The beliefs of those practicing mindfulness vs. psychoanalysis vary dramatically. Is mindfulness or psychoanalysis right?

Beliefs of Psychoanalysts

Many psychoanalysts believe symptoms or disturbing thoughts are, essentially, a manifestation of unconscious wishes or a defense against a wish. Change comes from understanding the latent meaning behind these thoughts. Some analysts may suggest even everyday slips of the tongue are not merely mistakes but, rather, an aspect of unconscious material leaking into consciousness. For example, a man who says I love my wife’s death, rather than I love my wife to death, may be interpreted as indicating some underlying repressed aggression.

Beliefs Tied to Mindfulness

In contrast, third wave cognitive psychotherapy minimizes the meaning of thoughts. Thoughts are often seen as not having meaning. Thoughts are similar to transient physical sensations or weather conditions. A mindfulness practitioner may suggest we are not our thoughts. Separating ourselves from thoughts is curative and the therapeutic goal. Musing over the thought content can actually lead to more pathology in certain circumstances. As we can see there is a big difference between how psychoanalysis and mindfulness based therapies may view thoughts. Who is correct?

Mindfulness vs. Psychoanalysis for a Patient with Obsessive-Compulsive Disorder

A recent National Public Radio (NPR) podcast, Dark Thoughts, eloquently addresses the divide between mindfulness and psychoanalysis by following the experience of a patient with obsessive-compulsive disorder (OCD) (pure obsessional OCD, in this case). The patient is struggling immensely with intrusive thoughts of stabbing his wife or hurting others. These thoughts create intense anxiety and the man is paralyzed with fear. He is horrified by his symptoms and at times suicidal. The patient first sees a psychoanalytic informed therapist and the therapy goes poorly. The therapist appears to be slightly afraid of him. The message the patient received from the therapist is that there is a link between his thoughts and aggressive urges. The subtext is unconsciously the patient has rage that is breaking through.

The patient then sees a cognitive behavioral-based therapist who uses mindfulness techniques and he obtains much more relief. Third wave approaches such as mindfulness deal with intrusive, aggressive thoughts by teaching the patient to diffuse their meaning. Everyone has aggressive thoughts; however, patients suffering with OCD have difficulty dismissing them and consistently check in to see if they are present. Teaching patients mindfulness skills to shift away from (yet acknowledging) the intrusive thoughts is part of the treatment. The message the patient learns via mindfulness is essentially his thoughts are not important and do not warrant in-depth exploration.

Integrating Psychoanalysis and Mindfulness May Be What is “Right”

In the end, the NPR piece suggests that the winner is third wave psychotherapy and the loser is old school analysis. Although I am strong proponent of mindfulness for OCD I feel the NPR piece exemplifies the identity crisis the field of psychotherapy is going through. Psychotherapy has a split sense of self that is broken up into good and bad representations. I believe the treatment for the identity crisis psychotherapy is facing is integration. I agree it is too concrete to view an intrusive symptom of aggression as a wish or desire. Where psychoanalytic approaches can be beneficial is not solely looking at the content of the thought, but helping patients analyze the meaning of their thought process. It’s important to explore why the patient with OCD has difficulty dismissing an aggressive thought as opposed to what the thought literally means. Understanding the psychodynamics of the thought process such as guilt proneness, rather than the specific content of thought, along with mindfulness or exposure techniques can be helpful. This approach retains both useful aspects of psychoanalysis and mindfulness therapeutic frameworks and can lead to both symptom reduction and long lasting change.