Amy Novotney가 2017년 12월 미국심리학회의 출판물인 Monitor on Psychology의 48권 11호에 기고한 글
한글 번안:
어린 시절과 진로의 시작
7살 때, 프라튜샤 투말라-나라(Pratyusha Tummala-Narra)는 정치적 긴장이 가득한 인도를 떠나 가족과 함께 미국으로 이주했다. 그러나 인종적·민족적 소수자로 살아가며 겪은 적응의 어려움은 그녀에게 뚜렷한 방향을 제시했다. 결국 미시간주립대학교에서 심리학 박사학위를 선택하게 된 것이다.
지난 20년 동안 그녀는 임상가로 활동하면서 정신분석적 관점에 다문화적, 페미니스트적 시각을 결합해왔다. 특히 이민자와 소수민족 내담자들이 문화 적응, 차별, 트라우마를 다루는 데 집중해왔다. 그녀의 작업은 지그문트 프로이트의 사상에 뿌리를 두고, 의식 밖에 자리할 수 있는 내담자의 생각과 감정이 어떻게 사회적·문화적·정치적 경험에 영향을 미치는지 탐구한다.
프로이트의 유산과 미국 내 변화
투말라-나라는 현재 보스턴 칼리지에서 상담·발달·교육심리학 교수로도 재직 중이다. 그녀는 이렇게 강조한다.
“프로이트는 논란이 많은 인물이지만, 그와 동료들이 유럽 전역에 무료 클리닉을 세워 계급에 상관없이 누구나 정신치료를 받을 수 있게 했다는 사실은 종종 잊혀집니다.”
그러면서 덧붙였다.
“정신분석이 1900년대 초 미국에 들어왔을 때, 중산층 이상만 접근 가능한 치료로 변모했는데, 그것은 프로이트의 의도가 결코 아니었습니다. 그는 심리역동적 치료를 모든 사람을 위한 보편적 치료로 보았습니다.”
정신분석의 쇠퇴와 비판
한때 심리치료의 왕좌에 있던 정신분석은 지난 40년간 미국 정신건강계에서 영향력을 잃어왔다. 이유는 다양하다. 일부는 정신분석 이론가들이 치료 효과에 대한 연구에 소홀했다고 지적한다. 또 어떤 이들은 무의식과 같은 심층 심리를 탐구한다는 점에서 접근이 지나치게 추상적이라 비판한다. 반면 인지행동치료(CBT)는 부정적 감정을 유발하는 사고를 조정하는 데 집중하며, 훨씬 더 실용적으로 보인다.
여기에 오이디푸스 콤플렉스 같은 프로이트의 특정 이론들은 버려지고, 초기 관계와 그 영향에 대한 폭넓은 이해가 자리 잡았다. 오늘날의 단기 치료, 보험 제약 중심의 환경 속에서 정신분석은 “시대착오적이고 비효율적”이라는 낙인이 찍히기도 했다.
정신분석의 현재적 의미
그럼에도 불구하고, 오늘날의 정신분석가들은 입을 모아 말한다. 정신역동적 치료는 여전히 다른 치료법만큼, 아니 그 이상으로 효과적일 수 있다는 것이다.
투말라-나라는 지적한다.
“우리는 현재 매뉴얼 기반의 ‘실증적 치료’와 단기 모델에 지나치게 집중하고 있습니다. 하지만 실제 환자들은 홈리스, 빈곤, 트라우마, 차별 같은 복합적 문제를 겪고 있죠. 이를 다루려면 개인 전체에 대한 깊은 이해가 필요합니다. 단순히 매뉴얼만으로는 충분하지 않습니다.”
콜로라도 의과대학 정신의학과 임상 교수이자 개업 분석가인 조너선 셰들러(Jonathan Shedler)도 같은 맥락에서 말한다.
“정신분석은 프로이트로 끝난 것이 아닙니다. 물리학이 뉴턴에서 끝나지 않았듯, 행동주의가 왓슨에서 끝나지 않았듯, 정신분석도 진화해왔습니다.”
실제로 최근 정신분석가들의 과학적 헌신은 정신역동적 치료가 CBT 등 다른 치료법만큼이나 효과적이라는 증거를 빠르게 쌓아가고 있다.
축적되는 연구 증거
연구는 점점 더 명확해지고 있다. 최근의 다수 연구가 정신역동적 치료가 CBT보다 장기적 효과에서 우위를 가질 수 있음을 보여준다.
2015년, 런던대학교(UCL)의 피터 포나기(Peter Fonagy)는 영국 NHS를 통해 만성 우울 성인들을 대상으로 18개월간 주 1회 정신분석 치료와 ‘통상적 치료(CBT 포함)’를 비교했다. 치료 종료 시점에는 두 집단 모두 비슷한 개선을 보였다. 그러나 2년 후에는 큰 차이가 드러났다. 정신분석군의 44%가 더 이상 주요우울 진단 기준을 충족하지 않았지만, CBT군은 10%에 불과했다(World Psychiatry, Vol. 14, No. 3, 2015).
2016년 포나기의 또 다른 연구는 부모-영아 정신분석 심리치료를 다뤘다. 유아 발달 지표에서는 차이가 없었으나, 부모들은 양육 스트레스 감소와 자기 인식 향상 등 정신건강 측면에서 뚜렷한 개선을 경험했다(Infant Mental Health Journal, Vol. 37, No. 2, 2016).
2017년에는 암스테르담 자유대학교의 엘렌 드리센(Ellen Driessen)이 주도한 연구가 발표되었다. 결과는 명확했다. 단기 정신역동적 치료는 불안, 통증 완화, 삶의 질 향상 등에서 CBT만큼이나 효과적이었다(Journal of Consulting and Clinical Psychology, Vol. 85, No. 7, 2017).
