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NATIONAL HEALTH INSURANCE BILL, 2018

COMMENT BY

Life Esidimeni Expert Witness Team for the Alternative

Dispute Resolution (ADR) Process (2018)

with Justice Dikgang Moseneke

Compiled by Coralie Trotter with the assistance of a research team including Kelly Bild,

Raine Cohen, Vossie Goosen, Dr Karen Gubb, Deborah Hattingh, Hasmita Hardudh-Dass, Dr

Megan Jones, Batetshi Matenge, Bruce Laing, Lynn Symon and Dr Clinton van der Walt

Preamble

We thank the Minister of Health, Dr Aaron Motsoaledi, and the National Department of

Health (NDoH) for the opportunity to comment on the National Health Insurance (NHI) Bill,

2018. As mental health professionals and clinicians we are well aware that both the public

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and private healthcare sectors face significant challenges and that reform is long overdue.

We therefore welcome the Bill and its intention to reorganise the South African health

system in order to achieve equal access to quality care for all South Africans regardless of

race, socioeconomic status or type of illness, impairment or disability. Our comments are in

the interests of a health system which will serve the population of South Africa and improve

the health and mental health of all. We support a Bill that includes promotive, preventative,

curative, rehabilitative and palliative services and that addresses the marginalisation of

mental health. We also believe that any proposal which seeks a radical overhaul of the

health system should be carefully considered and empirically researched prior to

implementation as it is critical to establish a solid and viable foundation at the outset. We

certainly support universal health coverage (UHC) but it is submitted that the Bill in its

present form will not achieve its stated objectives. The Bill fails to address the dysfunction

and deficiencies of the current public system regarding corruption, mismanagement,

operational anarchy and lack of regard for the patient. The concern regarding this is that the

failure to acknowledge problems in the current system and learn from experience will result

in those problems being repeated going forward on a larger scale. We would like to

contribute positively to the debate by critically examining the Bill in relation to mental

health in an attempt to ensure that it provides a realistic and viable path to UHC. Although

we see significant problems with issues of funding and administrative costs we will restrict

ourselves to commenting specifically on issues related to the provision of mental health

services as this is our Scope of Practice.

The NHI Bill: Appropriate and Required Range of Personal Health Care Services

Section 38 of the NHI Bill refers to the accreditation of both public and private service

providers by the fund. Such providers, it is stated in 38(1), must deliver health service

benefits at the appropriate level of care and meet the needs of users and ensure service

provider compliance with specific criteria, including 38(2)(b)(i) provision of the minimum

required range of personal health care services specified by the Minster in consultation with

the Fund and published in the Government Gazette from time to time as required. In

38(2)(iii) adherence to treatment protocols and guidelines is mentioned. These terms are

not defined in the Bill.

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It is the purpose of this section to address the vague and potentially prescriptive nature of

these clauses regarding appropriate and required services without a comprehensive process

of consultation with service providers, in this case the group of psychoanalytically

orientated practitioners in South Africa. The concern is that psychoanalytic psychotherapies

may be unduly prejudiced in this climate and that this is not in the best interests of South

Africans. We would, therefore, like to enter the debate and dialogue from the beginning and

provide the necessary information so that it can be considered going forward in terms of

treatment guidelines and protocols. We also want to use this opportunity to invite further

engagement round the important but highly condensed issues contained in this submission.

Research and Psychoanalysis

We believe that as psychoanalytic practitioners we have a social responsibility to inform the

Minister of Health regarding the effectiveness of analytic work so that we do not run the

risk of being discarded by the mental health delivery systems. Psychoanalytic psychotherapy

has endured a storm of criticism historically. Detractors have argued that it lacks scientific

credibility and health care policy makers often assume that its evidence base is weak and

patchy without regard for the facts. It remains our responsibility to ensure that such

evidence is fairly and openly communicated to policy makers so that psychoanalytic

psychotherapies retain a legitimate place within the choice of evidence-based treatments

available for our patients. Psychoanalytic psychotherapy, in fact, has a strong and expanding

evidence base: there are now a significant number of respectable, well-designed studies

which demonstrate the efficacy of psychoanalytic psychotherapy. This research is

objectively strong and indicates that psychoanalytic therapy has a significant positive long-

term effect on patients. Seventy eight references dating from the year 2000 are included as

part of this submission. In addition, a presentation made by Prof Mark Solms on the

scientific basis of psychoanalysis is appended. Prof Solms is the chair of the Research

Committee for the International Psychoanalytic Association (IPA).

