Bulletin of the Psychoanalytic Research Society, Volume III, Number 1, Spring, 1994
Several years after we published our comprehensive analysis of the empirical evidence on Freud's ideas (Fisher & Greenberg, 1985), we became intrigued with the notion of doing a similar critical examination of the biological treatment of psychological problems. Our curiosity resulted in a book (The limits of biological treatments for psychological distress; Erlbaum, 1989). A close look at the literature confirmed our suspicion that there are a lot more similarities in the issues faced by psychoanalytic and biological researchers than either practitioners or the public may be aware of (see Fisher & Greenberg, 1989). In this brief article we would like to highlight a few of these parallels.
Interestingly, most devotees of psychoanalysis-both those who defensively shun the need to look at empirical evidence and those who embrace social science research findings-seem to have the uneasy feeling that biological treatments are based on "hard science", and therefore must be grounded on a firmer base than approaches rooted in the "softer" social sciences. The mention of drugs conjures up images of chemistry, test tubes, equations, and a treatment specificity that may be envied by many psychoanalytic practitioners. Forgotten is the fact that while biological treatments may be delivered with exact measurements of dosage levels and chemical composition, outcome (as with psychotherapeutic treatments) is still measured in terms of judgments about feelings and behaviors. Also forgotten are experimental analyses suggesting that the physical sciences do not necessarily show greater precision or reliability in research findings than do the social sciences (Hedges, 1987).
In a classic paper, Kiesler (1966) called attention to several myths in psychotherapy research. Among them was the "therapist uniformity assumption", wherein all analysts are grouped together in a research design with the assumption that their therapeutic behaviors (and outcomes) are more alike than different. Our exposition of the psychoanalytic research literature (Fisher & Greenberg, 1985) showed that analysts are a very diverse group who rarely display consensus about anything. Surprisingly, a look at the medication literature also shows unreliability in that the same drugs given to similarly defined patient groups frequently do not produce equivalent results. A host of multi-center studies document the fact that no matter what the treatment, some centers produce consistently better results than do others (Fisher & Greenberg, 1989; Greenberg & Fisher, 1989). Clearly there are nonspecific factors at work in drug treatments just as there are in psychotherapy treatments.
Over the years, psychotherapists (including Freud) have been rightfully criticized for trying to pass off their global judgments about case histories as objective evidence for the benefits of treatment. Critics have reasonably argued that those doing the treatment cannot be expected to render ratings of outcome that are unaffected by their vested interests in the success of treatment. Rarely are similar critiques aimed at the hundreds of published open-label drug studies where outcome is measured by clinician "global rating scales".
Of course, biological treatment advocates would point to the fact that many drug studies are conducted under double-blind conditions (where neither clinician nor patient is supposed to know who is receiving the drug and who is receiving the placebo), and would conclude that this protects biological research from accusations of bias. Although it is true that lack of blindness is a major problem for the psychotherapy researcher, our findings have raised serious questions about whether double-blind drug research is actually blind (Fisher & Greenberg, 1989; Greenberg & Fisher, 1989; Greenberg, Bornstein, Greenberg & Fisher, 1992). Recently, we reviewed every investigation we could find which addressed the issue of whether participants in double-blind drug trials are really unaware of whether they are receiving a drug or a placebo (Fisher & Greenberg, 1993). Twenty of the 23 studies we found produced evidence that both clinicians and patients knew well beyond chance whether real drugs or placebos were being administered. Thus, just like the analyst, the drug researcher can justifiably be accused of producing tainted data.
Another concept that offers possibilities for comparisons between biological and psychoanalytic treatment approaches is symptom substitution. Over the years there has been considerable debate about the degree to which substitute symptoms appear when patients are treated psychoanalytically or behaviorally. Although research evidence has indicated that this is less of a problem than first suspected, evidence does exist that shows certain conditions may foster the emergence of substitute symptoms (Fisher & Greenberg, 1985). It has been amusing to us to realize that psychotropic drug treatments produce far more new symptoms with greater frequency than ever envisioned by psychotherapists of any stripe. However, this fact is nicely obscured by labeling the new symptoms "side effects". This terminology downplays the importance of the new emerging symptoms and connotes the impression that they are tangential to the person experiencing them. Yet a review of the empirical evidence (Dewan & Koss, 1989) indicates that these treatment-induced symptoms can range from the superficial to the terminal, may occur in up to 100% of patients, and are more likely to be created by drug treatment than are therapeutic effects. It is ironic, in view of the evidence, how much more exercised psychotherapists are about the possible production of unwanted symptoms than pharmacologically-oriented clinicians seem to be.
One of the overriding challenges to the psychoanalytic structure is that the personality theory and the therapy with which it is supposedly intertwined are not directly linked. In opposition to Freud's position, both researchers and philosophers have argued that therapeutic successes cannot be used as evidence for the validity of the psychoanalytic theory of personality (Fisher & Greenberg, 1985; Grunbaum, 1984). There are simply too many other ways to account for outcome. A similar discontinuity between theories of psychopathology and treatment hangs over those espousing biochemical solutions. Reviewers of the biological research literature have also come to the conclusion that the potential success of medication treatments says nothing about the correctness of a biological etiology for psychiatric disorders. Indeed, scientific studies have failed to identify any consistent biochemical basis for schizophrenia, or for any of the affective or anxiety disorders (Breggin, 1991; Fowles, 1992; Nasrillah & Weinberger, 1986). Objective evidence for "biochemical imbalances" has proven to be just as illusory as the quest for documentation of libido theory.
Overall, our reviews indicate that beneath the surface differences there are many ways in which orthodox adherents to psychoanalysis and psychobiology are following similar paths and utilizing similar defenses regarding disconfirming evidence. For example, claiming that the patient groups studied are not diagnostically pure enough or that treatments must be continued for longer and longer periods of time has become increasingly common for both groups. Our hope is that our work will lead others to be more questioning in their search for substance and thereby raise the level of the research being done. Perhaps, too, it would be reassuring for analytic researchers to know that they have not cornered the market on uncertainty and that the fruits of their labors may not be softer than those of their biochemical brethren.