The documents received from Skills for Health regarding the development of National Occupational Standards for the practice of psychological therapies sets out a framework which aims to subsume these therapies within the context of healthcare provision. While this consultation is clearly in its early stages and receptive to input from the profession itself, there is a serious problem with the initial assumption of homogeneity over the fields of therapeutic aims and practice. While many forms of psychological therapy would have no problem in seeing themselves grouped under the rubric of healthcare, psychoanalytic therapy is quite specific in that it does not claim to offer healthcare, and its basic assumptions are incompatible with the service provision model that is implicit in the Skills for Health framework.
Set out below are some of the problems which arise with the Psychological Therapies Consultation document, focusing on their inapplicability to psychoanalytic therapy. First of all, it may be helpful to make some more general points. Psychoanalytic therapy involves a long term exploration of an individual's history through a process of dialogue and through an analysis of the relationship between patient and therapist. It is not a technique that can be applied to every patient, since it is rather a property of the relationship between patient and therapist itself. It is primarily the patient who does the work here and not the therapist: the therapist's role is to encourage the eliciting of unconscious material and, in a careful and unpredictable way, to respond to this material.
Psychoanalytic therapy thus involves input from both parties, and without this dual input cannot properly be said to exist. Patients are, as it were, put to the test, and it often takes a considerable number of meetings with a therapist to determine whether the therapy will actually start to get going. Visits to a psychoanalytic therapist and psychoanalytic therapy are not always the same thing. Psychoanalytic therapy involves a questioning of one's history and this may take a long time to become established, if at all. Therapists cannot make this happen, or even claim to 'offer' it. This situation is made more complex by the tension between conscious and unconscious processes that lies at the heart of the analytic approach.
One of the basic assumptions of psychoanalytic therapy is that due to the conflict between conscious and unconscious thought, what the patient asks for consciously will not be what they seek at an unconscious level. Likewise, it has been pointed out throughout the history of psychoanalytic therapy that there is often a difference here between what the patient wants at a conscious level and what the therapist wants: the patient may want to have their neurosis restored, while the therapist would aim to unravel and deconstruct the neurosis. As Ernest Jones, one of the founders of British psychoanalysis, put it, 'the patient comes for help to sustain the disease and resists all the efforts to cure it. To give up a neurosis would signify…to surrender certain cherished wishes and to dispense with the only protection [the patient] knows against the accompanying anxiety and misery. When a person is disturbed by neurotic symptoms his distress is only in part due to the painful effects of the symptoms themselves. What disturbs him far more is the inner feeling that his defensive systems are beginning to break down, which is indeed what the presence of manifest symptoms mean. What brings him for help is his need to strengthen and reinforce these defences - that is, the neurosis itself'(1).
This basic assumption divides psychoanalytic approaches from many other psychological therapies. It means that where the patient will seek therapy in order to restore their neurosis, the therapist will aim, on the contrary, to challenge and alleviate the neurosis itself. This signals an irresolvable tension at the level of any model that sees psychoanalytic therapy as a service provision: what the patient hopes for and what the therapist offers are radically incompatible. It is this very tension which provides the motor for the therapy itself.
The above points should help clarify the problems in attempting to introduce the framework of National Occupational Standards to psychoanalytic therapy. This form of therapy does not involve a 'product' or a 'service', and hence the NOS aim of "ensuring that the products are quality assured and fit for purpose" finds no immediate application.. Psychoanalytic therapy is different precisely because it rejects the ideology of service provision, and this is one of the reasons it proves attractive to many those who seek to embark on it.
Comments on the Document
Page 6
There are problems here with the way in which a transparency is assumed between conscious and unconscious processes. The idea of 'maintaining progress' is highly problematic since all psychoanalytic therapies would see the breakdown of progress as itself a fruitful and necessary period of the analytic work. Frustration, disappointment, and frictions between the patient and the therapist form part of the material of transference which will give a vital clue as to unconscious processes. Given the subjective time that is specific to each individual, it is not possible to impose any kind of standardised timetable of progress on a psychoanalytic therapy. If the patient is fed up, they are of course free to leave at any time.
Re the question of 'evidence', there are major issues with the current vogue for 'engaging with the evidence' as sociologists and historians of science have shown. What counts as evidence will depend on social and economic factors that vary from one culture to another and from one time period to another. For example, where at one moment therapists would look for fantasies at another they might look for concrete trauma. This is not to embrace relativism, but rather to recognise the way in which the variables that are accorded visibility will change historically. At the moment, the richness and diversity of the field of psychoanalytic therapy is shown by the fact that there are several models of evidence and, in most analytic traditions a healthy critical awareness as to the question of what counts as evidence in the first place.
Page 7
Point 1.8 may well be compatible with many forms of psychological therapies but is completely incompatible with psychoanalytic therapy. For the reasons outlined above, it is not possible to 'agree goals with the patient against the changes they are looking for'. Once again, this ignores the distinction between conscious wishes and unconscious desires, the very backbone of the psychoanalytic approach. Points 1 to 5 that follow are completely applicable to a therapy like CBT yet inapplicable to the psychoanalytic therapies. The key to psychoanalytic psychotherapy is the discrepancy between the conscious and unconscious wishes of the patient. The analytic therapist can in no way offer to satisfy the patient's demands and can in no way claim that any form of predictable outcome is possible. It's with the knowledge that the outcome of a psychoanalysis is profoundly unpredictable that each person can make the decision to embark on it or not. These same points apply to bullet points K1 to K4. They are perfect for CBT and inappropriate for psychoanalysis.