A brief summary of the research findings follows. Shedler (2010) found that empirical

evidence supports the efficacy of psychodynamic therapy and that the benefits are at least

as large as those of therapies promoted as 'empirically supported' and 'evidence based'.

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Again and again Shedler (2010, 2018) has argued that the starkest differences between

Cognitive behaviour Therapy (CBT) and psychoanalytic psychotherapies emerge some time

after therapy has finished. Ask how people are doing as soon as their treatment ends and

CBT looks convincing. But months or years later the benefits have often faded while the

effects of psychoanalytic therapies remain or have even increased. This suggests that such

therapies may restructure the personality in a lasting way. In short, patients who receive

psychodynamic therapy maintain therapeutic gains and appear to continue to improve after

treatment ends.

Finally, non-psychoanalytic therapies may be effective in part because the more skilled

practitioners utilise techniques that have long been central to psychodynamic theory and

practice. It is not unusual for therapists to incorporate processes and techniques not

associated with their treatment modality into practice. Studies examining transcripts or

recordings of therapy sessions suggest that psychoanalytic techniques and processes are

commonly used by non-psychoanalytic therapists (Kazdin, 2007, 2008).

Yakeley (2014) found that the accumulation of empirical evidence convincingly

demonstrates that psychoanalytic psychotherapy is not inferior in efficacy to other

psychological treatments. In fact, once again, the point is made that the benefits of

psychoanalytic psychotherapy may be long lasting and extend beyond symptom remission.

These findings provide evidence to show that psychoanalytic treatments are effective for a

wide range of mental disorders and challenge the current trend for a psychoanalytic

approach to be solely located in specialised personality disorder services rather than

available in generic mental health or psychological services treating more common mental

disorders such as anxiety and depression (Abbass et al, 2014a). This evidence also

underscores the importance of experience in psychoanalytic psychotherapy as part of the

training of all psychiatrists.

Fonagy (2015) found that not only does psychodynamic psychotherapy match other

modalities in efficacy but in some cases exceeds other treatment options (such as

psychopharmacology and CBT) for some mental health disorders. The consistent finding

from research reinforces that patients experience continuing psychological benefits long

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after treatment has ended (Abbass et al, 2009; de Maat et al, 2009; Leichsenring & Rabung,

2008; Fonagy, 2015; Leichsenring & Klein, 2014; Leichsenring, Rabung & Leibung, 2004) An

increasing number of studies and meta-analyses suggest that this is the case with larger

improvements found at follow-up than at the end of treatment. By contrast, the benefits of

other therapies tend to decay over time (de Maat, Dekker, Schoevers et al, 2006; Hollon et

al, 2005; Westen, Novotny & Thompson-Brenner, 2004).

It is apparent that the perception that psychoanalytic approaches lack empirical support

does not accord with available scientific evidence and may reflect selective dissemination of

research findings. Subsequent research replicates and extends the findings outlined above

(Abbass, et al, 2014; Buchholz, 2009; Burkeman, 2016; Shedler, 2018; Yakeley, 2014).

The NHI Bill: Vulnerable Population Groups

We support the Bill's inclusion of children and people with mental health disorders and

those with disabilities as a vulnerable population group in Section 54(2)(b)(iv).

There are several studies that demonstrate the efficacy of short-term psychoanalytic child

therapy (Göttken, White, Klein & von Klitzing, 2014; Weitkamp, Daniels, Hofmann,

Timmermann, Romer & Silke Wiegand-Grefe, 2014; Abbass, Raburg, Leichsenring, Refseth

& Midgley, 2013; McCrea, 2014). Early intervention is critical to promote development and

in the long term help to reduce crime and disorder and counteract the intergenerational

transmission of trauma.

A growing body of evidence suggests that psychoanalytic psychotherapy is effective for

many common mental disorders including depressive disorders, personality disorders,

anxiety disorders, eating disorders, post-traumatic stress disorder, somatic disorders and

substance-related disorders (Abbas, 2008, 2009; Bateman & Fonagy, 2008; Clarkin et al,

2007; Driessen et al, 2013; Fonagy, 2015; Shedler, 2018; Coleman, 2014; Rabung &

Leichsenring, 2012; Leichsenring, Abbass, Luyten, Hilsenroth, & Rabung, 2013; Leichsenring

& Klein, 2014; Burkeman, 2016; Gaskin 2014).

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Clarkin et al (2007) examined three different year-long outpatient treatments for borderline

personality disorder – dialectical behaviour therapy, transference-focused psychotherapy

and a dynamic supportive treatment – and found that transference-focused psychotherapy

(a psychoanalytic psychotherapy) was associated with change in six areas for patients:

suicidality, aggression, impulsivity, anxiety, depression and social adjustment. By contrast

dialectical behaviour therapy and supportive treatment were associated with fewer changes

in patients. A study by Bateman and Fonagy (2008) showed that mentalisation-based

therapy (a psychoanalytic psychotherapy adapted for personality disorders) leads to

enduring benefits five years after completion.

