I question the place of psychoanalysis and psychoanalytically oriented psychotherapy in the National Health Service (NHS), with reference to published material; and, particularly, in relation to primary care, health economics and medical ethics. I argue that there are pressing clinical, research, economic, and ethical reasons in support of the contention that an urgent review of the extent and impact of psychoanalytic practices in the health service is called for.

Wilkinson's (1) critique of psychoanalysis and psychoanalytically oriented psychotherapy is weakened by inconsistent use of crucial terms, a systematically biased selectivity in reviewing empirical evidence and prior debates, and a failure to address issues crucial for a scientific understanding of psychotherapy.

This book critically examines Freud's own detailed arguments for his major explanatory and therapeutic principles, the current neorevisionist versions of psychoanalysis, and the hermeneuticists' reconstruction of Freud's theory and therapy as an alternative to what they claim was a “scientistic” misconstrual of the psychoanalytic enterprise. The clinical case for Freud's cornerstone theory of repression – the claim that psychic conflict plays a causal role in producing neuroses, dreams, and bungled actions – turns out to be ill-founded for two main reasons: (...) Even if clinical data were valid, the method of free association has failed to support the psychoanalytic theory of unconscious motivation; Clinical data tend in any case to be artifacts of the analyst's self-fulfilling expectations, thus losing much of their evidential value. The hypothesis that psychoanalytic treatment is in reality a placebo poses a serious challenge to the assumption that insight is a key causal factor when therapy is successful. This challenge has yet to be met by psychoanalysts. Similar conclusions undermine the neorevisionist versions of psychoanalysis. The most influential hermeneuticists, on the other hand, are shown to have imposed an alien philosophy on psychoanalysis, partly through their reliance on gross misconceptions of the natural sciences. Karl Popper's criticism of the Freudian corpus as empirically untestable has misjudged its evidential weaknesses, which are more subtle. If there exists empirical evidence for the principal psychoanalytic doctrines, it cannot be obtained without well-designed extraclinical studies of a kind that have for the most part yet to be attempted. (shrink)

In this paper it is suggested that Freud's 'tally argument' (Grunbaum 1984) is not best interpreted as a risky claim concerning the efficacy of psychoanalytic therapy, but as a risky claim concerning the implications of theoretical psychoanalytic explanations of the efficacy of psychoanalytic therapy. Despite the fact that Freud never empirically established that these implications hold, the 'tally argument' does draw attention to a critical distinction that is too often neglected in contemporary empirical studies of psychoanalysis and other forms of (...) psychotherapy: between empirical evaluations of the efficacy of psychotherapy and empirical evaluations of theoretical explanations of the efficacy of psychotherapy, and the different forms of comparative enquiry relevant to each. It is argued that the contemporary neglect of this critical distinction, in conjunction with the common negative conception of placebo control treatments in psychotherapy research, has led to the epistemic impoverishment of experimental studies of the various professional psychotherapies. In consequence, although there is good empirical evidence for the efficacy of psychoanalysis and other forms of professional psychotherapy, there is no good empirical evidence for theoretical psychoanalytic explanations of the efficacy of psychoanalysis, or for traditional theoretical explanations of the efficacy of other forms of professional psychotherapy. (shrink)

John Greenwood (this issue) claims that neglect of an important methodological distinction has contributed directly to the "epistemic impoverishment" of empirical studies of all forms of professional psychotherapy. I challenge this claim, as well as other important claims he makes about the efficacy of psychoanalysis and other forms of psychotherapy.

Two inimical interpretations of psychotherapy look to many of the same features of empirical research. One camp infers that placebo effects are impossible in principle in psychotherapy; the other camp infers from the same research that psychotherapy is essentially placebo. I examine the crucial discussions and conclude that these opposing evaluations ensue because each group presumes a different baseline from which the significance of the research is gauged. I show how different baselines set different standards of significance and invite different (...) comparisons between therapeutic and non-therapeutic practices. Attention to this point about the baseline of significance puts the placebo debate in sharper relief and frames more clearly the merits and demerits of each position. It also leads to the conclusion that neither group really lays hold of in-principle claims, since both interpretations rest on context-dependent features of the empirical situation. Along the way, I discuss salient features of outcomes research, meta-analysis, and the role of symbols in therapeutic transactions. I close with some remarks that link the proliferation of therapies with cultural splintering generally and suggest how this might bear on the placebo issue. (shrink)

Psychotherapy is an activity which takes many forms and which has many aims. The present paper argues that it can be viewed as a form of moral suasion. Kant's concepts of free will and ethics are described and these are then applied to the processes and outcome of psychotherapy. It is argued that his ideas, by linking rationality, free will and ethics into a single philosophical system, offer a valuable theoretical framework for thinking about aims and ethical issues in psychotherapy.