Canadian
Psychiatric Association
Editorial
Contemporary Psychiatry, Psychoanalysis,
and Psychotherapy
Paula Ravitz, MD1
Keywords
psychiatry, psychoanalysis, psychotherapy
In his Perspective, “Is Psychoanalysis Still Relevant to
Psychiatry?” Paris1 presents a critical perspective on psycho-
analysis in the context of evidence-based care. Scientific
discourse demands critical dialogue, and so in this editorial,
I provide alternative perspectives on some of Paris’s argu-
ments and further thoughts on psychoanalytic training,
research, and treatment. My concern is that by unnecessarily
pitting psychiatry against psychoanalysis, we may throw out
the baby with the bathwater.
Psychoanalysis provided the modern origin of the talking
therapies. From its beginning with the works of Freud, it has
evolved to incorporate intersubjectivist etiological formula-
tions of pathology, suffering, and healing.2 Leuzinger-
Bohleber, editor of a recent comprehensive review of psy-
choanalytic research, comments that “not only a plurality of
theories has been developed but also a plurality of research
procedures, which is an indicator for any mature scientific
discipline” (p. VIII).3 Paris1 points out how the principles of
psychoanalysis and its derivative, psychodynamic psy-
chotherapy, have progressed to incorporate infant research
and to reconcile themselves with neurobiology. Beyond
those influences, current psychoanalytic thought is informed
by theory of mind, feminist theory, queer theory, sociology,
cognitive psychology, nonlinear dynamics, evolutionary
biology, political science, anthropology, Buddhism, evolu-
tionary psychology, and ethology. Many aspects of this rich
interdisciplinary landscape of influences lie outside the
domain of science and its standards of evidence, but not all.
Indeed, there is no doubt about the strength of evidence
supporting various modalities of psychotherapy as treatment
or their place in psychiatry. Canadian position papers and
working group papers on psychotherapy published over the
past 4 decades highlight that psychotherapy treatments are
integral, core components of psychiatric practice.4-6 In these
position papers, psychoanalysis is not separately discussed;
however, as Paris1 notes, the founding authors of numerous
theories of psychopathology (e.g., Bowlby, Beck, Fonagy,
and Bateman) from which psychotherapy treatments have
been developed acknowledge their indebtedness to
Association des psychiatres
du Canada
The Canadian Journal of Psychiatry /
La Revue Canadienne de Psychiatrie
2017, Vol. 62(5) 304-307
ª The Author(s) 2017
Reprints and permission:
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DOI: 10.1177/0706743717704762
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psychoanalytic ideas. The most recent Canadian Psychiatric
Association (CPA) position paper on psychotherapy in psy-
chiatry underscores “the unique contributions psychiatrists
can make when they are able to integrate psychological and
biological approaches within a treatment plan 6 .” Psy-
chotherapies are recommended as effective treatments for
many psychiatric disorders, with a strong evidentiary base
of support, whether used alone, sequenced with pharmaco-
logical treatments, or combined with medication. They are
thus included in international consensus treatment
guidelines.7-11 In the recently updated Canadian Network for
Mood and Anxiety Treatments (CanMAT) depression guide-
lines, cognitive behavioural therapy and interpersonal psy-
chotherapy are first-line treatments, and psychodynamic
psychotherapy is a second-line recommended treatment.8
Meta-analyses and systematic reviews of psychodynamic
and psychoanalytic psychotherapy research that include
controlled trials have established empiric, evidence-based
support, especially for short-term psychodynamic
psychotherapy.3,12 Further evidence from randomised con-
trolled trials (RCTs), while fraught with challenges, is indeed
needed given the high intensity and high costs of psychoana-
lytic treatment and in light of public health needs to improve
access to mental health care.13 It is true that one of the hazards
of the “mature science” that has produced multiple psycho-
dynamic and psychoanalytic approaches is that it is difficult
to make comparisons and to generalise findings to practice. It
is reassuring, however, that the effect sizes of psychothera-
pies in general are equivalent to and sometimes greater
than pharmacotherapy treatments, with superior results in
1
Department of Psychiatry, Mt. Sinai Hospital, University of Toronto,
Toronto, Ontario
Corresponding Author:
Paula Ravitz, MD, Department of Psychiatry, Mt. Sinai Hospital 600,
Toronto, ON M5G 1X5, Canada.
Email: Paula.ravitz@sinaihealthsystem.ca
La Revue Canadienne de Psychiatrie 62(5)
long-term follow-up for some conditions, especially anxiety
disorders.8,14-22
As Paris1 points out, psychoanalysis uses intensive indi-
vidual single cases for training and exposition of clinical
techniques. Case reports do not test hypotheses, but neither
are they intended to. Their value is substantial but is intended
to support case-based education, the development of theory,
and qualitative research. Case reports with close examina-
tion of the details of individual patients’ stories form a core
of analytic training and discourse, grounding clinical obser-
vations within theories. It is a method that has been valuable
enough to be retained in psychiatry23 and other forms of
psychotherapy training.24-26
Of course, sources of evidence are not confined to RCTs
and cases. Experimental studies integrate anatomical,
genetic, and neurophysiological observations to elucidate
the roles of interpersonal and mental processes in pathologi-
cal functioning,27-34 and process research examines modera-
tors and mediators of outcome. An epistemic framework for
research that integrates advances in psychoanalysis, psy-
chotherapy, neurobiology, and psychology using multiple
methods is compatible with 21st-century research agendas.3,35
This research need not be seen as an “attempt to rescue psy-
choanalysis” but merely as the natural progress of discovery
that has always been a driving force in science.