Researchers at London’s Tavistock clinic published results from the first rigorous National

Health Service (NHS) study of long-term psychoanalysis as a treatment for chronic

depression. It concluded that eighteen months of analysis worked far better – and with

much longer-lasting effects – than 'treatment as usual' on the NHS which included CBT. Two

years after the various treatments ended forty four percent of analytic patients no longer

met the criteria for major depression compared to one-tenth of the others. In the NHS study

conducted at the Tavistock clinic, and published in 2015, chronically depressed patients

receiving psychoanalytic therapy stood a forty percent better chance of going into partial

remission during every six-month period of the research than those receiving other

treatments. Around the same time the Swedish press reported a finding from government

auditors that a multimillion pound scheme to reorient mental healthcare towards CBT had

proved completely ineffective in meeting its goals (Burkeman, 2016).

One can state with confidence that the scientific evidence base for psychoanalytic

psychotherapy is strong and credible and that such therapies are effective in the treatment

of a wide range of mental health conditions and disorders. Sweeping assertions that

psychoanalytic work lacks any scientific credibility (for example, Barlow & Durand, 2005)

perpetuating such assertions are a disservice to patients. In the often fractious and

sometimes competing world of psychological therapies it is important for all researchers to

collaborate more and to think carefully and thoughtfully about what is really in the best

long-term interests of patients. Patients deserve the most appropriate treatments, as the

Bill states.

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The observed reduction in symptoms may also contribute to reductions in healthcare use

and costs and improved occupational functioning. Psychoanalytic psychotherapies may

represent an economical approach to problems as complex as chronic pain, personality

disorder, panic disorder, self-induced poisoning and other challenging-to-treat conditions. It

is also less expensive than even one year of some psychotropic medications depending, of

course, on who is delivering the therapy and the medication (Abbass et al, 2014). While all

those with common mental disorders do not respond to psychoanalytic psychotherapies, it

is prudent to consider such relatively low-risk talking approaches before medication,

treatment combinations or more invasive procedures are employed. This is of particular

importance in the atmosphere of current global healthcare and economic restrictions.

Psychoanalysis and its Broader Use in Society

Psychoanalysis is not only a theory of the human mind and an effective therapeutic practice

with many varied applications but also a way of understanding cultural and social

phenomena, group behaviour and politics.

A recent, cogent example of this is provided here in relation to the Gauteng Mental Health

Marathon Project (2015) which left human wreckage in its wake. As is well known the

Gauteng Mental Health Department in South Africa embarked on a catastrophic process of

irrationally and hurriedly relocating 1562 mental health care users from psychiatric

institutions to unlicensed non-governmental organisations (NGOs) resulting in the deaths of

144 individuals.

A group of twenty registered psychoanalytic mental health professionals who spoke eight

languages among them provided expert testimony at the Alternative Dispute Resolution

(ADR) Process under retired Deputy Chief Justice Dikgang Moseneke at the request of

Section27. All the clinical work was done pro bono.

This was essentially a humanitarian project but it utilised psychoanalytic principles from

beginning to end. A psychoanalytic clinical protocol was devised specifically to consult the

families without repeating the previous trauma. Core psychoanalytic theories were used to

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make sense of the relocation, disappearance, dehumanisation and torture of the psychiatric

patients and the traumatic impact on all those concerned. The report then constructed a

coherent and compelling explanation and narrative of why the displacement had

degenerated into an atrocity for both the patients and the family members. In other words,

psychoanalytic thinking infiltrated the conceptual process as well as the intervention and

testimony presented at the arbitration. In addition, this project rendered psychoanalysis

accessible to ordinary people through the media and demonstrated both its utilitarian value

and usefulness in terms of understanding the human mind and group behaviour. This

required taking sophisticated psychoanalytic concepts and making them accessible to those

at the arbitration and all the South African viewers.

This human rights and social justice case demonstrates the profound value of applying

psychoanalysis outside the consulting room in a community setting. It was clear during this

project that there was a significant gap between available psychological, sociological,

psychiatric and medical research, evidence and theory and the use of it in a meaningful way

in the real world.

