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Is Psychoanalytic Psychotherapy Empirically Validated?

Is psychoanalytic psychotherapy empirically validated?

Is psychoanalytic psychotherapy empirically validated? The short answer is, yes. And empirical support for this long-established approach is rapidly growing.

Why do some people assume that it isn’t evidence-based? Probably because empirical research on psychoanalytic psychotherapy has been slower in coming than for some other clinical approaches.

There are a number of reasons why empirical validation of psychoanalytic psychotherapy has lagged behind other therapeutic approaches.

First, psychoanalytic psychotherapy is relatively difficult to assess with standard empirical techniques. Empirical research typically relies on quantitative data, observable outcomes, unvarying procedures applied across cases, large sample sizes, and replication of findings. Experiments with random assignment to discrete conditions with a control group (i.e., randomized-controlled studies) are considered the “gold standard” in research because they are highest in internal validity (i.e., determining cause-effect relationships). Each of these elements is problematic for psychoanalytic psychotherapy.

Let’s first consider the type of data involved. The aim of psychoanalytic psychotherapy is not merely to reduce problem behaviors; rather, it is to help deepen self-understanding and to achieve some outcomes that are important for an individual’s quality of life but difficult to measure. Psychoanalysis and psychoanalytic psychotherapy provide a setting where an individual’s personal truths can become known, understood, and shared. Some outcomes may be assessable through self-report, rating scales, or behavioral outcomes. Patient self-reports, however, may not reflect the deeper, sometimes ineffable changes that lead to greater health. Their validity can also be undermined by fabrications and/or a patient’s wish to validate (or invalidate) a treatment process. Even observable behavior change does not always accompany or reflect growth and improved well-being attained in psychoanalytic psychotherapy.

As we are complex creatures, psychoanalytic theories are also inherently complex, providing models for appreciating the uniqueness of the human experience. These models are difficult to understand, let alone to operationalize, by a researcher who is not an experienced psychoanalytic psychotherapist. And most researchers are not experienced psychoanalytic psychotherapists.

Then, there are procedures that must be standardized across cases in research studies. Psychoanalytic psychotherapy considers such constructs as the changing phenomenology of the patient and the transference relationship with the clinician—both difficult, if even possible, to replicate in a meaningful way, as each case is unique. The gold standard of research involves random assignment to condition. Random assignment requires that discrete conditions be pre-determined, which may be difficult, if even feasible, when the clinician’s focus is on responding to the changing, unconscious needs of an individual. Is psychoanalytic psychotherapy empirically validated? Because research involving psychoanalytic psychotherapy has tended to involve observational or case studies, the studies have not always been “counted” as evidence. Hence, the approach is often assumed not to be evidence-based.

Furthermore, psychoanalytic psychotherapy often deals with issues that cannot be resolved quickly. This factor has several implications. First, many researchers depend on number of publications for tenure, academic promotion, etc., making long-term studies less desirable. No wonder there are so many more outcome studies on cognitive-behavior therapy (CBT). And, statistical power relies on having a large enough sample size to reveal subtle differences. When therapy is individualized and longer term, gathering a large sample is impractical.

Finally, psychoanalytic psychotherapy occurs through the relationship with the therapist—a vehicle that is viewed as sacred and to be protected from contamination by outside factors. As such, psychoanalytic psychotherapists have tended to be suspicious of and protective against incorporating empirical assessments that could influence the therapeutic process.

In contrast, cognitive-behavior therapy focuses on modifying observable behaviors and/or conscious cognitions, with protocols that are brief, relatively simple to manualize, and conducive to randomized controlled studies. Consequently, many research studies have been published on this approach, leading some to assume that it is the only valid type of therapy for many conditions. A self-fulfilling prophecy is then also engaged, with greater recognition leading to greater access to further research funding, for even more outcome studies and confidence in the approach.

Is psychoanalytic psychotherapy empirically validated? Despite the many challenges, the quality and quantity of research testing psychoanalytic psychotherapy is increasing. More proponents of the approach are becoming convinced of the importance of providing research evidence and becoming creative in ways to test its complex features. Midgley et al. (2021) recently published a narrative synthesis of such outcome studies, including a growing number of randomized-controlled studies involving psychodynamic techniques.

There are future challenges, however. More funding is needed for studies that are complex and difficult to operationalize. Randomized-controlled studies have routinely been favored by the scientific community; hopefully, observational studies will also come to “count” as empirical evidence. As noted by Midgley et al. (2021), “Whilst the findings of these studies cannot be considered as ‘rigorous’ as those of experimental studies, such studies may be more representative of a ‘real-world’ context, where treatments are not often delivered according to a specific manual, treatment length is not predetermined, and patients often present with a mixed picture of mental health issues” (p. 12).

I value the words of Eric Kandel, neuroscientist and Nobel Laureate: “Psychoanalysis still represents the most coherent and intellectually satisfying view of the mind” (1999, p. 505).

To learn more about Midgley et al.’s (2021) narrative synthesis of outcome studies on psychodynamic psychotherapy, please see their open-access article: Midgley, N., Mortimer, R., Cirasola, A., Batra, P., & Kennedy, E. [2021]. The evidence-base for psychodynamic psychotherapy with children and adolescents: A narrative synthesis. Frontiers in Psychology, 12, 1-18. doi: 10.3389/psyg.2021.662671.

You may also earn 2 CE credits for reviewing the article by registering for the online course, Evidence Base for Psychodynamic Psychotherapy With Children and Adolescents.

You may also enjoy our blog, Is Psychodynamic Psychotherapy Evidence-Based?

Interested in earning a Certificate of Advanced Study in Psychoanalytic Psychotherapy? Simply complete 48 CE credits with our psychoanalytic courses, including at least three course courses. Entirely online, accessible 24/7, and paced at your convenience.