포나기는 이렇게 말한다.
“중요한 것은 특정 환자 집단에 가장 잘 맞는 치료를 찾는 것입니다. 사람들의 문제를 깊이 이해할 필요가 있고, 그 점에서 정신분석은 정교한 마음의 모델을 제공합니다.”
셰들러 역시 2010년 종합 리뷰에서 불안과 우울 같은 흔한 문제에 대해 정신역동적 치료가 다른 ‘근거 기반 치료’ 못지않게 효과적이며, 효과가 훨씬 오래 지속된다고 결론지었다(American Psychologist, Vol. 65, No. 2).
2006년 메타분석(2014년 업데이트, 33개 무작위 대조 연구, 환자 2,173명)은 단기 정신역동적 치료(40시간 미만)를 받은 환자들이 불안·우울 증상 감소를 경험했으며, 그 효과는 9개월 이상의 추적 관찰에서 더욱 커졌다. 이는 정신역동적 치료가 치료 종료 후에도 변화 과정을 촉발한다는 점을 보여준다.
셰들러는 말한다.
“CBT의 효과는 치료가 끝나는 순간부터 약해지기 시작합니다. 보통 6개월~1년 안에 그 효과는 사라집니다.”
반대 의견
물론 반론도 있다. 밴더빌트대학교의 스티븐 홀론(Steven Hollon)은 2013년 메타분석을 인용하며, “CBT를 받은 환자들은 항우울제 복용자들보다 재발률이 절반 이하로 낮다”고 주장한다(BMJ Open, Vol. 3, No. 4).
그는 이렇게 덧붙였다.
“우울증은 본질적으로 만성적이고 재발하는 병이므로 증상 재발은 자연스러운 일입니다. 그러나 CBT가 약물보다 지속적 효과를 보인다는 분명한 증거가 있습니다. 정신역동적 치료도 지속 효과가 있을 수 있으나, 아직 충분히 연구되지 않았습니다. 증거가 없다는 것이 효과가 없다는 뜻은 아니지만, 한 세기 넘게 존재해왔음에도 제대로 검증된 바가 부족합니다.”
오늘날의 정신역동적 치료
셰들러는 정신분석이 여전히 프로이트 시대의 오래된 방식으로만 행해진다고 생각하는 것은 큰 오해라고 강조한다. 오늘날 대부분의 치료는 주 1회 진행된다. 투말라-나라는 대다수 내담자와 주 1~2회 만나며, 치료 기간은 수주에서 수년에 걸쳐 다양하다.
그녀는 내담자의 어린 시절 경험과 가족 관계, 현재의 어려움을 집중적으로 탐색한다. 자유연상을 장려하고, 초기 기억과 꿈을 다루며 현재의 고통을 이해할 단서를 찾는다. 이러한 과정은 내담자가 자기 자신과 타인에 대한 새로운 이해와 더 나은 관계 방식을 찾도록 돕는다.
또한 치료 관계 속 전이와 역전이를 탐구함으로써 내담자는 관계 패턴을 새롭게 경험한다. 예컨대 치료자가 인종 문제를 회피한다면, 내담자도 무의식적으로 이를 축소할 수 있다. 이러한 교착을 함께 다루는 것은 진정성 있는 관계 형성과 고통스러운 정서를 견디고 다루는 능력을 기르는 데 핵심적이다.
셰들러는 이렇게 요약한다.
“환자가 치료자와 맺는 관계는 다른 관계에서 무슨 문제가 일어나는지, 또 무엇이 잘 되는지를 보여주는 창입니다. 우리는 단순히 문제 이야기를 듣는 것이 아니라, 그것을 실제로 경험하고 있는 셈입니다.”
미래 전망
시티칼리지의 엘리엇 주리스트(Elliot Jurist)는 이렇게 기대한다.
“증거가 축적되면 정신분석에 대한 낙인이 줄고, 가치 있는 부분이 더 널리 활용될 수 있을 것입니다.”
아델피대학교의 자크 바버(Jacques Barber) 역시 같은 희망을 전한다. 다만 그는 정신역동적 치료 연구가 대규모 표본을 필요로 하기에 미국 내 연구 자금 지원이 부족하다고 지적한다.
그는 말한다.
“어떤 치료도 모든 환자에게 효과적일 수는 없습니다. 중요한 질문은 ‘어떤 치료가 어떤 환자에게 가장 잘 맞을까?’입니다. 다음 세대는 이 질문에 답해야 할 것입니다.”
투말라-나라는 학생과 전문가, 교육자들에게 정신분석 이론의 타당성과 현대적 관련성을 알리는 일이 중요하다고 강조한다.
펜실베이니아주립대 켄 레비(Ken Levy)는 학계와 학술지, 심사 과정에서 사상의 다양성과 사고의 폭을 존중하는 문화가 필요하다고 말한다.
“심리학의 가장 큰 성취는 서로 다른 생각들이 충돌하는 과정에서 이루어졌습니다.”
그 예로, 발터 미셸(Walter Mischel)의 인지-정서적 성격 이론은 대상관계 이론, 애착 이론 같은 정신역동 모델과 맞닿아 있다. 레비는 설명한다.
“미셸이 처음 ‘성격은 존재하지 않는다’고 주장했을 때, 오히려 성격 연구가 부흥했고, 지금은 그의 이론이 성격 연구의 핵심 틀 중 하나가 되었습니다. 서로 다른 의견의 충돌이 학문을 발전시킨 대표적인 사례입니다.”