Psychoanalysis played an essential part in this landmark judgement. The importance of this

cannot be overstated given the unfortunate history in South Africa of violent assault in the

form of colonisation, the Anglo-Boer war, the atrocities of Apartheid and the recent

Xenophobic attacks. This project illustrated that the repetition of this historical legacy in any

tragedy such as Life Esidimeni needs to be confronted and digested by psychoanalytic

thinkers and practitioners and offer society a space to think about unfolding events at a

deeper level and to provide containment for the horrors people inflict upon each other. In

so doing, positions are taken about the meaning and importance of these past and current

happenings, a perspective is created and sense is made of an emotional experience which

can now also be thought about to some extent.

Justice Dikgang Moseneke (2018) stated in his final report: ‘This is a harrowing account of

death, torture and disappearance of utterly vulnerable mental health care users of an

admittedly delinquent provincial government. It is also a story of the searing and public

anguish of the families of the affected mental health care users and the collective shock and

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pain of many other caring people in our land and elsewhere in the world’. It is partly as a

result of the psychoanalytic report compiled and the subsequent cross-examination that this

lexicon came to be accepted and valued. In her final argument Advocate Adila Hassim

quoted only the testimony provided by the team. This was again quoted in Justice

Moseneke's final award.

This crisis was addressed through collaborative effort not only with the families but with

mental health professionals and the legal fraternity. The team format was a breakthrough as

it was the first time it was used legally in South Africa. It was also the first time that

psychoanalytic clinicians have given evidence in a public interest human rights and social

justice case. The collaboration between the legal fraternity and the mental health

professionals allowed the team as a whole to speak for a group of vulnerable, poor people.

The intersection of human rights (the right to health and dignity) and psychoanalysis was

central in this context and illustrates the broader value of psychoanalysis for our society.

The NHI Bill: Certificate of Need

The Bill states that in order to be accredited by the Fund 38(2)(a) a service provider must be

in possession of and produce proof of certification by the Office of Health Standards

Compliance and, where relevant, proof of registration by the Health Professions Council. In

section 53 there is a reference to an amendment to the National Health Act (The numbering

is incorrect here and should refer to section 38 not 36). It is important that the

requirements to obtain this Certificate of Need are unambiguously clear and discussed with

interested parties.

The Certificate of Need will be withdrawn if the service provider has their accreditation with

the Fund withdrawn or if it is not renewed. This amendment seems to suggest that health

providers will have no alternative but to obtain accreditation with the Fund in order to

obtain the Certificate of Need. Without the latter a clinician will not be able to practice. This

has serious consequences for the health profession and needs to be clarified and reviewed.

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The NHI Bill: Payment of Service Providers

Section 39(1) states that the Fund, in consultation with the Minister, must determine the

nature of service provider payment mechanisms. Section 39(2) states that payments will be

based on performance. How performance is to be assessed is unclear and this poses

significant problems for health providers going forward as does the lack of provision for

direct payment of service providers. In addition section 6(2)(e) states that health

professionals must be able to provide the services at the lowest possible fee without

compromising the quality of the service rendered. The tariffs set by the NHI Fund in terms of

this Bill must take into account the realistic and reasonable costs incurred by healthcare

providers in rendering the service. The methodology to be followed in determining the

tariffs must be transparent, inclusive and procedurally fair. Section 5(1)(f) states that the

fees will be determined annually after consultation with health care providers in the

prescribed manner and in accordance with the provisions of this Act. However, no provision

is made for direct health care provider representation on any of the committees. This is a

serious flaw in the Bill and will be untenable in reality. Failure to adhere to a reasonable fee

determination process will have deleterious long-term consequences on the availability and

sustainability of provision of healthcare services.

The NHI Bill needs to provide for health provider consultation and negotiation in a formal

and representative forum and indicate how representation will occur on both the

Stakeholder Advisory Committee and the Health Benefits Pricing Committee.

Section 10(3)(a/b) states that treatment will not be funded if a health care professional is

able to reasonably demonstrate that either no medical necessity exists for the service or

that no cost-effective intervention exists for the service. This is an unfortunate clause as it

implies that the user’s right of access to healthcare is one of cost considerations alone.

Section 10(3) implies that reimbursement will follow a process of scrutiny on a case by case

basis and that care will be reimbursed on a case by case basis. We also have a concern here

in terms of the confidentiality of patient material. The Bill contains no clear provisions on

how reimbursement of healthcare providers will be managed. Section 35(2) and (3) clearly

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provides that funds will be transferred directly to health establishments but no such

certainty is present with regard to healthcare professionals.

In conclusion, we want to reiterate our intention to participate constructively in the

discussion of the NHI Bill and emphasise that this is an invitation to further engagement and

debate regarding the important but highly condensed issues contained in this submission. A

statement by Prof Mark Solms on the scientific basis of psychoanalysis follows as an

appendix. Prof Solms is the chair of the Research Committee for the International

Psychoanalytic Association (IPA).

