Existential Psychoanalysis and Behavioural Approaches to The Mind

If I take death into my life, acknowledge it face it squarely, I will free myself from the anxiety of death and the pettiness of life-and only then will I become free to become myself” (Heidegger)

Facebook and Twitter are two relatively new ways of people bonding in groups seeking out like minded individuals that one otherwise may not ever meet in daily life. The groups feature in Facebook is particularly useful. When I finished my PhD and was still eager to discuss philosophy and its relation to science so I set up a group to discuss these issues on Facebook called ‘Philosophy, Science and Utube’. The group now has over 8000 members and has a lot of very serious academics as in it. Around the same time as I set up ‘Philosophy, Science and Utube’ my friends Matt, Simon and Bill set up their group ‘Analytic Philosophy’ which has close to 10,000 members and again is filled with some very serious academics.  For pretty much any group out there one will find a Facebook discussion group chocked full of people waiting to discuss the relevant issues.

As a member of various groups on different theoretical disciplines I often come across, different tribal allegiances, different theoretical stances, different standards of evidence etc. In a psychoanalytic discussion group I was a member of world famous and much respected psychoanalyst George Atwood made a disparaging comment about Aaron T Beck the father of cognitive behavioural therapy. Atwood’s comment began with the claim that Aaron T Beck is the Devil, and in his comment sketched a very implausible psychoanalytic theory, for which he provided no evidence, as to why Beck created cognitive behavioural therapy. I criticised what I perceived as Atwood’s closed minded dismissal of an entire discipline, and argued harshly that it would make life very difficult for his patients if he took this closed minded approach with them. His friend Robert Stolorow who co-authored many books with Atwood went on the attack and argued that I should be banned from the group for a personal attack on Atwood (apparently personal attacks are only allowed if they are directed toward Beck). I replied that my criticism was directed towards his dogmatic attack on an entire discipline not towards Atwood himself, and Stolorow replied that my behaviour was typical of cognitive behavioural therapists[1] who do not have the emotional ability to recognise when they are insulting people. The obvious reply to this was that since his statement is of the form ‘All people who study x are deficient in capacity y’ he was engaging in a personal attack on every person on the planet who studies Cognitive Behavioural Therapy[2]. So again he had no problem with personal attacks as long as they were directed at people who study CBT.

I didn’t bother continuing with the argument with Atwood and Stolorow as it was too heated and there was no chance of either side learning from the other at this point. I have recently been thinking about the discipline of psychoanalysis and its relation to other sciences of the mind and it put me in mind of the argument with Atwood and Stolorow. Stolorow’s claim that people who specialise in behaviour analysis, and cognitive behavioural therapy are less emotionally attuned than psychoanalysts while insulting, isn’t necessarily false. A neurologist could correctly argue that people who study philosophy are on average worse than neurologists at distinguishing between tremors associated with Parkinson’s disease and tremors associated with MS. Stolorow could argue that his claim has the same logical status as the claim made by the neurologist. If we read Stolorow’s claim this way then we can look at it not as an insult to CBT or behavioural analysts but rather as an empirical claim which may or may not be true.

In fact one could flip the focus of Stolorow’s claim around and focus on a psychoanalyst’s competency to assess a person’s behavioural environment.  So, for example, consider a child with severe intellectual disability who engages in self injurious behaviour such as severe head banging. We have ample evidence to indicate that an Applied Behavioural Analyst through assessing the child’s environment, circumstances of occurrence, causal antecedents of the behaviour etc and implementing a differential reinforcement programme will be able to reduce the amount of self injurious behaviour the child engages in.[3] So here we could argue that we have a nice division of labour. The behavioural analyst deals with external behaviour and is probably not the best person to evaluate emotional stuff, and the psychoanalyst deals with emotional problems and is probably not the best observer of external behaviour. So there is no conflict of approaches just people dealing with different areas of life using different tools. If only life were that simple.