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원문 전문:
At age 7, Pratyusha Tummala-Narra emigrated from India to the United States with her family, leaving behind a country rife with political tensions. Her struggles to adjust to life as a racial and ethnic minority led her to pursue a PhD in psychology from Michigan State University. For the past 20 years, she has worked as a clinician, integrating psychoanalytic, multicultural and feminist perspectives into her practice, which focuses on helping immigrant and ethnic-minority clients deal with acculturation, discrimination and trauma. Her work draws on the ideas of the founder of psychoanalysis, Sigmund Freud, to explore how her clients' thoughts and feelings that may lie outside awareness affect their social, cultural and political experiences.
As controversial as Freud may be, people often forget that he and his colleagues opened free clinics throughout Europe so that people of any class could have access to psychotherapy, says Tummala-Narra, who is also a professor of counseling, developmental and educational psychology at Boston College.
"When psychoanalysis came to the United States in the early 1900s, it developed into a form of treatment that seemed to only be accessible to the middle and upper-middle classes, which was never Freud's intention," she says. "He viewed psychodynamic therapy as a universal treatment for all people."
Once the ruler of the therapy world, psychoanalysis and psychodynamic therapy fell out of favor in the United States among many mental health professionals over the past 40 years, due to several factors. Some experts cite a lack of commitment by psychoanalytic theorists to conduct research on the therapy's effectiveness. Others see the treatment as too abstract because it seeks to help clients uncover deeper, often unconscious aspects of experience, while approaches such as cognitive-behavioral therapy (CBT) focus more on helping clients adjust thoughts believed to cause negative emotions. Further, many of Freud's specific ideas, such as the Oedipus complex, have been dropped in favor of a broader view of early relationships and their impacts. And others say psychodynamic therapy is just not relevant or efficient in today's quick-fix, insurancelimited marketplace.
But today's psychoanalytic practitioners say that for many mental health issues, psychodynamic therapy is at least as effective as, if not better than, other therapy approaches—and should not be ignored.
"As a field we've moved into focusing heavily on what are considered to be empirically supported treatments, largely based on protocol and in short-term models of psychotherapy," Tummala-Narra says. "Yet as practitioners, we're seeing patients who are suffering from multiple stressful events in their lives, including homelessness, poverty, trauma and discrimination. Helping them deal with all of these complicated issues really requires a depth of understanding of the whole person and how these events are affecting their relationships with people and how they function in the world. To truly help our clients, we can't always just rely on a protocol-based treatment."
Plus, psychoanalytic thinking has evolved rapidly since Freud, says Jonathan Shedler, PhD, a clinical professor of psychiatry at the University of Colorado School of Medicine who also has a private practice. "The development of psychoanalytic thought did not end with Freud any more than the development of physics ended with Newton, or the development of the behavioral tradition in psychology ended with Watson," Shedler says.
And most important, these practitioners say, a new commitment to science by psychoanalytic researchers and practitioners has led to a growing body of evidence that psychodynamic therapy is as effective as—and sometimes more beneficial than—CBT and other therapies.
Mounting research
Several recent studies have found that psychodynamic theory can provide more long-term benefits than CBT. In 2015, University College London psychoanalyst and clinical psychologist Peter Fonagy, PhD, led a study through the National Health Service in England comparing 18 months of once-a-week psychoanalytic therapy with "treatment as usual," which included CBT, among adults with chronic depression. The researchers found that 18 months of psychoanalysis provided similar benefits in terms of observer-based and self-reported depression scores compared with the control treatment. But the team also found that patients who received psychoanalytic therapy experienced much longer effects: Two years after treatment ended, 44 percent of patients who received psychoanalysis no longer met the criteria for major depression, compared with 10 percent of the CBT group ( World Psychiatry , Vol. 14, No. 3, 2015 ).
A second study, led by Fonagy and published in 2016, looked at parent-infant psychoanalytic psychotherapy, which aims to improve the interaction between parent and child. Participants were randomly assigned to receive parent-infant psychotherapy or supportive primary care. The authors found no significant difference in outcomes for either intervention on measures of infant development, parent-infant interaction or the parent's ability to consider the baby's mental state as well as their own. However, parents who had received parent-infant psychotherapy showed improvements on several measures of maternal mental health, such as less parenting stress and more positive views of themselves as parents ( Infant Mental Health Journal , Vol. 37, No. 2, 2016 ).
Another study published this year, led by Ellen Driessen, PhD, a postdoctoral psychology research associate at VU University in Amsterdam, found that short-term psychodynamic therapy for depression is at least as effective as CBT with regard to many important aspects of patient functioning, including reducing anxiety and pain and improving quality of life ( Journal of Consulting and Clinical Psychology , Vol. 85, No. 7, 2017).
"To me, the important thing is finding the psychological therapies that work best for particular patient groups and, to find those treatments, I think we have to have a better understanding of the nature of the problems that people come to us with," Fonagy says. "That's where I think psychoanalysis can help, because it does have a very sophisticated model of the mind."
In a 2010 comprehensive research review, Shedler found that, particularly for common conditions such as anxiety and depression, psychodynamic therapy is at least as effective as all the other therapies that he says are branded and promoted as evidence-based ( American Psychologist , Vol. 65, No. 2 ). Moreover, he says, the benefits of the psychodynamic approach appear to endure much longer than those of CBT.
For example, a 2006 meta-analysis he includes in his review—which was updated in 2014 to include 33 randomized controlled trials of 2,173 patients with a range of common mental disorders—showed a reduction in anxiety and depressive symptoms among participants who received short-term (less than 40 hours) psychodynamic therapy. These benefits continued increasing over time and were actually greater at long-term follow-up, nine months or more after the intervention ended. This suggests that psychodynamic therapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended, Shedler says.