The Institute of Advanced Psychological Studies is approved by the American Psychological Association to sponsor continuing education for psychologists. The Institute of Advanced Psychological Studies maintains responsibility for this program and its content.

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Is Psychodynamic Psychotherapy Evidence-Based?

Evidence-Based Psychodynamic Psychotherapy

Is Psychodynamic Psychotherapy Evidence-Based?

The public—and many clinicians—often assume that it is not. In fact, many university courses teach that only cognitive-behavioral approaches have current empirical support. This assumption is false and does a disservice to the field and to the public alike. A growing number of studies demonstrate that psychodynamic psychotherapy is evidence-based, and support the value of psychoanalytic and psychodynamic approaches, especially for complex cases and long-term change.

Some Psychological Approaches Are Easier to Research Than Others

Clinical psychology is a multifaceted discipline, with a history that spans over 100 years. Since its origins, approaches and perspectives have come and gone in popularity. Classical psychoanalysis, object relations theory, and ego psychology; humanistic client-centered, gestalt, and existential therapies; behavior therapies; cognitive, cognitive-behavioral, and mindfulness-based cognitive therapies; interpersonal therapy; eye movement desensitization therapy; dialectical behavior therapy; integrative or holistic therapy—and the list continues to grow. Some approaches have been studied more than others. Many show promising results in some studies, only to be found to be limited in others. Some win favor because they are simple to research, and so garner publicity and research grants. Others draw attention because they are easy to teach and to master, or are short in duration and so inexpensive. Psychoanalytic and psychodynamic approaches are complex; they are not easily taught and they pose challenges to research. But, despite this, they continue to have many followers and are gaining impressive scientific support.

A Growing Body of Research Supports the Value of Psychodynamic Psychotherapy, Despite Its Complexity

Is psychodynamic psychotherapy evidence-based? Absolutely! Numerous current scientific studies support the value of psychodynamic and psychoanalytic approaches. In fact, meta-analyses—studies that gather evidence across multiple studies—demonstrate the effectiveness of psychodynamic and psychoanalytic work and indicate that, in some cases, psychodynamic approaches may be more effective in the long-run than other therapeutic models (e.g., Abbass et al., 2014; Baardseth et al., 2013; Bastos et al., 2015; Buchheim et al., 2012; Busch, 2015; Grande et al., 2009; Johansson et al., 2010; Kallestad et al., 2010; Klug et al., 2016; Leichsenring & Rabung, 2011; Midgley & Kennedy, 2011; Parker & Turner, 2014; Rizeanu, 2016; Shedler, 2010; Shepherd & Beail, 2017; Soares et al., 2018; Waldron et al., 2013; Waldron, Gazzillo, & Stukenberg, 2015).

Psychodynamic Psychotherapy Is Often Misperceived

As noted by Shedler (2010) in an article published by the American Psychologist—a well-regarded publication of the American Psychological Association, “the perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings” (p. 98). This faulty perception has led some educational programs to downplay its significance or even dismiss it as an “outdated” approach. It is in the public interest that the field conduct scientific inquiry into the potential benefits and mechanisms of all therapies that clinicians have found to be valuable. Researchers cannot adequately investigate theories that they do not fully understand—research draws from a theoretical base (Britzman, 2012), which must be clearly understood before meaningful studies can be conducted regarding its mechanisms (e.g., Gazzillo et al., 2017; Laska, Gurman, & Wampold, 2014; Waldron et al., 2015). It is, therefore, crucial for science as well that the field continue to be educated about the premises of these valuable therapeutic approaches. Unlike some behavioral theories, many of the constructs of psychodynamic and psychoanalytic theory can only be assessed indirectly. Fortunately, many researchers are accepting the creative challenge.

It Is Important to Continue Researching All Psychotherapy Approaches

It is important for psychologists, psychoanalysts, and counselors to stay current, with scientifically grounded evidence, regarding issues relevant to enhancing their service to the public and the profession. Research, and informed discussion and practice, strengthen the profession. Is psychodynamic psychotherapy evidence-based? Yes, psychodynamic and psychoanalytic therapies are indeed empirically validated as valuable approaches for a wide range of disorders and clients. And, to quote Eric Kandel, neuroscientist and Nobel Laureate, “Psychoanalysis still represents the most coherent and intellectually satisfying view of the mind” (1999, p. 505).

Interested in learning more about the evidence for its approach with children and adolescents? You may find the following article and course valuable: Evidence Base for Psychodynamic Psychotherapy With Children and Adolescents.

More References for Evidence-Based Psychodynamic Psychotherapy

Abbass, A. A., Kisely, S. R., Town, J. M., Leichsenring, F., Driessen, E., De Maat, S., Gerber, A., Dekker, J., Rabung, S., Rusalovska, S., & Crowe, E. (2014). Short-term psychodynamic psychotherapies for common mental disorders (review). Cochrane Database of Systematic Reviews, 7, 1-108. doi: 10.1002/14651858.CD004687.pub4

Baardseth, T. P., Goldberg, S. B., Pace, B. T., Wislocki, A. P., Frost, N. D., Siddiqui, J. R., Lindemann, A. M., Kivlighan III, D. M., Laska, K. M., Del Re, A. C., Minami, T., & Wampold, B. E. (2013). Cognitive-behavioral therapy versus other therapies: Redux. Clinical Psychology Review, 33, 395-405. http://dx.doi.org/10.1016/j.cpr.2013.01.004

Bastos, A. G., Guimaraes, L. S. P., & Trentini, C. M. (2015). The efficacy of long-term psychodynamic psychotherapy, fluoxetine and their combination in the outpatient treatment of depression. Psychotherapy Research, 25(5), 612-624. https://doi.org/10.1080/10503307.2014.935519

Britzman, D. P. (2012). What is the use of theory? A psychoanalytic discussion. Changing English: Studies in Culture and Education, 19(1), 43-56. https://doi.org/10.1080/1358684X.2012.649143

