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As relatively few of the individuals who suffer from significant psychiatric morbidity have the benefit of any kind of professional help, it must be obvious that there are many roots to recovery which do not involve psychoanalysis, psychotherapy or indeed any kind of systematic intervention. What any treatment needs to demonstrate therefore, is that it is more effective than the natural processes of healing which human society provides (note for example Freud’s famous comments about the therapeutic potential of Lourdes (Freud, 1933)). From a historical point of view, Hans Eysenck (1952) was the first to raise this issue in connection with psychoanalytic therapy. He claimed, on the basis of insurance statistics as well as Fenichel’s Berlin I Study of the outcomes of the Berlin Psychoanalytic Institute, that more individuals recovered in a two year period when they were untreated than when they were treated in psychoanalysis. More recently, it was demonstrated that even using Eysenck’s data a more sophisticated analysis reveals that whereas half of treated patients improved within a couple of months, only 2% of those untreated improved over the same time period (McNeilly & Howard, 1991). Whatever the status of Eysenck’s own figures, there is no doubt that spontaneous improvement rates are sizeable for most psychological disorders (Bergin, 1971; Lambert, 1976; Subotnik, 1975). For example, from naturalistic follow up studies we know that individuals with borderline personality disorder tend to “burn out” in middle age (Stone, 1990). Thus statements about the effectiveness of psychoanalysis cannot be made on the basis of clinical reports of individual cases, however successful – certainly not without unequivocal knowledge about the course of the disorder. Ideally the course of untreated individuals should be compared with those who receive treatment. It is impractical and unethical to withhold treatment from an individual for the duration of a longterm treatment such as psychoanalysis and this has posed major problems for those intending to carry out outcome studies. As psychoanalysis is not generally available it seems sensible to compare its effectiveness with either the best available alternative treatment or so-called “treatment as usual”. The former has the advantage of offering an apparently meaningful comparison from the point of view of a referrer or referring agency, but equally has the potential of prompting meaningless comparisons where the aims of treatment are not comparable and apples are being compared with oranges. Such comparisons also require that the researcher has comparable expertise with both the methods of treatment, as well as large sample sizes as the difference between the two methods is likely to be small. The alternative contrast with a treatment as usual group, has the advantage of telling us how much difference a treatment might make were it to be added to routine care but has the disadvantage of potentially great heterogeneity in the control group and inadequate information concerning the treatment received by the control group (Roth & Fonagy, 1996). >.(1.&Y*&2!$,!%23/4$.4&(1%3!(&2&1(/4! The choice of a particular research methodology will always be a compromise, reflecting the intentions, interests (and resources) of investigators. Some of the major strategies used in psychoanalytic research, together with their strengths and weaknesses, will be considered in turn. A full account of these issues in psychotherapy research is given in Kazdin (1994). Q$*D<0!7260!6(B&$06! The belief that knowledge based on groups of individuals is somehow more likely to be generalisable – that is, applicable beyond the specific locus of its discovery – than is the case for knowledge based upon individual cases, is fatally flawed (Fonagy & Moran, 1993). In single case designs the focus is on the individual patient rather than a group average, even where a group of patients were studied. Single-case studies may be descriptive or quantitative. The former group is well represented in the traditional psychoanalytic case history. The method has many strengths, including high
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