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Appendix

The Scientific Basis of Psychoanalysis by Prof Mark Solms (in press with Frontiers in

Psychology)

I recently published an article in the British Journal of Psychiatry (International Edition;

Solms, 2018) whose contents I would like to share with APsaA’s membership. The article is

based on a paper I presented at the 2017 Winter Meeting, when I took over directorship of

the Science Department.

My aim is to set out here what we psychoanalysts may consider to be the core scientific

claims of our discipline. Such stock-taking is necessary due to widespread misconceptions

among the public, and disagreements among ourselves regarding specialist details, which

obscure a bigger picture upon which we can all agree. Agreement on our core claims, which

enjoy strong empirical support, will enable us better to defend them against the prejudice

that psychoanalysis is not ‘evidence-based’.

I shall address three questions: (A) How does the emotional mind work, in health and

disease? (B) On this basis, what does psychoanalytic treatment aim to achieve? (C) How

effective is it? My arguments in relation to these questions will be:

(A) Psychoanalysis rests upon three core claims about the emotional mind that were once

considered controversial but which are now widely accepted in neighbouring disciplines.

(B) The clinical methods that psychoanalysts use to relieve mental suffering flow directly

from these core claims, and are consistent with current scientific understanding of how the

brain changes.

(C) It is therefore not surprising that psychoanalytic therapy achieves good outcomes – at

least as good as, and in some important respects better than, other evidence-based

treatments in psychiatry today.

(A) Our three core claims about the emotional mind, I submit, are the following: (1) The

human infant is not a blank slate; like all other species, we are born with a set of innate

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needs. (2) The main task of mental development is to learn how to meet these needs in the

world, which implies that mental disorder arises from failures to achieve this task. (3) Most

of our methods of meeting our emotional needs are executed unconsciously, which requires

us to return them to consciousness in order to change them.

These core claims could also be described as premises, but it is important to recognise that

they are scientific premises, because they are testable and falsifiable. As I proceed, I will

elaborate these premises, adding details, but I want to differentiate between the core

claims themselves and the specifying details. The details are empirical. Whether they are

ultimately upheld or not does not affect the core claims. Detailed knowledge changes over

time, but core claims are foundational. Everything we do in psychoanalysis is predicated

upon these three claims. If they are disproven, the core scientific presuppositions upon

which psychoanalysis (as we know it) rests will have been rejected. But as things stand

currently, in 2018, they are eminently defensible, strongly – indeed increasingly – supported

by accumulating and converging lines of evidence in neighbouring fields. This continues to

justify Kandel’s (1999) assertion that ‘Psychoanalysis still represents the most coherent and

intellectually satisfying view of the mind’.

I turn now to each of the proposed three claims.

CLAIM 1. The human infant is not a blank slate; like all other species, we are born with a set

of innate needs. These needs are regulated autonomically up to a point, beyond which they

make ‘demands upon the mind to perform work’, as Freud (1915) put it. Such mental

demands constitute his ‘id’. They are ultimately felt as affects. That is why affect is so

important in psychoanalysis. The affect broadcasting a need releases reflexive or instinctual

behaviours, which are hard-wired predictions (action plans) that we execute in order to

meet our needs -- e.g., we cry, search, freeze, flee, attack. Universal agreement about the

number of innate needs in the human brain has not been achieved,1 but most mainstream

taxonomies (e.g. Panksepp 1998) include at least a subset of the following emotional ones:2

1 The taxonomy of innate needs is an empirical question of the kind I mentioned earlier; it does not affect the

basic claim that we are born with a set of innate needs, which are felt as affects and which trigger stereotyped

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We need to engage with the world -- since all our biological appetites (including

bodily needs like hunger and thirst) can only be met there.3 This is a foraging or

seeking instinct. It is felt as interest, curiosity and the like. (It coincides roughly but

not completely with Freud’s concept of ‘libido’; see Solms, 2012.)

We need to find sexual partners. This is felt as lust. This instinct is sexually dimorphic

(on average) but male and female inclinations exist in both genders. (Like all other

biological appetites, lust is channelled through seeking.)

We need to escape dangerous situations. This is fear.

We need to destroy frustrating objects (things that get between us and satisfaction

of our needs). This is rage.

We need to attach to caregivers (those who look after us). Separation from

attachment figures is felt not as fear but as panic, and loss of them is felt as despair.

(The whole of ‘attachment theory’ relates to this need, and the next one.)