"For the most common conditions, such as anxiety and depression, the benefits of CBT start to dissipate the day the treatment ends," Shedler says. "The typical finding is that by six months to a year, there is no indication that there was any benefit whatsoever."
Not everyone agrees with that assessment. Vanderbilt University psychology professor Steven Hollon, PhD, past president of the Association for Behavioral and Cognitive Therapies, notes that individuals do relapse following successful treatment with either CBT or an antidepressant medication, but prior CBT cuts the relapse rate by more than half, according to a 2013 meta-analysis he co-authored ( BMJ Open , Vol. 3, No. 4 ).
"Depression tends to be a chronic or recurrent disorder, so subsequent symptom return is what you would expect, but we have clear evidence that CBT has an enduring effect as compared to medication," Hollon says. "Psychodynamic therapy may have an enduring effect, too, but that has simply never been adequately investigated. Absence of evidence is not evidence of absence, but the approach has been around for over a century and simply has not been all that adequately tested."
Psychoanalytic practice today
One of the greatest misconceptions regarding psychodynamic therapy is that it has remained unchanged since Freud introduced it at the turn of the century, Shedler says.
"There have been sea changes in psychoanalytic theory and technique, but psychology textbooks continue to offer portrayals that are a century out of date," he says. "People still think that patients come in four or five days a week for an hour at a time and lie on a couch," he says.
While a few psychoanalytic therapists still practice that way, today most see their patients once a week. Tummala-Narra says she works with most of her clients once or twice weekly, and that the length of their treatment varies, with some clients lasting several weeks, and others several years.
The approach focuses on helping patients understand themselves more deeply so they can identify the factors underlying their difficulties and stop repeating the same patterns, Shedler says.
"A central way of understanding the psychodynamic approach is that there's more to human beings than meets the eye," he says. "There's what you can see on the surface of things—presenting problems or symptoms or a diagnosis—and there's what is going on psychologically that's underlying the patient's problems."
The approach differs from other therapy techniques in that it seeks to help clients uncover underlying reasons for their feelings and behaviors, which may initially be outside the client's awareness. Other approaches focus more on helping clients adjust unhelpful present thoughts.
"Psychologists who practice psychodynamic therapy are more interested in some of the complexities and subtleties of clinical work, and are less content to define success just in terms of something like lessening symptoms," says Elliot Jurist, PhD, psychology professor at the City University of New York and editor of Psychoanalytic Psychology. "They tend to pursue the more ambitious goal of helping someone move toward psychological health, rather than just getting rid of what they're suffering from."
Tummala-Narra focuses her client discussions on past experiences, such as a client's childhood and relationships with family members, as well as present challenges. "As the family is typically the initial space for socialization, I pay close attention to what messages clients have learned from parents, siblings, grandparents and other significant people in their life," she says.
She encourages her clients to follow their thoughts wherever they lead, also known as free association, and inquires about early childhood memories and dreams to help facilitate discussion of the meaning of clients' experiences. "Learning about each aspect of experience helps me and the client understand in more depth the nature and history of the current suffering." That, she says, leads to insights that help the client move toward considering and engaging in new, more productive and fulfilling ways of thinking about themselves and others.
Psychodynamic therapy also allows patients to explore and rework their relationships through the therapeutic relationship by examining transference and countertransference dynamics, Tummala-Narra says. For example, the therapist may avoid or minimize the role of racism in the client's life if he or she feels uncomfortable or has conflicted feelings about race and racism, she says. "The client in turn may unconsciously collude with the therapist's discomfort, and minimize the role of racism in his or her life. Working through impasses or enactments of these dynamics is critical to psychoanalytic practice, and offers an opportunity to engage in a unique relationship that promotes authenticity and the ability to tolerate and work through painful affective experiences."
Shedler agrees, noting that this is a crucial dividing line between the psychodynamic perspective and other therapy approaches. "The relationship that the patient creates with the therapist is a window into what goes right and what goes wrong in the patient's other relationships," he says. "We're not just hearing about what causes the person's problems, we're actually experiencing it firsthand in the office."
Looking toward the future
Given the research supporting the effectiveness of psychoanalysis, Jurist says he is hopeful that more practitioners will be open to providing it. "My hope is that this will help reduce the stigma around psychodynamic thinking and that people will take things that they find valuable and use it in their practice," he says.
Jacques Barber, PhD, dean of psychology at Adelphi University, shares Jurist's hope that the growing body of evidence that psychoanalytic therapy is effective will boost interest among researchers and practitioners. Unfortunately, he notes, funding to study psychodynamic therapy in the United States is difficult to come by because it requires a large sample size and can be hard to implement.
"We know that no treatment is effective for all patients," Barber says. "Now the important question is, how do we try to predict what kind of treatment will work best for which kind of patient? I think this is what the next generation will need to deal with."
Tummala-Narra agrees, pointing to the need for those in the profession to enlighten students, professionals and educators about the validity and relevance of psychoanalytic theory in contemporary practice.
"We need to broaden the perspective in terms of what's thought about as effective psychotherapy, rather than relying on one subset of techniques or methods," she says.
Ken Levy, PhD, a clinical psychology professor at Penn State University who maintains a small psychodynamically oriented private practice, adds that review panels, journals and psychology departments also need to pay more attention to valuing the idea of diverse thinking and diverse ideas.
"Some of the greatest achievements in psychology have occurred in the context of people having different ideas about things," he says.
For example, Walter Mischel's cognitive-affective personality theory is consistent with psychodynamic models such as object relations and attachment theories.
"Mischel initially saying that there was no such thing as personality led to a resurgence in personality research that now has Mischel as one of the leading frameworks in personality theory," Levy says. "That happened because people had differences of opinion."
