There is no doubt that in the last decade of the century, the public imagination has been captured by molecular genetics as it applies to the brain as well as neurochemistry. Indeed there have been significant advances in our understanding of the brain. This has put psychotherapy under more pressure as it is more difficult to come up with exciting new discoveries in psychotherapy that will capture the imagination of the public like molecular genetics. It is likely that the brain will remain, for the next 50 years at least, very much to the forefront of the public and the journalistic concerns. All this will only underpin even more the philosophy of the logical positivists, which values empirical propositions based on actual observations and which will continue to have a huge influence on Irish psychiatry in the 21st century. This positivistic psychiatry, with its uncritical acceptance of Popperian empirical realism, has defined acceptable knowledge in a very narrow reductionistic way. The dominant view will continue to be that all that can be known about psychological problems is commensurate with what can be measured.
The Challenge for Psychotherapists
It is going to be even more difficult in the future for psychotherapists to find space for the theory of psychoanalysis and derived psychotherapeutic and counselling techniques or for interpretations given to patients which resonate with the dialectic of experience and have the ‘ring of truth’. The great challenge for psychotherapists and counsellors will be to find the space in the dialogue. It is going to be an enormous uphill battle for psychotherapists and counsellors to counter this positivist psychiatry, which has focused on biology and the “‘mind machine’ Biological psychiatrists and biological psychologists will continue to be more comfortable with so-called objective, “macho” knowledge which Karl Popper calls “it is known”, but have difficulty with subjective knowledge, which Karl Popper calls “I know”.
Nevertheless the 21st century is going to provide a challenge to both those who focus on a biological view and those who focus on a psychological view. They will need to dialogue with each other and combine the rational and romantic views of the human being. This integration and respect for the other point of view is going to be a major challenge in the 21st century.
Human beings will only benefit where both points of view are applied as appropriate. Unfortunately at present the schism between those who practise the biological approaches and those who practise the psychological approaches is growing ever wider. Indeed the concern expressed by Sir Denis Hill many years ago (1954) when he was Professor of Psychiatry at the Institute of Psychiatry in London, is even more true now than it was then. He stated that “there is a risk that a psychiatry dominated by physical methods of treatment, and promoting little but physiological research related to them, will regress to unpsychological attitudes to mental disorder such as existed at the beginning of the 20th century.”
New Forms of Psychotherapy
Chris Dare (1996) points out that new forms of psychotherapy will be invented and that some of these will have a long term effect on the development of psychotherapy as a subject. He sees mergers of some schools of psychotherapy and splits in others. He believes that the evolution of psychotherapy will be modified by the necessity of providing evidence for the effectiveness of the psychotherapies. On the positive side he points out that the search for meaning in psychotherapy will continue. It is interesting that he believes that psychodynamic psychotherapy will become increasingly similar to cognitive behaviour therapy. I believe that he is correct in pointing out that consumer pressure will have a considerable effect in the provision of psychotherapies for human problems. Indeed there will be development in the 21st century of consumer groups’ demand in the provision of psychotherapy from governments. At present we have consumer groups for almost every possible condition but none as far as I am aware pressing for the increase in psychotherapy as its main aim.
The need for psychological interventions at any one time is enormous and estimated to be 15 to 20% of the population, and since the 2nd World War this figure is probably increasing. There is definite increase in suicidal behaviour, depression and psychosocial problems in children. Clearly this increase cannot be explained on the basis of genetic data or of simple biological factors. We have to look to the psychosocial domain to explain this increase in rates of psychological problems. We have not explained satisfactorily why the rates of psychological problems are increasing particularly in a time of increasing affluence. It is surprising that with an increase in affluence there is a parallel increase in alienation and depression, and inevitably, psychotherapists and counsellors will have an increased role in dealing with these problems. There certainly is enough work for everyone.
Hard Data Required
It is critical that in the 21st century the gap between psychotherapy researchers and clinicians reduces. At present unfortunately the two groups of workers tend to work independently and are not much influenced by each other. This is a very serious matter because hard data of a quantifiable nature is going to be necessary if governments are to be persuaded to increase the budgetary commitment to psychotherapy. It is particularly unfortunate that there is such a gap between clinicians and researchers when there is such strong evidence in favour of psychotherapy and indeed psychotherapy could be argued for purely on economic grounds. It is going to be critical that psychotherapists and counsellors take on the challenge of hard data and not turn away from it or dismiss it. It is highly likely in the 21st Century that governments and Health Boards who purchase psychotherapy services for various populations will only do so on the basis of strong scientific evidence of a quantifiable nature. Simple assertions of the value of psychotherapy and counselling will no longer carry any weight. The relationships then will be simple economic ones between purchasers and providers of services, and it will be necessary for psychotherapists to speak the appropriate language of this relationship.