We need to care for and nurture others, especially our offspring. This is the so-called

maternal instinct, but it exists (to varying degrees) in both genders.

We need to play. This is not as frivolous as it appears; play is the medium through

which social hierarchies are formed (‘pecking order’), in-group and out-group

boundaries are maintained, and territory is won and defended.

CLAIM 2. The main task of mental development is to learn how to meet our needs in the

world. We do not learn for its own sake; we do so in order to establish optimal predictions

as to how we may meet our needs in a given environment. This is what Freud (1923) called

‘ego’ development. Learning is necessary because even innate predictions have to be

reconciled with lived experience. Evolution predicts how we should behave in, say,

predictions. I am well aware that the taxonomy I cite below differs from Freud’s. Unlike many of his followers. Freud (1920) accepted that biology might well ‘blow away the artificial fabric of our hypotheses [about drives]’. 2 Panksepp (1998) distinguishes between bodily, emotional and sensory needs, which correspond roughly with

the terms ‘drive’, ‘instinct’ and ‘reflex’. Here I am focusing on the emotional needs -- which are felt as separation distress, rage, etc – not the bodily ones -- which are felt as hunger, thirst, etc – or sensory ones – which are felt as pain, disgust, etc. My focus is somewhat arbitrary, but I am highlighting the category of needs that most commonly gives rise to psychopathology. 3 The fact that we can only meet our needs by engaging with others is why life is difficult. You cannot

successfully copulate with yourself, attach to yourself, etc, although this does not stop us from trying! (The psychoanalytic theory of ‘narcissism’ arises from these simple facts.)

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dangerous situations in general, but it cannot predict all possible dangers (e.g., electrical

sockets); each individual has to learn what to fear and how best to respond to the variety of

actual dangers. The most crucial lessons are learned during critical periods, mainly in early

childhood, when we are – unfortunately -- not best equipped to deal with the fact that our

innate predictions often conflict with one another (e.g., attachment vs rage, curiosity vs

fear).4 We therefore need to learn compromises, and we must find indirect ways of meeting

our needs. This often involves substitute-formation. Humans also have a large capacity for

delaying gratification and for satisfying their needs in imaginary and symbolic ways.

It is crucial to recognise that successful predictions entail successful emotion regulation, and

vice-versa. This is because our needs are felt. Thus successful avoidance of attack reduces

fear, successful reunion after separation reduces panic, etc, whereas unsuccessful attempts

at avoidance or reunion result in persistence of the fear or panic, etc.

CLAIM 3. Most of our predictions are executed unconsciously. Consciousness (short-term

‘working memory’) is an extremely limited resource, so there is enormous pressure to

consolidate learnt solutions to life’s problems into long-term memory, and ultimately to

automatize them (for review see Bargh & Chartrand 1999, who conclude that only 5% of

goal-directed actions are conscious). Innate predictions are effected automatically from the

outset, as are those acquired in the first two years of life, before the preconscious

(‘declarative’) memory systems mature (cf. infantile amnesia). Multiple unconscious (‘non-

declarative’) memory systems exist, such as ‘procedural’ and ‘emotional’ memory, which

operate according to different rules. These stereotyped systems (cf. the repetition

compulsion) bypass thinking (i.e, the secondary process) and define the system

unconscious.

The following fact is of utmost importance. Not only successful predictions are automatized.

With this simple observation, we overcome the unfortunate distinction between the

‘cognitive’ and ‘Freudian’ unconscious (Solms, 2017). Sometimes a child has to make the

best of a bad job in order to focus on the problems which it can solve. Such illegitimately or

prematurely automatized predictions (i.e., wishes as opposed to realistic solutions) are

4 This is why childhood, and the quality of parental guidance, are so important in psychoanalysis.

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called ‘the repressed’. In order for predictions to be updated in light of experience, they

need to be ‘reconsolidated’; that is, they need to enter consciousness again, in order for the

long-term traces to become labile once more (Nader et al 2000, Sara 2000, Tronson & Taylor

2007). This is sometimes difficult to achieve, however; not least because procedural

memories are ‘hard to learn and hard to forget’ and some emotional memories – which can

be acquired through just a single exposure -- appear to be indelible; but also because the

essential mechanism of repression entails resistance to reconsolidation despite prediction

errors. The theory of reconsolidation is very important for understanding the mechanism of

psychoanalysis. This leads to my second argument, concerning our treatment.