Buchheim, A., Viviani, R., Kessler, H., Kächele, H., Cierpka, M., et al. (2012). Changes in prefrontal-limbic function in major depression after 15 months of long-term psychotherapy. PLoS ONE, 7(3). https://doi.org/10.1371/journal.pone.0033745

Busch, F. N. (2015). Discussion: Psychoanalytic research: Progress and questions. Psychoanalytic Inquiry, 35, 196-203. https://doi.org/10.1080/07351690.2015.987607

Gazzillo, F., Waldron S., Gorman, B. S., Stukenberg, K. W., Genova, F., Ristucci, C., Faccini, F., & Mazza, C. (2017). The components of psychoanalysis: Factor analyses of process measures of 27 fully recorded psychoanalyses. Psychoanalytic Psychology, advance online publication, 1-12. http://dx.doi.org/10.1037/pap0000155

Grande, T., Dilg, R., Jakobsen, T., Keller, W., Krawietz, B., Langer, M., Oberbracht, C., Stehle, S., Stennes, M., & Rudolf, G. (2009). Structural change as a predictor of long-term follow-up outcome. Psychotherapy Research, 19(3), 344-357. https://doi.org/10.1080/10503300902914147

Johansson, P., Høglend, P., Ulberg, R., Amlo, S., Marble, A., Bøgwald, K.-P., Sørbye, Ø., Sjaastad, M. C., & Heyerdahl, O. (2010). The mediating role of insight for long-term improvements in psychodynamic therapy. Journal of Consulting and Clinical Psychology, 78(3), 438-448. http://dx.doi.org/10.1037/a0019245

Kallestad, H., Valen, J., McCullough, L., Svartberg, M., Høglend, P., & Stiles, T. C. (2010). The relationship between insight gained during therapy and long-term outcome in short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Psychotherapy Research, 20(5), 526-534. https://doi.org/10.1080/10503307.2010.492807

Kandel, E. (1999). Biology and the future of psychoanalysis: New intellectural framework for psychiatry revisited. American Journal of Psychiatry, 156, 505-524.

Klug, G., Zimmermann, J., & Huber, D. (2016). Outcome trajectories and mediation in psychotherapeutic treatments of major depression. Journal of the American Psychoanalytic Association, 64(2), 307-343. https://doi.org/10.1177/0003065116644742

Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51(4), 467-481. http://dx.doi.org/10.1037/a0034332

Leichsenring, F., & Rabung, S. (2011). Long-term psychodynamic psychotherapy in complex mental disorders: Update of a meta-analysis. The British Journal of Psychiatry, 199, 15–22. https://doi.org/10.1192/bjp.bp.110.082776

Midgley, N., & Kennedy, E. (2011). Psychodynamic psychotherapy for children and adolescents: A critical review of the evidence base. Journal of Child Psychotherapy, 37(3), 232-260. http://dx.doi.org/10.1080/0075417X.2011.614738

Parker, B., & Turner, W. (2014). Psychoanalytic/psychodynamic psychotherapy for sexually abused children and adolescents: A systematic review. Research on Social Work Practice, 24(4), 389-399. https://doi.org/10.1177/1049731514525477

Rizeanu, S. (2016). Psychotherapy of borderline personality disorder. Romanian Journal of Experimental Applied Psychology, 7(3), 76-81. doi: 10.15303/rjeap.2016.v7i3.a7

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109. doi: 10.1037/a0018378,

Shepherd, C., & Beail, N. (2017). A systematic review of the effectiveness of psychoanalysis, psychoanalytic and psychodynamic psychotherapy with adults with intellectual and developmental disabilities: Progress and challenges. Psychoanalytic Psychotherapy, 31(1), 94-117. https://doi.org/10.1080/02668734.2017.1286610

Soares, M. C., Mondin, T. C., Silva, G. D. G. D., Barbosa, L. P., Molina, M. L., Jansen, K., Souza, L. D. M., & Silva, R. A. D. (2018). Comparison of clinical significance of cognitive-behavioral therapy and psychodynamic therapy for major depressive disorder: A randomized clinical trial. Journal of Nervous and Mental Disease, 206(9), 686-693.

Waldron, S., Gazzillo, F., Genova, F., & Lingiardi, V. (2013). Relational and classical elements in psychoanalyses: An empirical study with case illustrations. Psychoanalytic Psychology, 30(4), 567-600. Waldron, S., Gazzillo, F., & Stukenberg, K. (2015). Do the processes of psychoanalytic work lead to benefit? Studies by the APS Research Group and the Psychoanalytic Research Consortium. Psychoanalytic Inquiry, 35, 169-184. https://doi.org/10.1080/07351690.2015.987602

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Value of Psychoanalysis

Some of you have read my earlier blog, “Isn’t Psychoanalysis Dead?” I lamented that psychoanalytic theory is often excluded from discussions in psychology courses—at what I believe is a great loss to future clinicians’ ability to understand their clients/patients deeply. Well, I recently ran into another example of the value of psychoanalysis, of its omission from typical training, and of the limitations that excluding it from training may pose to successful treatment, even beyond psychotherapy.

I was recently talking with a young woman who is completing her doctorate in Physical Therapy. When she learned that I am a psychologist, she mentioned that she’d taken Abnormal Psychology to fulfill an undergraduate requirement and how interesting parts of the course had been. “Which parts had been most helpful?” I asked, trying to gain some pointers for my own upcoming class in Abnormal Psychology, which includes many exercise science majors. She noted that, while depression and anxiety can affect a person’s physical health, some things in the course hadn’t felt relevant–she felt the course had been too limited. And then SHE began lamenting that no one had ever even talked about Freud or the possible value of psychoanalysis or psychoanalytic psychotherapy. She added that her psychology instructor had said they would be skipping the chapter on psychoanalytic theory “because no one uses it anymore.” She continued, “sure, he developed his theory a century ago, and some aspects may make more sense than others, but wasn’t some of it still helpful to know? And what about all the new stuff now coming out in neuropsychology and neuro psychoanalysis? Aren’t psychology teachers aware of it?” One of her colleagues, who apparently had been introduced to some basics in psychoanalytic theory, commented that he’d actually recently seen a case of a Conversion Disorder, with physical symptoms without physical basis—“like with Anna O!” He noted the many possible connections between some physical symptoms and unconscious conflicts, and how helpful that notion had been to his work. Having many lenses through which to understand an individual’s experience is helpful to those in fields both inside and outside of psychology.