Attachment and other theories used in formulation need
not be seen as “another theory to blame parents” but rather as
useful paradigms to understand early life adaptation and
current difficulties such as affect regulation or maladaptive
adult patterns of relating. Contemporary attachment theorists
and developmental psychologists are taking into account
temperament, early life experiences, social environments,
and epigenetics in the etiology and treatment of psychiatric
problems.36-38 With respect to the consideration of allopar-
enting, the very first question of the gold standard of asses-
sing adult attachment, the Adult Attachment Interview, is
“who raised you?” assuming that early life primary care
providers are biological or adoptive parents, but this can also
be interpreted more broadly.39 Every argument can be under-
mined by cherry-picking.
Paris1 raises questions about the role of psychoanalysis in
psychiatry, which are similarly important for many kinds of
medical therapeutics. Insufficient numbers of RCTs, publi-
cation bias, training requirements, nonstandardised applica-
tions of guidelines, and the high-intensity, costly treatments
require scrutiny.
Psychiatry residency training does not prepare psychia-
trists to practice psychoanalysis; however, its theories are
taught—theories that have evolved over time to inform con-
temporary psychodynamic psychotherapy practices and
remain core aspects of various time-limited psychotherapy
models. These dynamically informed constructs include the
importance of the therapeutic alliance, the establishment of
shared goals, and the need to actively listen to our patients
with empathy and attentive presence. Some key concepts of
psychoanalysis have endured and form the basis of
305
psychodynamic psychotherapy: some of mental life is
unconscious; past experiences influence our present ones;
trauma and neglect are sources of pathology; transference
to the therapist and others is a primary source of data for
understanding; countertransference can provide information
about the patient’s impact upon others; unpleasant or threa-
tening thoughts, memories, feelings, desires, or perceptions
are sometimes kept out of awareness, resulting in difficul-
ties, symptoms, and problematic behaviours; and psycho-
pathology is determined by the interaction of complex
biological and psychological forces. We can retain the fruits
of the psychoanalytic thought without retaining the historical
methods of psychoanalysts, but psychiatry would be much
poorer without these insights.
Although there are fewer controlled studies of psycho-
analytic treatment, there is in fact evidence for the efficacy
of both short- and long-term psychodynamic psychotherapy
(LTPP).12 Leichsenring and Rabung’s systematic review40
of 23 studies conducted between 1984 and 2008 identified 11
prospective RCTs and 12 observational studies of >1000
patients receiving LTPP in which there was a large within-
group effect size of 0.96 (95% confidence interval, 0.87-
1.05) for pre- to posttreatment overall outcomes, and for the
8 studies that included a comparison group, the overall
between-group effect size was even larger at 1.8 (95% CI,
0.70-3.4). There is no question that more research is needed
and that the plurarity of analytic models along with the fea-
sibility challenges of studying long-term models makes this
difficult. Although dismantling studies have been suggested,
it may be that the unique combination of elements in affect-
focused psychotherapies accounts for their effectiveness.41
Psychiatrists in particular need to possess both knowledge
and skills in evidence-supported psychotherapies, including
psychodynamics, to act as medical experts, consultants,
stewards of clinical service teams, shared care collaborators,
and trainers of future generations of mental health profes-
sionals. Psychotherapy expertise enhances the psychiatrist’s
capacity to use a biopsychosocial formulation to guide
assessment and treatment decisions, form and sustain ther-
apeutic alliances, motivate patients to engage in treatment
and health-promoting behaviours, and ethically manage the
complicated dynamics of clinician-patient relationships.42
The next decade will no doubt generate innovations to
further improve psychotherapy’s effectiveness and access
for individuals with mental illness. Our prime minister, Jus-
tin Trudeau, and national health minister, the Honourable
Jane Philpot, along with many of the provincial ministries
of health are to be commended for their increased support of
mental health access that includes psychological treatments.
Psychotherapy treatments can effectively address suffering
and enhance outcomes and the quality of care of mental
illnesses across a spectrum of health care settings. As
evidence-based practitioners and psychiatrists, we must use
what is best for our patients and be trained in a broad range
of effective treatments, including psychotherapies and psy-
choanalytic principles. Based on 40 years of outcome and
306
process research, it is clear that psychotherapy treatments are
helpful for patients with psychiatric disorders and therefore a
critical component to be preserved in the training and prac-
tice of psychiatrists of the 21st century.
Acknowledgements
I thank my colleagues who provided multiple perspectives on these
issues, especially Robert Maunder, Rex Kay, Allan Peterkin, Chris-
tine Dunbar, and Molyn Leszcz.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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