(B) My second argument is that the clinical methods that psychoanalysts use to relieve

mental suffering flow from the above core claims, which are consistent with current

understanding of how the brain changes. The argument unfolds over three steps:

(a) Psychological patients suffer mainly from feelings. The essential difference

between psychoanalytic and psychopharmacological methods of treatment is

that we believe feelings mean something. Specifically, feelings represent

unsatisfied needs. (Thus, a patient suffering from panic is afraid of losing

something, a patient suffering from rage is frustrated by something, etc.) This

truism applies regardless of etiological factors; even if one person is

constitutionally more fearful, say, than the next, or cognitively less capable of

updating predictions, their fear still means something. To be clear: emotional

disorders entail unsuccessful attempts to satisfy needs. That is, psychological

symptoms (unlike physiological ones) involve intentionality.

(b) The main purpose of psychological treatment, then, is to help patients learn

better ways of meeting their needs. This, in turn, leads to better emotion

regulation. The psychopharmacological approach, by contrast, suppresses

unwanted feelings. We do not believe that drugs which treat feelings directly can

cure emotional disorder; drugs are symptomatic (not causal) treatments. To cure

an emotional disorder, the patient’s failure to meet underlying need/s must be

addressed, since this is what is causing the symptoms. However, symptomatic

relief is sometimes necessary before patients become accessible to psychological

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treatment, since most forms of psychotherapy require collaborative work

between patient and therapist (see below). It is also true that some types of

psychopathology never become accessible to psychotherapy. We must also

concede that patients just want to feel better; they do not want to work for it.

(c) Psychoanalytical therapy differs from other forms of psychotherapy in that it

aims to change deeply automatized predictions, which – to the extent that they

are consolidated into non-declarative memory – cannot be reconsolidated in

working memory. Non-declarative (i.e., unconscious) predictions are

permanently unconscious. Psychoanalytic technique5 therefore focuses on:

Identifying the dominant emotions (which are consciously felt but not

always recognized as arising from specific needs and predictions).

These emotions reveal the meaning of the symptom. That is, they lead

the way to the particular automatized predictions that gave rise to the

symptom.

The pathogenic predictions cannot be remembered directly for the very

reason that they are automatized (i.e. non-declarative). Therefore, the

analyst identifies them indirectly, by bringing to awareness the repetitive

patterns of behaviour derived from them.

Reconsolidation is thus achieved through reactivation of non-declarative

traces via their derivatives in the present (this is called ‘transference’

interpretation). Automatized predictions cannot be retrieved into

working memory, but patients can be made aware of the here-and-now

enactments of those predictions. This is the essence of psychoanalytical

cure.

Such reconsolidation is nevertheless difficult to achieve, mainly due to the

ways in which non-declarative memory systems work (they are ‘hard to

learn, hard to forget’ and in some respects ‘indelible’) but also because

repression entails intense resistance to the reactivation of insoluble

problems. For all these reasons, psychoanalytic treatment takes time –

5 See Blagys & Hilsenroth, 2000; Smith & Solms, in press.

18 | P a g e

and frequent sessions -- to facilitate ‘working through’. Working through

entails numerous repetitions of transference interpretations in relation to

ongoing derivates of repressed predictions, while new (and crucially,

better) predictions are slowly consolidated. (Funders of psychological

treatments need to learn how learning works.)

(C) My third argument is that psychoanalytic therapy achieves good outcomes – at

least as good as, and in some respects better than, other evidence-based treatments

in psychiatry today. This argument unfolds over four stages:

(a) Psychotherapy in general is a highly effective form of treatment. Meta-analyses of

psychotherapy outcome studies typically reveal effect sizes of between 0.73 and

0.85. (An effect size of 1.0 means that the average treated patient is one standard

deviation healthier than the average untreated patient.) An effect size of 0.8 is

considered a large effect in psychiatric research, 0.5 is considered moderate, and

0.2 is considered small. To put the efficacy of psychotherapy into perspective,

recent antidepressant medications achieve effect sizes of between 0.24 (tricyclics)

and 0.31 (SSRIs).6 The changes brought about by psychotherapy, no less than drug

therapy, are of course visualizable with brain imaging (see Beauregard 2014).

(b) Psychoanalytic psychotherapy is equally effective as other forms of psychotherapy

(e.g. CBT). This has recently been demonstrated conclusively by comparative meta-

analysis (Steinert et al., 2017). However, there is evidence to suggest that the

effects last longer -- and even increase -- after the end of the treatment. Shedler’s

(2010) authoritative review of all randomized control trials to date reported effect

sizes of between 0.78 and 1.46, even for diluted and truncated forms of

psychoanalytic therapy.7 An especially methodologically rigorous meta-analysis

(Abbass et al 2006) yielded an overall effect size of 0.97 for general symptom

improvement with psychoanalytic therapy. The effect size increased to 1.51 when

the patients were assessed at follow-up. A more recent meta-analysis by Abbass et

6 See Turner et al 2008, Kirsch et al 2008.

7 I would like to thank Jonathan Shedler for his generous help with this paper.

19 | P a g e

al (2014) yielded an overall effect size of 0.71 and the finding of maintained and

increased effects at follow-up was reconfirmed.