Since the need for health and psychological services is limitless so far as we can determine, and the resources of any government are finite, decisions will always have to be made on which treatments to support. These will increasingly be made on the basis of empirical evidence and not on what some famous professional might state was the case in the past. The psychoanalytic psychotherapies could be at risk unless much greater emphasis is placed on empirical evidence. Unfortunately psychoanalytic psychotherapy and counselling is not well suited to the randomised-controlled trial, which is the gold standard for treatment efficacy. In this research model, persons with psychological problems are randomly allocated to psychoanalytic psychotherapy and to an alternative intervention, for example, placebo therapy or behaviour therapy. It is important then that the patients who are in receipt of these treatments are as homogeneous as possible. This is the model used in drug trials.
Chiesa and Fonagy (1999) discuss alternative models of investigation. They are interested in effectiveness as it is shown in the real world of psychotherapy and counselling practice.
Seligman (1995) points out that many efficacy studies “omit too many crucial elements of what is done in the field.” The Association for Psychoanalytic Psychotherapy in the U.K. has proposed a multi-centre study which they expect will have “the additional advantage of being able to offer expectable success rates and of making a major contribution to bench marking, which is one of the recommendations of the Strategic Review” of psychotherapy services in the U.K. (Chiesa and Fonagy, 1999; Department of Health, 1997a; 1997b; 1998) This study will examine the effectiveness of psychotherapy in “real life”, that is routine clinical practice in the Health Service. Nevertheless reviews of the effectiveness of psychoanalytic treatments have shown them to be valuable (IPA, 1999).
Fonagy and Target (1996), in a landmark study of child psychoanalysis of 763 patients, showed that “child psychoanalysis to be particularly effectively for seriously disturbed children under 12 years suffering from a variety of psychiatric disorders, particularly those which involve anxiety.”
In terms of child psychotherapy most studies show an overall improvement rate of between 67% and 78%. The spontaneous improvement rate (that is improvement without treatment) has been put at about 25% (Kolvin et al., 1981).
Howard (1986) has shown that there is a positive relationship between the amount of psychotherapy and the amount of patient benefit i.e. by 8 sessions approximately 50% of (2,400) patients had improved, and by 26 sessions 75% had improved.
The benefit of a psychotherapeutic approach to relieving human misery is strong. It is possible to argue for psychotherapy purely on economic grounds, i.e. that it reduces general medical service demands by 20% and reduces inpatient hospital stays (Talley, et al., 1994; Anchor, 1989). The research is also very clear that it is more effective than placebo and more effective than no treatment (Fitzgerald, 1987; Mallan, 1973). In addition it speeds up the rate of recovery of patients with many psychological problems. There is also evidence that some patients with serious psychological problems gain a benefit which is additive from a combination of pharmacological and psychotherapeutic interventions. The additive effect is due to differential effects of the two treatments. In addition there is growing interest in psychotherapy integration and this will happen much more in the future (Stricken and Gould, 1993; Karasu, 1982). There is also evidence that group and individual therapy work in different ways (Sheehan and Fitzgerald, 1994). The differential effects of different forms of psychodynamic approaches are clearly a focus for further research.
Theory of Mind
There is no doubt that the theory of psychoanalysis will evolve in the future in unexpected ways as it has in the past. We have moved from an instinctual theory propounded by Sigmund Freud to an object relations theory and now to appropriating elements from cognitive psychology for example ‘theory of mind’ concepts which are enriching psychoanalysis.
Theory of mind approaches are useful in patients with Asperger’s syndrome, where there are meta-representational deficits. A theory of mind deficit means that one person is unable to perceive and comprehend the thoughts and feelings of others, i.e. that other people have minds.
We are now much more sensitive to meta-representational deficits that patients have i.e. the ability to think about thoughts which include one’s own as well as other people’s. We are trying to help people with severe problems to “read minds”, a capacity which is necessary to explain and predict the behaviours of other people in a social world. It is this meta-representational deficit that makes life confusing and frightening and leads many people to withdrawal and avoidance (Leslie, 1987). It people with these deficits are given interpretations based on an energy discharge model of psychoanalysis these interpretations will not make any sense to them.
These patients’ deficits are in the object relations area but the new type 0f interpretation and effort to help them is quite far from the object relations model of psychoanalysis as originally delineated. There is little doubt that, in the 21st century, psychoanalysis will see further theoretical developments along the lines described here.
It is very likely that in the 21st century conferences will take place where psychotherapists and counsellors will be in discussion with biochemists and brain neuroimagers about the effects of psychotherapy on various biological and neuroimaging parameters.
[Michael Fitzgerald is Henry Marsh Professor of Child & Adolescent Psychiatry T.C.D.]
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