Psychoanalysts sometimes deal with behavioural problems with their clients. Valerie Sinason and Neville Symington have both worked with people with severe intellectual disabilities who have emotional and behavioural problems. Sinason even worked with intellectually disabled people who cannot speak (but who seem to understand language), by analysing their play with toys to try and to discover unconscious difficulties they have. By making explicit these difficulties to her clients she helped them to move on and decrease their destructive behaviour. Reports by care givers indicate that Sinason’s work did help improve her client’s behaviour though these anecdotal reports are much harder to assess than the objective measurements used by behavioural analysts.

My point is that there is simply not any clear division of labour between these disciplines. If a psychoanalyst and behavioural analysts (whether CBT or not) claims that the other discipline is deficient in various different areas then it is important to note who is correct. Behavioural Analysts treat people with anxiety disorders and so do psychoanalysts. While CBT and psychoanalysts both deal with essentially the same problems in using their different approaches.

We do know that the empirical evidence doesn’t really favour one approach over the other in terms of outcomes. Philosopher Charlotte Blease has recently noted[4] that 300 different studies have shown that there is only 1 percent difference in outcomes. Psychoanalysis seems to have slightly better long term outcomes than CBT but overall there seems to be very little difference between the approaches in terms of outcomes. There is little empirical research on the difference of outcomes between psychoanalysis and Clinical Behavioural Analysis.  Clinical Behaviour Analysis is a form of therapy which tries to remain closer to the functional approach of people like Skinner and more modern behavioural research in Relational Frame Theory; they tend to move away from more cognitive approaches like CBT. Clinical Behaviour Analysis such as ‘Community Reinforcement Approach and Family Training’, or ‘Behavioural Activation’, are relatively recent. There hasn’t been as much comparative research into its merits in comparison to CBT and Psychoanalysis yet. But the research so far is promising and indicates it can match up to either CBT or Psychoanalysis.

Given that there is no evidence that behavioural approaches and Psychoanalytic approaches are more successful than each other in therapeutic settings one might wonder why a more ecumenical approach isn’t adopted. We could argue that different approaches to psychotherapy will work on different people depending on their temperament. Is it just dogmatism of therapists who have a childish urge to assert “my discipline is the best” despite the evidence failing to find any significant differences of the success rate of the different approaches? I would argue that the answer to the previous question is NO.

People like Atwood and Stolorow are arguing from a philosophical perspective. When Stolorow notes that people who work from a behavioural perspective lack emotional insight he is arguing that they do not understand a key facet of the human condition. Stolorow in his blog has criticised CBT as being a form of commercialism. Neat short sessions can cure people’s psychological ailments at a nice price, in a very short time; maybe 8 sessions or so. This approach fits perfectly with a capitalist society where people’s primary role is as a worker, and if the worker has difficulties we need to get them back to work as quickly as possible, with as little fuss as possible. Things like mental anguish or grief are not aspects of life to be worked through but symptoms to be cured. In short on Stolorow’s picture mental health, like all other aspects of our existence, are reduced to commodities.

In an interview with the Centre for Psychoanalytic studies Stolorow recounted how he wrote a series of psychobiography’s with George Atwood on how the theories of Freud, Jung et al were shaped by the personalities of the theorists. To encompass this fact they looked to phenomenology as a way of grounding the theories in phenomenological experience.

When trying to ground his psychoanalytic practice in phenomenology Stolorow went to the work of Heidegger[5]. A key aspect of Heidegger’s theory that Stolorow was interested in was his account of authenticity. So for Heidegger humans suffer a primordial sense of guilt, it is not moral guilt but a condition of possibility of moral guilt, a sense of being accountable to oneself for oneself. Instead of holding oneself responsible for ones existence interms of some public norm (inauthenticity), one holds oneself responsible for himself. You have to be accountable to yourself first existentially before you can become morally accountable. The other aspect of authenticity is being aware of our being towards death and accepting our finitude. For Heidegger people normally try to escape from their finitude by engaging in idle talk. From a clinical perspective Stolorow notes that emotional trauma forces us into our finitude. Death is brought into the foreground by various emotional trauma it reminds us that we and everyone we know will die. When this happens our everyday defence mechanisms are meaningless.  When we are in the state of authentically being towards death we have less interest in being busy in the world. This can explain depressive states where people lose interest in sex and food etc.