원문 출처: https://www.apa.org/monitor/2017/12/psychoanalysis
Amy Novotney가 2017년 12월 미국심리학회의 출판물인 Monitor on Psychology의 48권 11호에 기고한 글
한글 번안:
어린 시절과 진로의 시작
7살 때, 프라튜샤 투말라-나라(Pratyusha Tummala-Narra)는 정치적 긴장이 가득한 인도를 떠나 가족과 함께 미국으로 이주했다. 그러나 인종적·민족적 소수자로 살아가며 겪은 적응의 어려움은 그녀에게 뚜렷한 방향을 제시했다. 결국 미시간주립대학교에서 심리학 박사학위를 선택하게 된 것이다.
지난 20년 동안 그녀는 임상가로 활동하면서 정신분석적 관점에 다문화적, 페미니스트적 시각을 결합해왔다. 특히 이민자와 소수민족 내담자들이 문화 적응, 차별, 트라우마를 다루는 데 집중해왔다. 그녀의 작업은 지그문트 프로이트의 사상에 뿌리를 두고, 의식 밖에 자리할 수 있는 내담자의 생각과 감정이 어떻게 사회적·문화적·정치적 경험에 영향을 미치는지 탐구한다.
프로이트의 유산과 미국 내 변화
투말라-나라는 현재 보스턴 칼리지에서 상담·발달·교육심리학 교수로도 재직 중이다. 그녀는 이렇게 강조한다.
“프로이트는 논란이 많은 인물이지만, 그와 동료들이 유럽 전역에 무료 클리닉을 세워 계급에 상관없이 누구나 정신치료를 받을 수 있게 했다는 사실은 종종 잊혀집니다.”
그러면서 덧붙였다.
“정신분석이 1900년대 초 미국에 들어왔을 때, 중산층 이상만 접근 가능한 치료로 변모했는데, 그것은 프로이트의 의도가 결코 아니었습니다. 그는 심리역동적 치료를 모든 사람을 위한 보편적 치료로 보았습니다.”
정신분석의 쇠퇴와 비판
한때 심리치료의 왕좌에 있던 정신분석은 지난 40년간 미국 정신건강계에서 영향력을 잃어왔다. 이유는 다양하다. 일부는 정신분석 이론가들이 치료 효과에 대한 연구에 소홀했다고 지적한다. 또 어떤 이들은 무의식과 같은 심층 심리를 탐구한다는 점에서 접근이 지나치게 추상적이라 비판한다. 반면 인지행동치료(CBT)는 부정적 감정을 유발하는 사고를 조정하는 데 집중하며, 훨씬 더 실용적으로 보인다.
여기에 오이디푸스 콤플렉스 같은 프로이트의 특정 이론들은 버려지고, 초기 관계와 그 영향에 대한 폭넓은 이해가 자리 잡았다. 오늘날의 단기 치료, 보험 제약 중심의 환경 속에서 정신분석은 “시대착오적이고 비효율적”이라는 낙인이 찍히기도 했다.
정신분석의 현재적 의미
그럼에도 불구하고, 오늘날의 정신분석가들은 입을 모아 말한다. 정신역동적 치료는 여전히 다른 치료법만큼, 아니 그 이상으로 효과적일 수 있다는 것이다.
투말라-나라는 지적한다.
“우리는 현재 매뉴얼 기반의 ‘실증적 치료’와 단기 모델에 지나치게 집중하고 있습니다. 하지만 실제 환자들은 홈리스, 빈곤, 트라우마, 차별 같은 복합적 문제를 겪고 있죠. 이를 다루려면 개인 전체에 대한 깊은 이해가 필요합니다. 단순히 매뉴얼만으로는 충분하지 않습니다.”
콜로라도 의과대학 정신의학과 임상 교수이자 개업 분석가인 조너선 셰들러(Jonathan Shedler)도 같은 맥락에서 말한다.
“정신분석은 프로이트로 끝난 것이 아닙니다. 물리학이 뉴턴에서 끝나지 않았듯, 행동주의가 왓슨에서 끝나지 않았듯, 정신분석도 진화해왔습니다.”
실제로 최근 정신분석가들의 과학적 헌신은 정신역동적 치료가 CBT 등 다른 치료법만큼이나 효과적이라는 증거를 빠르게 쌓아가고 있다.
축적되는 연구 증거
연구는 점점 더 명확해지고 있다. 최근의 다수 연구가 정신역동적 치료가 CBT보다 장기적 효과에서 우위를 가질 수 있음을 보여준다.
2015년, 런던대학교(UCL)의 피터 포나기(Peter Fonagy)는 영국 NHS를 통해 만성 우울 성인들을 대상으로 18개월간 주 1회 정신분석 치료와 ‘통상적 치료(CBT 포함)’를 비교했다. 치료 종료 시점에는 두 집단 모두 비슷한 개선을 보였다. 그러나 2년 후에는 큰 차이가 드러났다. 정신분석군의 44%가 더 이상 주요우울 진단 기준을 충족하지 않았지만, CBT군은 10%에 불과했다(World Psychiatry, Vol. 14, No. 3, 2015).
2016년 포나기의 또 다른 연구는 부모-영아 정신분석 심리치료를 다뤘다. 유아 발달 지표에서는 차이가 없었으나, 부모들은 양육 스트레스 감소와 자기 인식 향상 등 정신건강 측면에서 뚜렷한 개선을 경험했다(Infant Mental Health Journal, Vol. 37, No. 2, 2016).
2017년에는 암스테르담 자유대학교의 엘렌 드리센(Ellen Driessen)이 주도한 연구가 발표되었다. 결과는 명확했다. 단기 정신역동적 치료는 불안, 통증 완화, 삶의 질 향상 등에서 CBT만큼이나 효과적이었다(Journal of Consulting and Clinical Psychology, Vol. 85, No. 7, 2017).
