmes of women’s studies, queer theory, postmodernist studies, and critical theory.
At point five below, I look at some problems triggered by emerging knowledge from other disciplines. Freud may have been ahead of his time as far as his speculative neurology is concerned (this is the fond hope of his fans), or his theories may turn out to be increasingly superseded by scientific discoveries. At the very least we have to say that currently there is little consensus here.2,3 Evolutionary psychology, cognitive neuroscience, and neuroparasitology, for example, offer some hypotheses and testable propositions that challenge psychoanalytic aetiologies and the ability of talking therapy to effect improvements. Ongoing research casts doubt on the competency of uncovering therapies to explain and address many specific disorders such as obsessive compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD).
2. Changing practice components
Practice traditions have developed across decades and settings but began with Freud’s own (often short-term and what would now be considered ‘unorthodox’ improvisational) methods. Psychoanalysis became time intensive (several times a week) and interminable (often lasting many years). For different reasons, including the pragmatic, economic and experimental, many practitioners began to work to a pattern of only twice a week for about two years (psychoanalytic psychotherapy). Psychoanalytic principles found their way into new forms of couple, family, group and organisational therapy. Under pressure from changing economic and accountability norms, new forms of time-limited psychodynamic therapies arose, including intensive brief dynamic therapy, short-term dynamic psychotherapy, and brief dynamic interpersonal therapy.
The more stringent requirements of some psychoanalytic theorists become impossible to observe in certain settings. In university counselling services, for example, therapists may find themselves uncomfortably rebranded as wellbeing practitioners; they may have less discretion than they would in private practice as to which clients they take on; they must usually be part of a team of practitioners who do not necessarily share their therapeutic beliefs; they cannot easily distance themselves from the institution and personnel that form part of the clients’ world; and they often cannot control the physical environment. The chaise longue, free association, ‘working through’ and other methods used by the private practice analyst do not work in the busy university’s salaried wellbeing practitioner’s office. None of these changes should surprise us, since analysts have for decades disagreed between themselves about the aims of therapy.4
When counselling young students in university settings, practitioners can rarely think in terms of years of treatment, of lengthy dream interpretation, long silence during sessions, uncovering early childhood material and watching clients ‘get worse before they get better’. Time and resource pressures mean that clients often need their egos strengthening (not dismantling), and coping mechanisms being taught to enable them to pass through crises as quickly as possible, in order to pass exams. The vexed question of ‘pure’ psychoanalysis being diluted into lesser intensity psychoanalytic psychotherapy, and even more diluted into psychodynamic counselling, is salient here. But since there is no realistic possibility of long-term analysis being provided for the masses (nor even for thousands of students), the ethical and practical question of modified psychodynamic therapy must be faced.5 Understandably, therapists want to do a good job and dislike corner-cutting compromises, but for most clients therapeutic interventions are a timely, modest form of help rather than a life-changing project of ‘making the unconscious conscious’. I know of no evidence to support this, but I suspect that many therapists covertly compare themselves to shamanic healers of the psyche rather than to nurses on life’s battlefield.
3. Pressures to produce empirical evidence
Hans Eysenck made what remains one of the most challenging criticisms of psychoanalytic psychotherapy in 1952.6 His paper suggested that psychoanalytic psychotherapy did not improve on results achieved by placebos or the passage of time. It challenged the tradition of peer-reinforced faith in psychoanalytic lore and case study justification, and eventually spurred generations of research. In the field of outcome research, however, CBT had stolen a march on other therapy models, its methods lending themselves to manualisation and standard practices that could be readily studied. Psychodynamic therapy, like the humanistic approaches, has begun to catch up, and some newer (opportunistic?) brands are now designed with empirical research criteria built in.7
Quantitative outcome research is not the only valued form of evidence, however. From around the 1970s, when brief therapies were being investigated, the American experience of public therapy provision stimulated studies of brief therapy in different settings, of different theoretical kinds, and linked with clients’ preferences. It was realised that, contrary to therapists’ own assumptions and preferences, a majority of clients with access to free, open-ended therapy (such as much counselling in higher education in the 1970s to 1990s) commonly opted instead for quite short-term therapy.8
Among the many research interests in this field, consider the heavy emphasis placed by psychodynamic theorists, trainers and practitioners on the personal analysis or therapy of the practitioner. Among the arguments in favour of this costly element of training are these: the therapist must know what it is like sitting in the client’s place; the therapist should make her own unconscious conscious to mirror or confirm the psychodynamic model; the therapist must experience transference in order later to grasp the significance of countertransference; the practitioner functions far better after having processed her own material. This last point is of particular interest. Anecdotal evidence suggests that psychodynamic therapists probably have no better mental health than others, and small organisations of psychodynamic practitioners with psychodynamically informed managers are hardly more efficient or conflict-free than others. Indeed some research confirms what should be obvious – that psychotherapists generally are not the paragons of mental health we might expect. Nor are they immune from the shocks of everyday life and the challenges of the later lifespan.9 If nothing else, this should probably nudge us into accepting the modesty of therapeutic aims and results.
