Existential and experimental psychotherapies

  Several schools of psychotherapy have evolved which utilize the techniques of psychodynamic psychotherapy without accepting the theory. Existential psychotherapy, as its name suggests, makes no assumptions about what people ‘should be like’ but focuses on helping the patient express their identity in their own chosen way. Existential psychotherapies have some affinity with Jungian approaches and have become more popular as society becomes less rigid and conformist.

  Freud’s patients usually knew what their families and society expected of them and were anguished because they could not achieve it. In the early 21st century we are more likely to experience aimlessness and emptiness rather than guilt at not living up to expectations. Alienation and confusion are now the dominant complaints so psychotherapies have become more structured to provide boundaries and containment.

  These more here-and-now therapies blend imperceptibly into the personal growth movement. It can be difficult sometimes to decide whether a gestalt therapy or encounter group is a treatment to reduce suffering or an exercise to increase personal happiness and fulfilment. Perhaps it doesn’t matter what the purpose is so much as who gets it. There can be little doubt that depressed and demoralized psychiatric patients benefit greatly from activities such as these which improve general morale and self-esteem. In the treatments of self-harming young women, addressing self-esteem directly may be one of the most effective interventions.

  Psychodynamic psychotherapies are currently under attack in psychiatry. They are criticized for inadequate research to establish that they really do work. Also, the requirement for therapists to undergo treatment themselves and to continue with supervision throughout their professional lives compromises objectivity and smacks of a ‘cult’ rather than a profession. Some research has been conducted in the short-term dynamic therapies and their results are generally good. However, more detailed studies to identify which aspects are effective, and which redundant, remain to be done. The opportunity may even have passed. So many of the core features of psychodynamic psychotherapy are now absorbed into routine care (the Type A and B treatments referred to above) that their contribution as specific treatments may be difficult to isolate and evaluate.

  The strength of criticism is not surprising as psychoanalysis really did oversell itself. In America (North and South) between 1940 and 1970 it virtually drove all other thinking out of mental health care – most people thought that a psychiatrist was a psychoanalyst. Psychotic patients, for whom analysis had little to offer, were neglected, as were the basic skills of diagnosis and treatment. Critics accused American psychiatry in this period, with its high status and expanding workforce, of simply turning its back on the severely mentally ill and on science altogether. President Kennedy tried to refocus the profession in the early 1960s but without success and it required the pharmacological revolution to achieve it.

  A more scientific and self-critical psychiatry, obliged to establish itself with hard won research data, has taken its revenge on psychoanalysis (and some would say is now making many of the same mistakes – Chapter 6).