포나기는 이렇게 말한다.
“중요한 것은 특정 환자 집단에 가장 잘 맞는 치료를 찾는 것입니다. 사람들의 문제를 깊이 이해할 필요가 있고, 그 점에서 정신분석은 정교한 마음의 모델을 제공합니다.”
셰들러 역시 2010년 종합 리뷰에서 불안과 우울 같은 흔한 문제에 대해 정신역동적 치료가 다른 ‘근거 기반 치료’ 못지않게 효과적이며, 효과가 훨씬 오래 지속된다고 결론지었다(American Psychologist, Vol. 65, No. 2).
2006년 메타분석(2014년 업데이트, 33개 무작위 대조 연구, 환자 2,173명)은 단기 정신역동적 치료(40시간 미만)를 받은 환자들이 불안·우울 증상 감소를 경험했으며, 그 효과는 9개월 이상의 추적 관찰에서 더욱 커졌다. 이는 정신역동적 치료가 치료 종료 후에도 변화 과정을 촉발한다는 점을 보여준다.
셰들러는 말한다.
“CBT의 효과는 치료가 끝나는 순간부터 약해지기 시작합니다. 보통 6개월~1년 안에 그 효과는 사라집니다.”
반대 의견
물론 반론도 있다. 밴더빌트대학교의 스티븐 홀론(Steven Hollon)은 2013년 메타분석을 인용하며, “CBT를 받은 환자들은 항우울제 복용자들보다 재발률이 절반 이하로 낮다”고 주장한다(BMJ Open, Vol. 3, No. 4).
그는 이렇게 덧붙였다.
“우울증은 본질적으로 만성적이고 재발하는 병이므로 증상 재발은 자연스러운 일입니다. 그러나 CBT가 약물보다 지속적 효과를 보인다는 분명한 증거가 있습니다. 정신역동적 치료도 지속 효과가 있을 수 있으나, 아직 충분히 연구되지 않았습니다. 증거가 없다는 것이 효과가 없다는 뜻은 아니지만, 한 세기 넘게 존재해왔음에도 제대로 검증된 바가 부족합니다.”
오늘날의 정신역동적 치료
셰들러는 정신분석이 여전히 프로이트 시대의 오래된 방식으로만 행해진다고 생각하는 것은 큰 오해라고 강조한다. 오늘날 대부분의 치료는 주 1회 진행된다. 투말라-나라는 대다수 내담자와 주 1~2회 만나며, 치료 기간은 수주에서 수년에 걸쳐 다양하다.
그녀는 내담자의 어린 시절 경험과 가족 관계, 현재의 어려움을 집중적으로 탐색한다. 자유연상을 장려하고, 초기 기억과 꿈을 다루며 현재의 고통을 이해할 단서를 찾는다. 이러한 과정은 내담자가 자기 자신과 타인에 대한 새로운 이해와 더 나은 관계 방식을 찾도록 돕는다.
또한 치료 관계 속 전이와 역전이를 탐구함으로써 내담자는 관계 패턴을 새롭게 경험한다. 예컨대 치료자가 인종 문제를 회피한다면, 내담자도 무의식적으로 이를 축소할 수 있다. 이러한 교착을 함께 다루는 것은 진정성 있는 관계 형성과 고통스러운 정서를 견디고 다루는 능력을 기르는 데 핵심적이다.
셰들러는 이렇게 요약한다.
“환자가 치료자와 맺는 관계는 다른 관계에서 무슨 문제가 일어나는지, 또 무엇이 잘 되는지를 보여주는 창입니다. 우리는 단순히 문제 이야기를 듣는 것이 아니라, 그것을 실제로 경험하고 있는 셈입니다.”
미래 전망
시티칼리지의 엘리엇 주리스트(Elliot Jurist)는 이렇게 기대한다.
“증거가 축적되면 정신분석에 대한 낙인이 줄고, 가치 있는 부분이 더 널리 활용될 수 있을 것입니다.”
아델피대학교의 자크 바버(Jacques Barber) 역시 같은 희망을 전한다. 다만 그는 정신역동적 치료 연구가 대규모 표본을 필요로 하기에 미국 내 연구 자금 지원이 부족하다고 지적한다.
그는 말한다.
“어떤 치료도 모든 환자에게 효과적일 수는 없습니다. 중요한 질문은 ‘어떤 치료가 어떤 환자에게 가장 잘 맞을까?’입니다. 다음 세대는 이 질문에 답해야 할 것입니다.”
투말라-나라는 학생과 전문가, 교육자들에게 정신분석 이론의 타당성과 현대적 관련성을 알리는 일이 중요하다고 강조한다.
펜실베이니아주립대 켄 레비(Ken Levy)는 학계와 학술지, 심사 과정에서 사상의 다양성과 사고의 폭을 존중하는 문화가 필요하다고 말한다.
“심리학의 가장 큰 성취는 서로 다른 생각들이 충돌하는 과정에서 이루어졌습니다.”
그 예로, 발터 미셸(Walter Mischel)의 인지-정서적 성격 이론은 대상관계 이론, 애착 이론 같은 정신역동 모델과 맞닿아 있다. 레비는 설명한다.
“미셸이 처음 ‘성격은 존재하지 않는다’고 주장했을 때, 오히려 성격 연구가 부흥했고, 지금은 그의 이론이 성격 연구의 핵심 틀 중 하나가 되었습니다. 서로 다른 의견의 충돌이 학문을 발전시킨 대표적인 사례입니다.”