Page 8
We welcome the points made here about the distinction between different forms of therapy and the recognition in Point 2 that it is difficult to talk about the 'same' therapy applied to different patients. Each therapy will be completely individual, coming about through the unique relationship between patient and therapist. Psychoanalytic therapy cannot be applied to a patient like a plaster or a pill. And the form it takes will differ quite widely from one patient to the next and from one period of time to the next in the same patient's treatment. This emphasis on uniqueness has always made psychoanalytic psychotherapy incompatible with systems of external evaluation based on statistical methods.
Page 9
An important point is made here that it is not always clear 'what distinguishes effective practice from ineffective'. Since the psychoanalytic approach puts the burden of work on the patient and not the therapist, whether the analysis is effective or not depends almost entirely on the patient. There are many cases where a patient manages to make significant progress and change despite having a dim-witted analyst, just as there are cases where no progress at all is made despite having a brilliant analyst. It all depends on the unique chemistry of each treatment, which will produce its own unique aims, methods and problems.
The term 'problem' is worth thinking about here as it appears in the subsequent point on page 9 about identifying the patient's problems. In contrast to many other forms of therapy, psychoanalytic therapy sees a distinction between what society would deem a problem and what the patient him or herself would perceive as a problem. Society might view aspects of the patient's behaviour as deviant or problematic whereas the patient him or herself may see them as perfectly normal. Furthermore, psychoanalysis posits a fundamental distinction between surface symptoms and underlying structures. Anorexia, for example, could be a symptom of hysteria or schizophrenia. In itself there is no such thing, from the psychoanalytic angle, as the treatment of anorexia. Rather, what matters is to see what place the anorexic symptoms take in the underlying structure of that particular patient. Thus, where society might see an easily identifiable problem - anorexia - the psychoanalytic therapist might see a much more complex problem - say, hysteria or schizophrenia which has as one of its symptoms a loss of appetite or an aversion to food. Given this particularity, it makes little sense for analytic therapies to think about 'symptoms and how to treat them'. The underlying structures are of paramount importance here.
Likewise, this emphasis on structure means that psychoanalytic therapy takes a holistic view of people's suffering. This cannot be reduced to symptoms which the treatment aims to remove, since it is rather the whole of the person that is in question. Symptoms, from this perspective, concern the person's whole existence, rather than being undesirable elements which can be subtracted without affecting the rest of the psyche. This implies that the aim of localised intervention on a symptom is both ill-starred and erroneous from an analytic perspective.
Page 10
Once again, all the points made on this page suit CBT perfectly but not psychoanalytic psychotherapy. Analytic therapies are not a form of health care provision.
Page 13
Points 1 to 10 suit CBT but not the analytic therapies. Point 1.1 is invalid for the reasons given above, although Point 1.4 and 1.8 seem very reasonable. The same applies to 2.2 to 2.15. These completely neglect the centrality of unconscious processes and the difference between conscious and unconscious demands and wishes. They also imply a transparency for both patient and therapist as to what is going on in the work. From a psychoanalytic perspective, it may often take several years for what is going on between the therapist and the patient to become clear. Psychoanalytic therapy is a long term business which tends not to rely on insights, but rather on the idea that change can occur through unconscious processes rather than conscious ones. Most of points 2.2 to 2.15 assume that therapy is an objectifiable situation that can be externally validated and clarified at all times.
Page 14
Points 3.1 to 3.6. These all suit CBT but not analytic therapies. The question of endings is notoriously thorny and has generated a vast literature. Many patients decide to end their therapy when their neurosis is restored and many therapists will contest this, insisting that the patient continue. It is only in a minority of cases that the patient will push through and continue the work of accessing unconscious structures. The history of psychoanalytic therapy also demonstrates that those therapies that end 'well' tend to be the least effective. Where genuine change has taken place, the patient often feels a reproach to their therapist, as if they have been robbed of what is most precious to them: their symptoms and hopefully, their neurosis itself. It should be stressed again here that what the analyst aims at is not necessarily the same as what the patient would wish. The friction and tensions that this causes are the very stuff of psychoanalytic work.
Page 16
All of the boxes here again suit a CBT model more than that of psychoanalytic therapy. Crucially, they tend to assume that we would know what is best for the patient. For example, regarding the stated aim 'help the patient develop self tolerance', we should ask why this would be an aim when perhaps it would be more appropriate for the patient to lose any self tolerance they might have. Likewise, 'to help the patient develop self identity and personal boundaries': in many cases of neurosis a strong sense of self identity and personal boundaries are the very problems to be dealt with. They define obsessional neurosis quite well, for example, and the therapist might spend years trying to chip away at the rigid self identity and boundaries of the patient. In general, the goals set out on this page assume a normative view of what mental health is. Psychoanalytic therapies, on the contrary, tend not to subscribe to the concept of mental health. Rather than suppressing symptoms, they aim to allow symptoms to speak: in other words, to find out what is being articulated and expressed in a symptom, however unpalatable and disturbing this might turn out to be.
(1) 'Papers on Psychoanalysis', 5th edition (1948), London, Karnac Books, 1977 reprint, p 360.