Eric Kandel, renowned neuroscientist, would agree with the enormous value of psychoanalysis. I know I’ve quoted Kandel before, but he’s a Nobel Laureate(!) and worth mentioning again. In 1999, he wrote, “…psychoanalysis enters the twenty-first century with its influence in decline. This decline is regrettable, since psychoanalysis still represents the most coherent and intellectually satisfying view of the mind” (1999, p. 505).

Writing about couples therapy, Judith Siegel, well-respected object relations couple therapist, has also noted that, “while object relations concepts provide a wealth of information regarding the ways family systems influence their offspring and the ways grown children revisit these influences as they select partners and engage in adult intimacy” (2010, p. 134), “today’s therapists enter training programs that do not uniformly include the psychoanalytic theories that were previously regarded as the cornerstone of therapy” (2010, p. 134).

How sad.

And it isn’t just recent courses in psychology. I too—several decades ago—had been taught that psychoanalytic theory had long since been “disproven.” (Just as I’d also been taught that the whole nature-nurture debate had been settled…) In a graduate psychology class, I’d even written a paper extolling the virtues of cognitive-behavioral approaches and arguing that psychoanalytic theory was a waste of time. And I believed it. Until I began to work with clients/patients for whom CBT was not enough…

Don’t get me wrong. I do believe that CBT can be helpful, as can humanistic approaches, Gestalt therapy, narrative therapy, mindfulness exercises, etc. etc. But therapy is not a “one size fits all” undertaking. The value of psychoanalysis is that it respect the “individualness” of the individual–it provides us with means to promote an awareness and understanding of the inner world and its influence over relationships in our patients. Psychoanalytic theory provides a valuable lens through which to understand the human condition and our patients’ suffering, and tools to help them build a meaningful life.

What was your introduction to psychoanalytic theory in your own undergraduate and/or graduate training? Was it dismissed for you as well? I’m wondering if this is primarily an American phenomenon, or if it’s world-wide and would love to get your input!

Please email me at mgersonphd@psychstudies.net regarding your experiences, and indicate whether I may share them in a future blog.

References

Kandel, E. R. (1999). Biology and the future of psychoanalysis. American Journal of Psychiatry, 156, 505-524.

Siegel, J. P. (2010). A good-enough therapy: An object relations approach. In Alan S. Gurman & ProQuest (Firm). Clinical casebook of couple therapy. New York, NY: Guilford Press.

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Psychoanalysis, Resilience, and Meaning-Making

Can psychoanalysis help build resilience? Psychoanalysis, resilience, and meaning-making may go hand-in-hand.

Resilience involves being able to do better than expected in the face of difficult circumstances. It requires inner strength. What factors may help promote such strength? Meaning-making—finding a sense of purpose and meaning in life—seems to be especially important.

Research has long pointed to the potentially important role that spirituality can play in building psychological well-being and resilience (e.g., Anum & Dasti, 2016; Fombuena et al., 2016; Foskett et al., 2004; Porter et al., 2017; Smith & Carlson, 1997). Studies have explored many aspects of spirituality—experiences of transcendence and awe that can come from sensing something greater than the self, feelings of connection with others, and the meaning-making involved in a personal search for purpose and meaning in life (intrapersonal spirituality). A recent study (Gerson, 2018) has found that intrapersonal spirituality—meaning-making—best predicts both resilience and life satisfaction, at least in early adulthood.

The study explored predictors of resilience and life satisfaction in over 400 undergraduates at two universities in the US. Measures included sense of purpose and meaning in life, spiritual connection to others, and feelings of spiritual transcendence, as well as a host of other variables. Contrary to many current studies which have focused on the importance of transcendent spirituality and social support, the study found that, at least in young adulthood, resilience is best predicted by more individual factors, including a personal sense of purpose and meaningful life. And the relationship between resilience and meaning-making is strong.

What implications may this finding have for psychoanalysis? We know that psychoanalysis seeks a deep understanding of the human psyche—rather than focusing merely on behavior change or symptom resolution, psychoanalysis explores deeper motivations and the potential sources of emotional turmoil. Psychoanalysis and intrapersonal spirituality share a common goal—that of meaning-making. Resilience requires stamina in the face of hardship. It makes sense that a mindset of seeking understanding and a meaningful life—and resilience—may be strengthened by the process of psychoanalysis. Psychoanalysis, resilience, and meaning-making may go hand-in-hand.

To learn more about psychoanalysis, see Classical Psychoanalytic Theory or other courses in psychoanalytic psychotherapy. You may find the brief article on Psychoanalysis and Mindfulness interesting as well.

References

Anum, J., & Dasti, R. (2016). Caregiver Burden, Spirituality, and Psychological Well-Being of Parents Having Children with Thalassemia. Journal of Religion and Health, 55, 941-955. doi: 10.1007/s10943-015-0127-1

Fombuena, M., Galiana, L., Barreto, P., Oliver, A., Pascual, A., & Soto-Rubio, A. (2016). Spirituality in Patients With Advanced Illness: The Role of Symptom Control, Resilience and Social Network. Journal of Health Psychology, 21(12), 2765–2774. doi: 10.1177/1359105315586213

Foskett, J., Marriott, J., & Wilson R. F. (2004). Mental Health, Religion and Spirituality: Attitudes, Experience and Expertise Among Mental Health Professionals and Religious Leaders in Somerset. Mental Health, Religion and Culture, 7, 5-22. https://doi.org/10.1080/13674670310001602490

Gerson, M. W. (2018). Spirituality, Social Support, Pride, and Contentment as Differential Predictors of Resilience and Life Satisfaction in Emerging Adulthood. Special Issue on Positive Psychology, Psychology.