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원문 전문:
At age 7, Pratyusha Tummala-Narra emigrated from India to the United States with her family, leaving behind a country rife with political tensions. Her struggles to adjust to life as a racial and ethnic minority led her to pursue a PhD in psychology from Michigan State University. For the past 20 years, she has worked as a clinician, integrating psychoanalytic, multicultural and feminist perspectives into her practice, which focuses on helping immigrant and ethnic-minority clients deal with acculturation, discrimination and trauma. Her work draws on the ideas of the founder of psychoanalysis, Sigmund Freud, to explore how her clients' thoughts and feelings that may lie outside awareness affect their social, cultural and political experiences.
As controversial as Freud may be, people often forget that he and his colleagues opened free clinics throughout Europe so that people of any class could have access to psychotherapy, says Tummala-Narra, who is also a professor of counseling, developmental and educational psychology at Boston College.
"When psychoanalysis came to the United States in the early 1900s, it developed into a form of treatment that seemed to only be accessible to the middle and upper-middle classes, which was never Freud's intention," she says. "He viewed psychodynamic therapy as a universal treatment for all people."
Once the ruler of the therapy world, psychoanalysis and psychodynamic therapy fell out of favor in the United States among many mental health professionals over the past 40 years, due to several factors. Some experts cite a lack of commitment by psychoanalytic theorists to conduct research on the therapy's effectiveness. Others see the treatment as too abstract because it seeks to help clients uncover deeper, often unconscious aspects of experience, while approaches such as cognitive-behavioral therapy (CBT) focus more on helping clients adjust thoughts believed to cause negative emotions. Further, many of Freud's specific ideas, such as the Oedipus complex, have been dropped in favor of a broader view of early relationships and their impacts. And others say psychodynamic therapy is just not relevant or efficient in today's quick-fix, insurancelimited marketplace.
But today's psychoanalytic practitioners say that for many mental health issues, psychodynamic therapy is at least as effective as, if not better than, other therapy approaches—and should not be ignored.
"As a field we've moved into focusing heavily on what are considered to be empirically supported treatments, largely based on protocol and in short-term models of psychotherapy," Tummala-Narra says. "Yet as practitioners, we're seeing patients who are suffering from multiple stressful events in their lives, including homelessness, poverty, trauma and discrimination. Helping them deal with all of these complicated issues really requires a depth of understanding of the whole person and how these events are affecting their relationships with people and how they function in the world. To truly help our clients, we can't always just rely on a protocol-based treatment."
Plus, psychoanalytic thinking has evolved rapidly since Freud, says Jonathan Shedler, PhD, a clinical professor of psychiatry at the University of Colorado School of Medicine who also has a private practice. "The development of psychoanalytic thought did not end with Freud any more than the development of physics ended with Newton, or the development of the behavioral tradition in psychology ended with Watson," Shedler says.
And most important, these practitioners say, a new commitment to science by psychoanalytic researchers and practitioners has led to a growing body of evidence that psychodynamic therapy is as effective as—and sometimes more beneficial than—CBT and other therapies.
Mounting research
Several recent studies have found that psychodynamic theory can provide more long-term benefits than CBT. In 2015, University College London psychoanalyst and clinical psychologist Peter Fonagy, PhD, led a study through the National Health Service in England comparing 18 months of once-a-week psychoanalytic therapy with "treatment as usual," which included CBT, among adults with chronic depression. The researchers found that 18 months of psychoanalysis provided similar benefits in terms of observer-based and self-reported depression scores compared with the control treatment. But the team also found that patients who received psychoanalytic therapy experienced much longer effects: Two years after treatment ended, 44 percent of patients who received psychoanalysis no longer met the criteria for major depression, compared with 10 percent of the CBT group ( World Psychiatry , Vol. 14, No. 3, 2015 ).
A second study, led by Fonagy and published in 2016, looked at parent-infant psychoanalytic psychotherapy, which aims to improve the interaction between parent and child. Participants were randomly assigned to receive parent-infant psychotherapy or supportive primary care. The authors found no significant difference in outcomes for either intervention on measures of infant development, parent-infant interaction or the parent's ability to consider the baby's mental state as well as their own. However, parents who had received parent-infant psychotherapy showed improvements on several measures of maternal mental health, such as less parenting stress and more positive views of themselves as parents ( Infant Mental Health Journal , Vol. 37, No. 2, 2016 ).
Another study published this year, led by Ellen Driessen, PhD, a postdoctoral psychology research associate at VU University in Amsterdam, found that short-term psychodynamic therapy for depression is at least as effective as CBT with regard to many important aspects of patient functioning, including reducing anxiety and pain and improving quality of life ( Journal of Consulting and Clinical Psychology , Vol. 85, No. 7, 2017).
"To me, the important thing is finding the psychological therapies that work best for particular patient groups and, to find those treatments, I think we have to have a better understanding of the nature of the problems that people come to us with," Fonagy says. "That's where I think psychoanalysis can help, because it does have a very sophisticated model of the mind."
In a 2010 comprehensive research review, Shedler found that, particularly for common conditions such as anxiety and depression, psychodynamic therapy is at least as effective as all the other therapies that he says are branded and promoted as evidence-based ( American Psychologist , Vol. 65, No. 2 ). Moreover, he says, the benefits of the psychodynamic approach appear to endure much longer than those of CBT.
For example, a 2006 meta-analysis he includes in his review—which was updated in 2014 to include 33 randomized controlled trials of 2,173 patients with a range of common mental disorders—showed a reduction in anxiety and depressive symptoms among participants who received short-term (less than 40 hours) psychodynamic therapy. These benefits continued increasing over time and were actually greater at long-term follow-up, nine months or more after the intervention ended. This suggests that psychodynamic therapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended, Shedler says.