4. Competition from alternative models of therapy
Almost from the beginning, Freudian psychoanalysis came under attack and significant modification from once close allies of Freud and subsequent generations of innovative founders of new schools. Jung and Adler formulated their own approaches but remained linked with psychoanalysis. Others, such as Klein, Winnicott and Fairbairn, developed psychoanalytic therapy in an object relations direction. Yet others, often once closely linked with the Freudian tradition – such as Perls, Reich, Moreno, Berne, Assagioli, and Janov – broke away to create various models of distinctively humanistic therapy, placing more emphasis on accessing emotion, catharsis, sensory and bodily experience. Still others, notably Beck and Ellis, criticised and deserted psychoanalytic therapy in order to found early versions of CBT. This is all well-known history, but its underlying epistemology has never been satisfactorily resolved. Why exactly is psychotherapy such a pluralistic, contentious or malleable field?
If there is one clear improvement to have come out of the field in the past few decades, it is probably that of integration. Consensus on aetiologies and effective treatments may never be arrived at, but some softening of attitudes across schools of therapy has occurred. Few would now disagree that significant common factors are in play in all therapies, and that these probably account for much of what success therapy has. Conscious efforts have been made in some cases to construct distinctive models, drawing from the best of different schools. For example, cognitive analytic therapy was designed with pressures of limited time in mind. Wachtel’s ‘cyclical psychodynamics’ is one of very few models to attempt to combine not only disparate elements of psychodynamic and behavioural schools but also to add in clinical attention to known areas of social disadvantage.10 In such ways, inter-school competition has proved fruitful. We might say that in the incessant struggle to adapt to the therapeutic marketplace, the most appealing models succeed.
5. Challenges from other academic disciplines and critics
The study of the human mind and behaviour is not the exclusive preserve of psychology, nor of any one subdiscipline within psychology. Philosophy has a longstanding claim, and today a strong philosophy of mind and mental health exists. Philosophers concerned with linguistic analysis and epistemological clarity have often been severe critics of the claims of psychoanalysis. Biomedical psychiatry both challenges and is challenged by psychotherapy. Considerable progress has been made in neurology since the time of Freud, much of which throws into doubt the concept of a unified agentic self, and some of which raises reservations about the scope of personal or talking therapist- facilitated change. Evolutionary psychology too produces theories of psychopathology that often diverge significantly from those held dear by the community of psychotherapists.11 However fashionable, Jacques Lacan, as well as Julia Kristeva and Luce Irigaray, have come under the close scrutiny of physicists and philosophers for their misuse of language and distortions of science.12
It is perhaps from certain political, economic and sociological perspectives that some of the most challenging critiques emanate. These suggest, for example, that funding for psychotherapy cannot be a socioeconomic priority from a left-wing position or that therapy must change to incorporate (usually anti-capitalist) political insights.13 From a right-wing viewpoint, one finds the charge that therapy embodies unrealistically soft attitudes to life and tacitly supports a left-wing ideology.14
One important critique concerns the placebo factor. Given the apparently successful outcomes across all theoretical orientations, the argument for ‘common factors’ is that the explicit claims for therapeutic concepts and procedures matter very little. What actually counts is the therapeutic relationship in all its non-specific warmth, interest, and corrective emotional experience. Therapists’ belief in their theories may reinforce their sense of self-efficacy as therapists and hence come across to clients as confidence. This means that practitioners may be benignly deceiving themselves, to the benefit of their clients.15
6. Real world challenges
Freud’s main focus was on intrapsychic topics (Civilisation and its Discontents notwithstanding), and Adler represented one of the earliest analysts to declare a stake in ‘social interest and community feeling’. Erich Fromm, Karen Horney and others moved towards explicitly sociopolitical positions, drawing partly from Marxism. Herbert Marcuse was among several left-wing academics to promote a Freudo-Marxist view as part of the 1960s and 70s Western counterculture. More recently, some Jungians have explored the ‘political psyche’. Among others, Paul Wachtel has made explicit practice links with social justice issues; Sue Gerhardt with childrearing;16 and Oliver James with so-called ‘affluenza’ in the ‘selfish society’.17
Clinical psychologists like David Smail and the Midlands Psychology Group established a devastating critique of therapy leading to a ‘social materialist psychology’, locating the causes of distress not in the individual psyche but in capitalism.18 Critical psychologists like Ian Parker similarly seek to show the limitations of institutionalised psychological practice and the need for far stronger links with social justice.19 Psychoanalysis and psychodynamic counselling do not appear to have kept pace with such developments. The UK, indeed Europe and North America, have changed hugely in demographic terms over the past few decades. Mass immigration and multiculturalism challenge therapists to provide services that are more ethically and religiously sensitive, sometimes using interpreters. Individuals whose origins lie in other cultures do not necessarily all share Western assumptions regarding causes of and remedies for distress. The social justice movement calls for much more attention to the claims of feminism, and the black, Asian and minority ethnic (BAME) and lesbian, gay, bisexual and trans (LGBT) communities. Therapists in general, but arguably psychodynamic practitioners in particular, were slow to respond to these challenges. Now we are seeing increased needs for understanding and treating the psychological distress of young men.