Porter, K. E., Brennan-Ing, M., Burr, J. A., Dugan, E., & Karpiak, S. E. (2017). Stigma and Psychological Well-Being Among Older Adults with HIV: The Impact of Spirituality and Integrative Health Approaches. The Gerontologist, 57(2), 219-228. doi: 10.1093/geront/gnv128

Smith, C., & Carlson, B. E. (1997). Stress, Coping, and Resilience in Children and Youth. Social Service Review, 71(2), 231-256. doi: 0037-7961/97/7102-0004

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Psychoanalysis and Mindfulness

Psychoanalysis and mindfulness may seem to have little in common. They both involve the mind and are often focused on taming disturbing thoughts and feelings. But their methods seem to be completely at odds with each other. Or are they? Let’s take a look at mindfulness and see how it may be an excellent adjunct to psychoanalysis.

Mindfulness

Try, for a minute, to do nothing at all. Don’t talk or move around or think about anything. Just be. For a full minute. What happens? If you’re like most people, you’ll find this to be harder to do than it sounds. Your thoughts may wander. “What’s the purpose of this?” Thoughts or images of the past or future may emerge. “What do I need to do tomorrow?” “I wonder what he meant by that?” . . .

The mind easily gets lost in endless thinking. Thoughts create emotions and emotions generate more thoughts, and so on. This may be fine when these are positive and pleasant thoughts and emotions. But often they are not. And often they’re not about the immediate present. Instead, they’re likely to be about past upsets or future worries. You may lay awake at night because you worry about what might happen tomorrow. Maybe you can’t stop thinking about that mistake you made last week. You may constantly be busy with the things that need to be completed.

Mindfulness teaches how to bring more balance to this tendency, by focusing the attention on the here and now—attention to the things that are happening in this very moment, in a non-judgmental way. Thinking about and learning from past mistakes, planning for the future, and acknowledging sorrows and worries are all important. But people often get lost in thoughts about the past and future, to the detriment of experiencing life in the present.

Note that acceptance plays a key role in mindfulness. Mindfulness is not turning off the mind. Mindfulness does not restrict, deny, or inhibit thoughts or feelings. Instead, through mindful attention and acceptance, you allow every feeling, emotion, sensation, or thought to be there. Instead of fighting against them, mindfulness fosters willingness to acknowledge, allow, and accept these internal states.

By letting go of this struggle, you may come to realize that many thoughts, worries, and feelings fade away automatically, and probably sooner than if they’d been fought against. Emotions come and go and thoughts, worries, and feelings often fade away automatically if allowed to. By letting go of the struggle against them and giving them room to exist, unhappy thoughts and feelings can be experienced as temporary and less overwhelming.

Mindfulness helps you create a different relationship with your thoughts, feelings, and emotions. When you become an observer of your own inner states, you are no longer identified by them or completely lost in them. You can still experience the emotions or feelings, but now have the choice of being fully taken by them or not.

Psychoanalysis

What I’ve just described for mindfulness is actually similar to the stance of the psychoanalyst. Inviting you to say whatever comes to mind without censoring your associations. Helping you become aware of the thoughts, feelings, and patterns that arise. Helping you make sense of them without judgment, until they can be dealt with instead of battled against.

Mindfulness practices are helpful tools for bringing a person back to the present moment. By allowing thoughts and feelings to be present without judgment, a person may also become more aware of the internal states, of recurring patterns of thoughts and feelings, and of issues that seem repeatedly to cause distress. This self-awareness can be very helpful in therapy.

Resistances to meditation—boredom, distraction, sleepiness, etc.—are also common complaints in mindfulness practice. They can be useful signals that outside guidance—as in psychoanalysis—may be helpful in removing barriers to further insights. And yes, now we may need to delve into transferences from . . . the past . . . But only so that the person can be freed from the past.

Psychoanalysis and Mindfulness

This brings us back to the question of whether psychoanalysis and mindfulness have anything in common. The more experience I have with both as a clinician, the more excited I am about how they can be used together in practice, to facilitate a person’s self-understanding for a fruitful life in the present.

To learn more about psychoanalysis, see Classical Psychoanalytic Theory. To learn more about the theoretical foundations of mindfulness, see Mindfulness Meditation Training: Introduction, Attention, and the Present Moment, or for its applications, see Mindfulness Meditation Training: Body Scan Meditation and Informal Mindfulness Practices.

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Tips for Meditation Challenges

You know it’s good for you. Many studies have shown the benefits of including meditation in your life. But, whether you already meditate regularly or just wish you could, you’re probably aware of challenges to establishing it as a regular practice. You may feel bored, restless, or impatient. Or start to feel physically uncomfortable. Maybe you can’t reign your thoughts back from wandering to worries or to the sound of a dripping faucet. Meditation challenges can interfere with your progress. Here I’ll share some tips for meditation challenges.

There are many kinds of meditation. I’ll be focusing on mindfulness meditation here, as research shows its benefits go far beyond relaxation. With mindfulness, a person learns to focus attention on the present moment, without judging or evaluating thoughts or feelings (see Mindfulness Training: Introduction, Attention, and the Present Moment for a full discussion on mindfulness and its benefits).

Let’s look at three common problems for all kinds of meditation—boredom, restlessness, and impatience—and some suggestions for managing them.

Tips for Meditation Challenges #1: Boredom

Your mind starts to wander. “I’ve got so much to do…” “When will this be over…” Boredom may allow your thoughts to focus on the past—and ruminations about past disappointments—or on the future—and anxieties about what’s in store next. Or it may just disengage you from the present moment. How can you bring your mind back, fully engaged with the present?