"For the most common conditions, such as anxiety and depression, the benefits of CBT start to dissipate the day the treatment ends," Shedler says. "The typical finding is that by six months to a year, there is no indication that there was any benefit whatsoever."
Not everyone agrees with that assessment. Vanderbilt University psychology professor Steven Hollon, PhD, past president of the Association for Behavioral and Cognitive Therapies, notes that individuals do relapse following successful treatment with either CBT or an antidepressant medication, but prior CBT cuts the relapse rate by more than half, according to a 2013 meta-analysis he co-authored ( BMJ Open , Vol. 3, No. 4 ).
"Depression tends to be a chronic or recurrent disorder, so subsequent symptom return is what you would expect, but we have clear evidence that CBT has an enduring effect as compared to medication," Hollon says. "Psychodynamic therapy may have an enduring effect, too, but that has simply never been adequately investigated. Absence of evidence is not evidence of absence, but the approach has been around for over a century and simply has not been all that adequately tested."
Psychoanalytic practice today
One of the greatest misconceptions regarding psychodynamic therapy is that it has remained unchanged since Freud introduced it at the turn of the century, Shedler says.
"There have been sea changes in psychoanalytic theory and technique, but psychology textbooks continue to offer portrayals that are a century out of date," he says. "People still think that patients come in four or five days a week for an hour at a time and lie on a couch," he says.
While a few psychoanalytic therapists still practice that way, today most see their patients once a week. Tummala-Narra says she works with most of her clients once or twice weekly, and that the length of their treatment varies, with some clients lasting several weeks, and others several years.
The approach focuses on helping patients understand themselves more deeply so they can identify the factors underlying their difficulties and stop repeating the same patterns, Shedler says.
"A central way of understanding the psychodynamic approach is that there's more to human beings than meets the eye," he says. "There's what you can see on the surface of things—presenting problems or symptoms or a diagnosis—and there's what is going on psychologically that's underlying the patient's problems."
The approach differs from other therapy techniques in that it seeks to help clients uncover underlying reasons for their feelings and behaviors, which may initially be outside the client's awareness. Other approaches focus more on helping clients adjust unhelpful present thoughts.
"Psychologists who practice psychodynamic therapy are more interested in some of the complexities and subtleties of clinical work, and are less content to define success just in terms of something like lessening symptoms," says Elliot Jurist, PhD, psychology professor at the City University of New York and editor of Psychoanalytic Psychology. "They tend to pursue the more ambitious goal of helping someone move toward psychological health, rather than just getting rid of what they're suffering from."
Tummala-Narra focuses her client discussions on past experiences, such as a client's childhood and relationships with family members, as well as present challenges. "As the family is typically the initial space for socialization, I pay close attention to what messages clients have learned from parents, siblings, grandparents and other significant people in their life," she says.
She encourages her clients to follow their thoughts wherever they lead, also known as free association, and inquires about early childhood memories and dreams to help facilitate discussion of the meaning of clients' experiences. "Learning about each aspect of experience helps me and the client understand in more depth the nature and history of the current suffering." That, she says, leads to insights that help the client move toward considering and engaging in new, more productive and fulfilling ways of thinking about themselves and others.
Psychodynamic therapy also allows patients to explore and rework their relationships through the therapeutic relationship by examining transference and countertransference dynamics, Tummala-Narra says. For example, the therapist may avoid or minimize the role of racism in the client's life if he or she feels uncomfortable or has conflicted feelings about race and racism, she says. "The client in turn may unconsciously collude with the therapist's discomfort, and minimize the role of racism in his or her life. Working through impasses or enactments of these dynamics is critical to psychoanalytic practice, and offers an opportunity to engage in a unique relationship that promotes authenticity and the ability to tolerate and work through painful affective experiences."
Shedler agrees, noting that this is a crucial dividing line between the psychodynamic perspective and other therapy approaches. "The relationship that the patient creates with the therapist is a window into what goes right and what goes wrong in the patient's other relationships," he says. "We're not just hearing about what causes the person's problems, we're actually experiencing it firsthand in the office."
Looking toward the future
Given the research supporting the effectiveness of psychoanalysis, Jurist says he is hopeful that more practitioners will be open to providing it. "My hope is that this will help reduce the stigma around psychodynamic thinking and that people will take things that they find valuable and use it in their practice," he says.
Jacques Barber, PhD, dean of psychology at Adelphi University, shares Jurist's hope that the growing body of evidence that psychoanalytic therapy is effective will boost interest among researchers and practitioners. Unfortunately, he notes, funding to study psychodynamic therapy in the United States is difficult to come by because it requires a large sample size and can be hard to implement.
"We know that no treatment is effective for all patients," Barber says. "Now the important question is, how do we try to predict what kind of treatment will work best for which kind of patient? I think this is what the next generation will need to deal with."
Tummala-Narra agrees, pointing to the need for those in the profession to enlighten students, professionals and educators about the validity and relevance of psychoanalytic theory in contemporary practice.
"We need to broaden the perspective in terms of what's thought about as effective psychotherapy, rather than relying on one subset of techniques or methods," she says.
Ken Levy, PhD, a clinical psychology professor at Penn State University who maintains a small psychodynamically oriented private practice, adds that review panels, journals and psychology departments also need to pay more attention to valuing the idea of diverse thinking and diverse ideas.
"Some of the greatest achievements in psychology have occurred in the context of people having different ideas about things," he says.
For example, Walter Mischel's cognitive-affective personality theory is consistent with psychodynamic models such as object relations and attachment theories.
"Mischel initially saying that there was no such thing as personality led to a resurgence in personality research that now has Mischel as one of the leading frameworks in personality theory," Levy says. "That happened because people had differences of opinion."
원문 출처: https://www.apa.org/monitor/2017/12/psychoanalysis