Off the couch and into the lab
As the use of Freudian therapy wanes, scientists study a basic question: Does it work?
The patient bemoans the girlfriend he dumped because he couldn't let her get too close. He berates himself as a loser who purposely fails in order to show his parents how badly they messed him up.
The therapist listens closely, humming "uh-huhs," and sometimes asks a question or makes a probing point. In a conference room at Massachusetts General Hospital, researchers watch the therapy session on video intently and score it using a set of 100 numerical ratings.
Did the therapist draw attention to uncomfortable emotions such as guilt or anger? Yes, a 9 out of a possible 9. Did the patient gain new insight? Not in today's session - a 2 on the 9-point scale.
Painstaking work like theirs, translating complex human interactions into hard data points, may be the last, best hope for saving what remains of Sigmund Freud - by showing that the style of deep, prolonged talk therapy he originated can work.
Freudian therapy rose early in the 20th century and reigned supreme for decades, dominating American psychiatry and permeating popular thinking with concepts like ego, repression, and the Oedipal complex. Psychoanalysts often developed years-long relationships with patients, delving into childhood memories, dreams, and hidden desires.
More recently, however, Freud's ideas have lost favor, and his style of therapy has fallen on hard times, victim of cost-conscious insurers and a focus on mental illness as biological brain disease. This decline has only been accelerated by many practitioners' insistence that what goes on between a therapist and a patient is too individual to lend itself to scientific research.
Left largely without studies demonstrating its positive effects, long-term talk therapy has been hard-put to justify itself to insurers, patients, and grant-givers. Treatment has shifted to drugs and quicker types of therapy with more evidence to back them up. They include cognitive behavioral therapy, which aims to change thinking and behavior in the here and now, and often lasts just a few weeks.
Of 650,000 therapists in the country, probably fewer than 200 make their living practicing traditional psychoanalysis, estimated Jonathan Engel, author of the new book, "American Therapy: The Rise of Therapy in the United States."
At Mass. General and elsewhere, researchers are ramping up a fight for long-term psychotherapy's survival, producing research that shows it helps some patients, and casts some light on how. One apparent finding: Just as the therapy lasts longer, it appears that its beneficial effects may often last longer.
The research efforts stem from the fear among practitioners that "we need to establish a new evidence base and we’d better do it soon," said Raymond Levy, clinical director of the hospital's Psychotherapy Research Program.
In October, a review in the Journal of the American Medical Association supported longterm "psychodynamic psychotherapy" for patients with complex mental disorders. The review of 23 studies reported that in a pool of more than 1,000 patients, long-term psycho-dynamic therapy - lasting at least a year, or 50 sessions - was significantly more effective at relieving symptoms than shorter-term therapy.
Similarly, in March, the American Journal of Psychiatry published a study of 41 patients with borderline personality disorder, a condition in which intense spates of neediness may bring on anger or despair.
Those who went through 18 months of intensive psycho-dynamic therapy and continued with 18 months of weekly group therapy were doing better, five years after treatment ended. They tended to be hospitalized less often, were less likely to be suicidal, needed fewer psychiatric drugs, and tended to function better in life and work.
It stands to reason that long, intense therapy can have lasting effects, said J. Stuart Ablon, director of Mass. General's Psychotherapy Research Program and, with Levy, co-editor of a new book, "Handbook of Evidence-Based Psychodynamic Psychotherapy."
"When you improve as a result of an understanding of why you were experiencing symptoms, you gain a much better sense of internal control that has obvious implications for your well-being going forward," Ablon said.
Quicker therapy or drugs may alleviate symptoms, he said, but if you do not understand The symptoms’ meaning, "they'll come back to bite you some other way."
The Mass. General team belongs to a growing international cadre.
A listserv, or online discussion group, for people interested in empirical research on psycho-dynamic therapy has grown since it was founded in 2004 to more than 400 members, said Mark Hilsenroth of Adelphi University, one of its moderators.
Participants include psychiatrists, psychologists, social workers, even neurologists.
What effect is all this having? Perhaps little on insurers' unwillingness to pay for most longterm therapy, researchers say. That may change, however, "as evidence accrues," Hilsenroth predicted.
But the research helps the myriad therapists who, though they are not psychoanalysts, incorporate some of Freud's ideas in their work, Hilsenroth said.
"It's saying that some of these things that we've been thinking for a while have some basis to them," he said.
And some might not. The research also aims to determine which practices in therapy help, and which apparently do not.
Michael W. Otto, director of Boston University's Center for Anxiety and Related Disorders and not a Freud fan, sees value in the research, even as he believes that short-term therapy can be more cost-effective and bring a patient relief more rapidly.
But Freudian therapy has so desperately needed scrutiny for so long that he heartily applauds the current research and its potential to help patients, though he worries that researchers are sometimes overenthusiastic about their findings.
"It's time to let research thrive and let Freud rest in peace," he said.
Carey Goldberg can be reached at goldberg@globe.com. 