First, be kind to yourself. Acknowledge the feelings—accept that they’ve occurred and let them be. Boredom is a common problem and an opportunity to practice refocusing on the present.

Become aware of the thoughts related to boredom. “What’s the point of doing this?”  “When will it be over?” “I can’t be bothered.” “This is a waste of time.” Allow them to be and then to pass on.

Attend to the sensations with curiosity. Where did the boredom come from? Where is it going? Where is it felt in the body? Where is it leading you—are you wanting to fall asleep?

Take a third party perspective and simply observe the boredom within you, as separate from yourself. You are not the boredom. It is simply an experience that will come and go. Do not judge it, just allow it to be.

Now, focus back on the breath, in the present moment. Observe your thoughts, feelings, and sensations as they come and go.

You are likely to find that feelings, thoughts, and sensations really do pass with time—this itself may be interesting. And it’s an important lesson to remember, next time you feel overwhelmed by any of them in other areas of your life.

Tips for Meditation Challenges #2: Restlessness

“I can’t stand laying here for one more minute…” Restlessness is similar to boredom, but with more energy. You may be feeling fidgety.

If you’re struggling with settling into meditating, begin with something more active. Mindful activities, in which you are fully focused on the present moment, can be beneficial in and of themselves. They may also help calm the mind and prepare it for meditation. You may wish to begin your meditation time with mindful walking or mindful yoga. Mindfulness Training: Body Scan Meditation and Informal Mindfulness Practices presents more ideas for informal mindfulness practices.

As with boredom, if restlessness occurs during meditation, observe your thoughts, feelings, and sensations, without reaction. Just notice what the mind wants but continue to sit or lay. This is an opportunity to discipline the mind. You are in control of your mind, not the other way around.

Tips for Meditation Challenges #3: Impatience

“Why am I not feeling better? I’ve been meditating every day for a week now!” Many beginning meditators expect to get immediate results from meditation. Meditation takes time, effort, and practice for results. It requires a great deal of patience.

The good news is that patience is something that can be built—it is strengthened with work and practice.

If impatience arises during meditation, simply observe the impatience without reacting. As with most feelings and thoughts, the impatience is likely to pass. Each time you are able to allow it to be, without reaction, you are building patience as a skill.

To reap its benefits, it’s important to schedule meditation into your daily routine and practice it for at least a month. If you’re ready to give up on it, ask yourself how long a period you could tolerate for now—15 minutes? 10 minutes? 5 minutes? Even if it’s only for 1 minute, start with that. Continue to practice it, as scheduled, gently increasing the time as you can.

With regular practice, you’ll notice your impatience lessening. And the patience you’re building is likely to translate to other areas of your life.

It’s Worth the Effort

The goal of mindfulness interventions is to teach participants to become aware of body sensations, thoughts, and emotions and to relate to them with an open, nonjudgmental attitude (e.g., Shapiro et al., 2005). Such an open state of mind can be cultivated by repeated practice.

Studies show that mindfulness meditation engages many underlying mechanisms, including regulating impulsivity and building self-control (e.g., Fetterman et al., 2010). It helps build skills that can translate into success in other areas of your life. Academic performance, interpersonal relationships, and life satisfaction have all been found to benefit from regular mindfulness exercises.

Every challenge to meditation presents an opportunity to strengthen your control over your mind. I hope some of these tips for meditation challenges are helpful to you.

Additional Resources

Mindfulness Training: Body Scan Meditation and Informal Mindfulness Practices provides more meditation tips as well as discussion and demonstrations on the body scan meditation and informal mindfulness practices.

See Facing Dreaded Projects (How to Make a Mole Hill Out of a Mountain) for more ideas on approaching tasks that seem insurmountable.

Learning about the theory behind mindfulness and research findings on its benefits may also be helpful—see Mindfulness Training: Introduction, Attention, and the Present Moment.

References

Fetterman, A. K., Robinson, M. D., Ode, S., et al. (2010). Neuroticism as a risk factor for behavioral dysregulation: A mindfulness mediation perspective. Journal of Social and Clinical Psychology, 29, 301-321.

Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. International Journal of Stress Management, 12, 164-176.

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Isn’t Psychoanalysis Dead?

Psychoanalysis

Isn’t psychoanalysis dead? I heard the question again just last week, this time from an undergraduate in my Abnormal Psychology class. I’ve heard it many times over the years, from colleagues and grad students as well. I had also been taught, all through college and throughout graduate training, that no one considered Freud’s work anymore. I suspect that most Americans have been taught the same.

I left my graduate training, armed with all the “best practices” in “empirically-based” primarily cognitive and behavioral techniques. I recall arguing with colleagues who mentioned psychoanalysis or psychodynamic approaches that research had not demonstrated their effectiveness. When one colleague commented that some patients had found them to be helpful, I privately wondered about his competence as a clinician.

Then I met Mary. She had been referred to me for depression. No problem, I thought. Lots of techniques had been demonstrated empirically to be effective in treating depression. When she asked if she could leave a cup in my office because medication had made her mouth dry, I had been trained to think only in terms of the practicality of having a cup available. But I quickly came to understand that such questions, and many others that followed, had far deeper significance—dependency needs, unconscious tests regarding acceptance, attempts to challenge boundaries, splitting. Her feelings—and relationship with me—were filled with turmoil. Idealizations swung to devaluations, and back again. She raged and despaired. She challenged all of my beliefs about the therapeutic process as manageable by the “right” charts and techniques.

I feel so fortunate to have met Mary early in my practice. To this day, I do believe that cognitive and behavioral techniques have merit, but I also see the enormous value of psychodynamic psychotherapy, as well as humanistic, emotion-focused, supportive, and countless other approaches. Humans are very complex creatures. Each therapeutic approach provides us with a lens through which to view a person. I believe we have a responsibility to become as familiar as we can with multiple ways of viewing each case, so that we can best address our patients’ needs in the moment, and as they evolve.