He distinguishes his approach to psychoanalysis from other psychoanalysts as follows[6]: Theye don’t have a content theory, and do not prescribe any universal content of experience, because sometimes those theoretical contents end up becoming the content of analytic practice as opposed to the unique experiences of the analysand (e.g Archetype, Super ego, etc).The try to treat every individual as an individual who has own unique intersubjective history. One exception of this treating people as unique contingent individuals is on the traumatising effect of finitude itself on us. For Stolorow this traumatising effect of finitude is a universal fact of the human condition which cannot be escaped. Though Stolorow does differ from Heidegger in that he thinks that being towards loss is just as important as being towards death. Heidegger wouldn’t have agreed with him on this.

We can see from this brief summary of Stolorow’s work that any analysis that focuses on behavioural changes to help individuals cope with the world will be inadequate because it misses out on essential facts about the human condition. Our relationship to our choices, and to our finitude are key facets of who we are, and any therapy that ignores this fact while it may have some pragmatic success will not get at the truth of the person they are helping. Stolorow views things like behavioural analysis and CBT as crude consumer tools which sell short term happiness at the cost of long term authentic understanding being achieved by the patient.

A couple of points need to be noted here. Firstly Stolorow’s attempt to provide a phenomenological theory to ground psychoanalysis is problematic. If he is going to ground his psychoanalysis in terms of phenomenological description he is going to have to deal with competing phenomenological descriptions. Why, for example, accept Heidegger’s analysis in ‘Being and Time’ over Husserl’s (slightly different) in ‘The Crisis of the Human Sciences’? Secondly, it think it is important to note that to some degree Stolorow’s claim that  those from a behavioural background lack emotional empathy would probably apply to other psychoanalysts. Neuropsychoanalysts with their attempts to ground Freud’s theory in modern neuroscience are miles away from the Phenomenological Psychoanalysis Stolorow practices. One could argue that they are entirely new disciplines? To some degree Neuropsychoanalysis has more in common with CBT and Relational Frame Theory than with phenomenological analysis. It would be interesting to hear if Stolorow and Atwood think Neuropsychoanalysts are emotionally deficient as well.

Stolorow’s problem with behavioural approach is philosophical. Likewise some Behavioural approaches will criticise psychoanalysts for over populating their ontology with entities that are not warranted by the behavioural facts. Again this is a philosophical complaint. I am a pragmatist. Since both approaches seem to work equally well I think people should use them as necessary, and try to devise other approaches that may be better than what has gone before them. The Heidegger I prefer is the Heidegger of the first part of ‘Being and Time’ the thinker who emphasises pragmatism, embodied cognition, implicit awareness. This is the Heidegger that Rorty talks about a lot. I think that Heidegger can have something important to add to discussions of the human condition. But I think appealing to the more metaphysical aspects of his worse are more trouble than they are worth.

[1] I am not a Cognitive Behavioural Therapist he just assumed I was because of my defence of Beck.

[2] Henceforth Cognitive Behavioural Therapy will be referred to as CBT.

[3] I won’t be dealing with pharmaceutical treatments in this blog post.  But it should be kept in mind that a good psychoanalyst or cognitive behavioural therapists, or behavioural analyst will use pharmaceutical treatments in tandem with their programmes where necessary.

[4] Charlotte Blease 2015 ‘Unthinkable is Psychotherapy a licence to deceive’?

[5] Note Stolorow is no amateur using the work of a philosopher he doesn’t understand. As well as having a PhD in Clinical Psychology he also has a separate PhD in Philosophy where he researched on Heidegger and Trauma.

[6] He discusses this in his interview with the Centre For Modern Psychoanalytic Studies.

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