7. Better informed and more demanding clients
Gone are the days when most clients were completely naive or uninformed about therapy. Today, not only is therapy much more widely accepted than 30 years ago, but it is written and broadcast about more. More pertinent research and advice is available, especially online, and some websites in the UK (more in the US) are driven by ex-clients sharing their experiences and, often, views on what has been unsatisfactory. Many clients have had one or two, or multiple previous experiences of therapy before seeing their latest therapist. In some cases, complaints and litigation have spurred the profession into clearer ethical statements, but also into less creative and risk-averse forms of therapy. Psychoanalytic therapy has, by far, received the largest volume of complaints (for example, in the writings of Jeffrey Masson, Anna Sands, Rosie Alexander, and Virginia Ironside). In most cases, dissatisfied ex-clients have pointed to mishandled transference, therapist abuse, lengthy and costly therapy, deterioration and ineffectiveness, as the most salient of problems.
The traditional defence of analysts has been along these lines: all presenting concerns are symptoms of underlying conflicts; clients may feel worse before they get better; therapy is inevitably long term; clients often act out when painful unconscious conflicts begin to surface; well-managed terminations are crucial. Psychodynamic counsellors working in educational settings may ironically find such criticisms helpful in justifying short-term therapy, which not only addresses symptoms but sidesteps many of the above complaints and criticisms. Brief therapy can be regarded as the first treatment of choice for a majority of presenting issues.20
8. The passage of time and erosion of tradition
Although psychodynamic treatment has obviously changed since its inception in the 1890s, we might reasonably ask whether its 120-year history has kept pace with developments in science, demographics, and society generally. For many, psychoanalysis already appears arcane and incredible, attempts to refute critics and bring it into the 21st century notwithstanding. I suggest that the main reactions to the above points are as follows.First, psychodynamics does not have the field to itself and cannot command the monolithic position of radical breakthrough it held over a century ago. This must lead to a constant awareness of questioned professional clinical identity and how it fits into a pluralistic framework. Some who would once have entered the psychodynamic field might now well opt instead for CBT training and practice. Secondly, others from within the fold – following Jeffrey Masson, Alice Miller and others aware of psychodynamic-specific critiques – might become disillusioned and seek other careers. Third, in the light of critical psychology, social materialist psychology, and critical thinking generally,21,22 some might find themselves disturbed by links between socioeconomic factors and the unwieldy epidemic of mental health problems. Despite the repeated call for better government funding for the treatment of non-physical illnesses, we may realise that this is unlikely to materialise. Conscientious practitioners may sometimes feel torn between the entrenched inner voice of their training; the idiosyncratic needs of each of many clients being seen; awareness of new knowledge that is hard to keep abreast of; the cognitive dissonance resulting from different streams of theory and knowledge claims; and the pressing need to continue to earn a livelihood.
In daily practice, psychodynamic and other practitioners face multiple micro-dilemmas. A client may need long-term therapy but not be able to access it. Compromises may have to be made in the face of agency and time pressures, entailing clinical decisions; for example, whether to curtail an uncovering process and instead provide a corrective emotional experience and ego-strengthening. Arguably, a particular onus exists for counsellors and wellbeing practitioners within colleges and universities, concerning intellectual integrity.23 Educational institutions often stand accused of bowing to the pressures of the new public management, dumbing down intellectually, and succumbing to over-protecting students. One of the biggest challenges then is for therapists to ‘dare to think’ (the ancient Greek injunction taken up by Kant – sapere aude) and to encourage students to do likewise. This can embrace radically rethinking psychoanalytic tradition (and indeed all psychotherapeutic tradition), rethinking education, and sharing with students the value of viewpoint diversity that has been eroded in recent decades.24 The approach sees intellectual maturity as an essential part of wellbeing rather than being in opposition to it.
Colin Feltham is Emeritus Professor of Critical Counselling Studies, Sheffield Hallam University and (external, part-time) Professor of Humanistic Psychology, University of Southern Denmark. His many publications include The SAGE Handbook of Counselling & Psychotherapy 4th edition (2017); Depressive Realism: Interdisciplinary Perspectives (2017) and Counselling and Counselling Psychology: A Critical Examination(2013).
Young people: not straight, not narrow
Open article: Growing numbers of young people are resisting traditional, binary gender identities and do not define themselves as heterosexual. University and College Counselling, September 2017
'Get out, stay out.' A careers mentoring scheme for lesbian, gay, bisexual and transgender (LGBT) students
Open article: Sean Russell highlights the benefits of a mentoring scheme for LGBT students at the University of Birmingham. University and College Counselling, May 2017
What could they be thinking? Understanding the adolescent brain
Open article: Michael Nagel explores the impact of brain maturation on emerging adult emotion and behaviour, highlighting the importance of awareness of this process on delivering effective therapeutic services. University and College Counselling, March 2017
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