This was for short-term psychoanalytic treatment. According to the meta-analysis

of De Maat et al (2009), which was less methodologically rigorous than the Abbass

studies, longer-term psychoanalytic psychotherapy yields an effect size of 0.78 at

termination and 0.94 at follow-up, and psychoanalysis proper achieves a mean

effect size of 0.87 and 1.18 at follow-up. This is the overall effect; the effect size

that she found for symptom improvement (as opposed to personality change) at

termination was 1.03 for long-term therapy, and for psychoanalysis it was 1.38.

Leuzinger-Bohleber et al’s subsequent study (in press [a]) shows even bigger effect

sizes: between 1.62 and 1.89 after three years of treatment. These are enormous

effects. (Follow-up data are of course not yet available from this ongoing study.)

The consistent trend toward larger effect sizes at follow-up --where the effects of

other forms of psychotherapy, like CBT, tend to decay -- suggests that

psychoanalytic therapy sets in motion processes of change that continue even

after therapy has ended (cf. ‘working through’, discussed above). It is important to

recognize that these findings concern symptom improvement only. Psychoanalytic

treatments are not directed primarily at symptomatic relief but rather at what

might be called personality change. Not surprisingly, therefore, psychoanalytic

treatments achieve much better results than other treatments on this outcome

measure. In Leuzinger et al’s ongoing study, for example, almost twice as many

patients receiving psychoanalytic treatment vs CBT reached their criteria for

‘structural change’ after three years (60% vs 36%; Leuzinger-Bohleber, in press

[b]).

(c) The therapeutic techniques that predict best treatment outcomes make good

sense in relation to the psychodynamic mechanisms outlined above. These

techniques are (Blagys & Hilsenroth 2000):

unstructured, open-ended dialogue between patient and therapist

identifying recurring themes in the patient’s experience

linking the patient’s feelings and perceptions to past experiences

20 | P a g e

drawing attention to feelings regarded by the patient as unacceptable

pointing out ways in which the patient avoids feelings

focusing on the here-and-now therapy relationship

drawing connections between the therapy relationship and other

relationships.

It is highly instructive to note that these techniques lead to the best treatment

outcomes, regardless of the ‘brand’ of therapy that the clinician espouses. In other

words, these same techniques (or at least a subset of them; see Hayes et al 1996)

predict optimal treatment outcomes in CBT too, even if the therapist believes they

are doing something else.

(d) It is therefore perhaps not surprising that psychotherapists, irrespective of their

stated theoretical orientation, tend to choose psychoanalytic psychotherapy for

themselves! (Norcross 2005)

CONCLUSION

I am well aware that the claims I have summarized here do not do justice to the full

complexity and variety of views in psychoanalysis, both as a theory and a therapy. I am

saying only that these are our core claims, which underpin all the details, including those

upon which we are yet to reach agreement. If we can agree on just these few claims,

underpinning the arguments presented in this article, we are much better placed to explain

our point of view to neighbouring disciplines and to the public. I believe that these claims

and arguments are eminently defensible, in light of available scientific evidence, and that

they make simple good sense.

However, it is far too soon to rest on our laurels. There is a pressing need, in particular, for

more outcome studies focused on the symptomatic and structural effects of long-term

psychoanalysis (versus not only CBT but also low-frequency and short-term psychoanalytic

psychotherapies). I am therefore pleased to announce that we at APsaA are launching a

major new research initiative in this respect (possibly in conjunction with the IPA). We have

appointed Marianne Leuzinger-Bohleber (cited above) to design a randomized control trial

21 | P a g e

which compares low-frequency and high-frequency psychoanalytic treatments. The study

design will need to focus on just one particular psychopathology, to begin with, and will

involve not only behavioural measures but also indexes of change in brain network

dynamics (and other biomarkers) over the course of the treatments.

A major disadvantage that we suffer in comparison with psychopharmacological and CBT

researchers is an almost total lack of financial support for psychoanalytic outcome studies

from commercial and statutory sources. If we are going to overcome the prejudice that

feeds this lack of support -- namely the self-fulfilling (and false, see Shedler, 2015) claim that

psychoanalysis is not evidence-based – then we will have to fund such studies ourselves, at

least to begin with.

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