I was heartened to hear a comment from another student later in the week that she appreciated that I included psychoanalytic approaches when talking about treatment options with patients. Interestingly, she is a foreign exchange student from a region of the world where such approaches are generally understood to be of value.

Isn’t psychoanalysis dead? To quote Eric Kandel, neuroscientist and Nobel Laureate, “Psychoanalysis still represents the most coherent and intellectually satisfying view of the mind” (American Journal of Psychiatry, 1999).

Resources

For the basics of psychoanalytic theory, see the course Classical Psychoanalytic Theory. For more on the psychotherapeutic relationship, you may find Psychodynamics of the Therapeutic Relationship interesting.

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An Unforgettable Patient: The “Meerkat Boy”

An Unforgettable Patient

An unforgettable patient was a child I will refer to as the “Meerkat Boy.” He was only 4 ½ years old. His father had mentioned to his own therapist that the child had rarely (if ever) spoken, was reclusive, and was defecating in the corners of rooms. The therapist recommended that the child be evaluated. Hence, my first meeting with the boy.

The child entered my office alone, apparently uninterested in having his parents join him. His skittish movements reminded me of a Meerkat, on the lookout for danger but nevertheless engrossed in exploring his environment. He moved through the room quickly and with curiosity, gently opening and poking through drawers. What was he searching for?

Suddenly, he stood straight up and beamed a broad, excited smile. He had found a treasure! He swung around and motioned for me to sit down in a nearby chair, positioning me so my face was at his level. He was about to share his treasure with me! He held out a roll of transparent tape. What next? He gently approached me, but no longer with caution. He took my head and began to wrap it in the tape.

Should I stop him? Should I be using this as an educational opportunity to teach him about boundaries? Should I insist that he put into words what he was demonstrating in action? The next 10 minutes were painfully long as I wrestled with how to be most helpful to him. But we’d only just met… So I said nothing. And, with both care and determination, he wrapped my head until the entire roll of tape was gone.

With that, he stood back examining his work with pride, and pronounced, “I wish I could do that to Mommy!”

I soon came to know that he was not on the Autism Spectrum or struggling with intellectual developmental delays, as others outside his family had suspected. The boy was a bright and curious child, coping with extraordinarily odd and intellectually disabled, although well-meaning, parents. His parents, after all, had not recognized anything unusual about his lack of language and odd behaviors, but had willingly brought him for therapy when this was suggested by a professional.

In meeting with the child’s mother, I learned that she also had some unusual interests that challenged normal boundaries. (“I wish I could do this to Mommy!”—that is, containing her with tape.) Whenever a family member used the bathroom, she would call all others to view the “product” before flushing. She had also removed all bathroom doors, purportedly due to a fear that her son might drown if allowed to be alone in the bathroom. The child’s preference to defecate privately in the corners of rooms now made sense to me. When his need for some privacy was explained to her as developmentally appropriate, she willingly returned the doors and stopped calling for audiences. He responded positively.

With my encouragement, she also enrolled him in a nearby preschool. Teachers responded to his intelligence and curiosity, and he thrived. More clues to his concerns about boundaries came with his first “show and tell” at school. Children were to bring something from home to share with the class. The day before the event, the boy came bounding into my office, both excited and anxious, to show me what his mother had prepared for the event. He pulled a clear plastic bag from his pocket and laid it on the ottoman. The baggie revealed a multi-year supply of cotton swabs dripping in ear wax. He announced that his mother had been saving it from before he was born. I worked hard to maintain my composure (and breakfast) and agreed that this was indeed something the other kids might find really interesting. Knowing though that some children (and the teacher) might not respond positively, I wondered out loud whether he might want to take something a little less unusual for this first share. His body language showed great relief and he proceeded to explore my office for something he could take instead. He decided on some paper clips, which he linked together into a long chain.

I passed the change in plans on to his mother and, although confused that there could be potential controversy, she complied. The linked paper clips also appeared to gain special meaning for the child, as thereafter he would ask if he could take two for his pocket whenever there was to be a break between our sessions.

I have had the great fortune to work with this young man periodically through the years, as various issues have arisen for him. I’m so glad that I’d chosen to observe and listen. He will always be an unforgettable patient.

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Thumb Sucking: Orthodonture or Psychotherapy?

Thumb Sucking

Thumb sucking can become a heated issue for parents. “How can I get my child to stop sucking her thumb?” is a common question asked by parents. And there are so many “remedies” on the market to help achieve this goal—bitter nail solutions, thumb wraps, children’s books to coax a child away from the act, and parenting books with numerous strategies. I rarely hear the question, “Why is my child sucking her thumb?” As a psychologist, I wish we would start there.

Yes, I too have heard from pediatric dentists that constant thumb sucking may impact the teeth, jaws, or roof of the mouth. But I’ve also read sources (e.g., American Dental Association, 2016) that suggest that we shouldn’t be too worried for a young child. And, as noted by the American Dental Association (2016), excessive pressure to halt thumb-sucking can in fact do more harm than good.

Children can be seen sucking their thumbs even before birth in the womb. It is a natural way to self-soothe and relax, and may build a sense of comfort and security in times of stress. Some children gradually develop other modes of self-soothing by the time they reach 4 years of age, especially when they learn to express themselves and connect to others with words and other activities.

But children are not all built the same. Temperaments differ. Some children are born with more intense feelings that are harder to manage. And environments do not have the same impact on all children. Some children relish being surrounded by activity and sounds, while these can overwhelm others. Of course, an especially stressful environment can cause problems for a child, but even a normal level of stress may overwhelm the coping mechanisms of some children.

If a child is over 4 and still wishing to suck her thumb, rather than jumping to eliminate this potentially important source of comfort, I would encourage parents to consider the needs of their individual child.

• Is the thumb sucking merely a habit which is no longer important as a source of calming?
• Is there something they can modify in the child’s environment to reduce stress?
• Can they help her develop other coping strategies?
• Or should they allow the child to continue sucking the thumb until she is ready to move on?

In some cases, future orthodonture may be a more desirable alternative than years of psychotherapy as an adult.

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What a T-Shirt and Ticklish Gorilla Can Teach a Psychotherapist About Building a Life That’s True to the Self

Identity Development

I’ve learned much from both my favorite t-shirt and a ticklish gorilla about identity development, self-awareness, and building a life that’s likely to be fulfilling.

First, for the t-shirt. My favorite t-shirt has a little label sewn on it that says, “Do what you like, like what you do.” I’ve thought a lot about this. How is it that we can come to know what we’ll like to do? It’s a question that I believe is related to identity development and self-awareness—areas that I’ve long been interested in as a psychologist, psychotherapist, and college professor.

How can we come to know who we are and what we’ll like?

Can we think our way there? Can we read about options on the internet, consider our intellectual strengths and temperament, select a path, and live happily ever after? Or is there benefit to meandering along unplanned trails, getting dusty and sweaty, and feeling the warm sun on our face? Which approach will provide us with a more fulfilling journey as we proceed through life?

I spent the entire summer after graduating from high school, thinking about exactly what college would be like. I read about it, dreamed about it, and had long discussions about it with my dog Louis, until I thought I had it all planned out. I would be a French major and then go on to Law School. And I would establish a law practice in Paris. It all made perfect sense. I loved French poetry and had taken French since the 3^rd grade—something not uncommon on the east coast—and so was pretty good with the language. I was analytical. And I thought Paris was a beautiful city. And so, here I am, today, a lawyer in Paris… My point is that I really had no idea what would be in store for me over the next few years.

So, I began my first year in college as a language major. The only field I’d ruled out was psychology—I thought that psychologists must be, by and large, strange people and kind of scary. But then, one day as I was stumbling through the halls on my way to a class, a psychology professor stopped me and asked if I’d like to run a study with him. What kind of study could one run in psychology anyway, I thought? Fortunately, I said, “Sure,” thinking of it as an opportunity to try something strange—strange, like eating chocolate-covered ants might be strange. But he soon had me researching in the library, constructing questionnaires, running all across campus to collect participants, learning about stats so I could analyze the findings… If I’d stopped and reflected on what he’d have me doing before I jumped in, I never would have said yes. I never would have considered psychology—a field that I’ve now been very happily working in for most of my life—if a professor hadn’t encouraged me to “try it on.”

Now for the ticklish gorilla. A delightful article by Bering (2010) was published in Scientific American several years ago. It was about evidence that animals have a sense of humor. I’d like to share this excerpt from the article:

When I was 20, and he was 27, I spent much of the summer of 1996 with my toothless friend King (a 450-pound Western Lowland gorilla, with calcified gums), listening to Frank Sinatra…, playing chase from one side of his exhibit to the other, and tickling his toes. He’d lean back…, stick out one huge ashen grey foot through the bars of his cage and leave it dangling there in anticipation, erupting in shoulder-heaving guttural “laughter” as I’d grab hold of one of his toes and gently give it a palpable squeeze. He almost couldn’t control himself when, one day, I leaned down to act as though I was going to bite on that plump digit. If you’ve never seen a gorilla in a fit of laughter, I’d recommend searching out such a sight before you pass from this world. (para. 2)

Now, a lot has been written in the field of psychology about identity development. And, with the help of neuroscience, a helpful distinction is starting to be made between identity and self, putting words to elements that are related but actually quite distinct (Gerson, 2014). Identity refers to a self-reflective third-person understanding of oneself, whereas self is a more primitive and core first-person sense or experience of oneself. Early on, we move from a purely personal experience as and become more reflective, as we become socialized and develop language (Gerson, 2014). We no longer merely experience with our senses, as we develop tools to reflect on and think about our experiences. We become our own observers. This development represents identity (me), as opposed to self, which involves our personal experience as an I. Our gorilla friend probably experienced more self-ness than clarity about his identity—but that’s for ethologists to verify. Human adults, on the other hand, often lose touch with their basic self.

If I asked you who you are, I might get a variety of answers. You might say “an adult,” “a generous person,” “a teacher,” “a psychotherapist,” and so on. These would tell me a little bit about your identity—descriptions that derive from observations of or reflections about yourself. But, now take a moment, and think back to your earliest remembered experiences. Try to experience what it felt like being you at the time, not as an observer, but as a participant. Did you feel excited, timid, curious? Now, you could probably tell me something about your self. Probably something our gorilla friend was acutely aware of during the play experience.

My experiences with my psychology professor had transformed both elements. They had changed not only how I thought about who I was, but also how I experienced my self, in the first person—I. And redirected me down a path that has allowed me to build a life doing what I really love.

Erikson (1959) (who did not distinguish in his writings between self and identity) wrote about the value of moratoria in identity development. I believe first-hand experiences are important for becoming aware of the paths that will be consistent with the self and lead to an optimally satisfying life.

References

Bering, J. (August, 2010). Laughing rats and ticklish gorillas: Joy and mirth in humans and other animals. Scientific American. https://blogs.scientificamerican.com/bering-in-mind/laughing-rats-and-ticklish-gorillas-joy-and-mirth-in-humans-and-other-animals/

Erikson, E. H. (1959). Identity and the life cycle: Selected papers. Psychological Issues, 1, 1-171.

Gerson, M. J. (2014). Reconsidering self and identity through a dialogue between neuroscience and psychoanalytic theory. Psychoanalytic Dialogues, 24(2).

Blog

All posts by Marylie W. Gerson, PhD

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Tips for Meditation Challenges

Tips for Meditation Challenges

Tips for Meditation Challenges #1: Boredom

Tips for Meditation Challenges #2: Restlessness