In this article, we discuss the fallacy that psychoanalysis is a practice that does not have evidence of effectiveness, carrying out a bibliographical research in several databases to verify if there are researches that support psychoanalysis as an evidence-based treatment. Throughout the article, we pin the importance of this research since in several countries that are references in the health field, for a practice to be accepted it must have effectiveness evidence and, although as exposed in the body of this research. As we demonstrated in our research, Psychoanalysis has numerous researches that show its effectiveness but, major countryies in the field of mental health as United States, United Kingdom and Canadá, do not consider Psychoanalysis as an evidence-based treatment. This finding led us to search and identify some reasons for this.

Keywords: psychoanalysis, mental health, evidence based practice

Since the 1990s, with advancements in neurosciences research, pharmacology and evidence-based practice, more and more importance has been given to mental health treatments efficiency and effectiveness empirical evidence.

Whether for public or private services, each country has its own body, agency or system that will regulate, welcome and make treatments available or block their insertion into the healthcare market within that particular country. According to this work, sanctioning and regulatory institutions do not intend to reflect on the causality of the pathology or on the scientificity of the evaluated treatments. In most cases, agencies receive the final product of what has been “scientifically” created with the aim of verifying the effectiveness, efficiency and viability of certain treatments, in order to determine whether they should be available or prohibited within the national territory.

In this article, based on a literature review, we will see how what is proposed as truth delivered by science to citizens in the field of mental health, not only in Brazil, but also internationally, necessarily depends on funding often unnecessary from companies supporting a particular practice, from organizations and institutions that broadcasting in the media what is good, what is useful and what should be avoided and, finally, the mindless state adherence with legislations that aim to support certain ideologies. In particular, when it comes to psychoanalytic treatment, we will see that the supposed “scientific truth” is a historically and geographically constructed way of thinking that has the support of “big pharmaceuticals” and governments in the name of profit and the distribution of a treatment low-cost that is not as effective as its propagators usually claim it to be.

Health institutions and protocols in Brazil and in the world

As well as the Sistema Único de Saúde (SUS) and the National Health Surveillance Agency (ANVISA) in Brazil, there are the National Health Service (NHS) in the United Kingdom, Canada's Health Care System (Medicare) in Canada and the Institut National de la Santé et de la Recherche Médicale (Inserm) in France. These institutions, for example, depend on empirical data to recognize, recommend and support the treatment modalities offered in their countries through approval, financing and public policy. They are also largely responsible for directing treatments through research that they organize and sometimes finance. Such researches, usually of a clinical nature, always intend to solve a specific problem in a certain region or population.

In the United Kingdom, researchers and health professionals created the NICE guideline where the National Institute for Health and Healthcare Excellence determined protocols to guide the country's health professionals regarding what practices are supported by the government and how to apply them accordingly in line with the specificity of each case.

The main elements analyzed by NICE for a practice to be recommended in the guideline are the effectiveness of a given treatment empirical evidence, the financial viability for the treatment to be offered to the population, its availability and trained professionals. For example, the first-choice treatment for major depressive disorder, according to NICE guidelines, are treatments based on Cognitive Behavioral Therapy as well as the use of psychotropic medication. However, among the other possible treatments, although with some reservations, the document points to brief psychodynamic psychotherapy which, according to the document published in 2022, has evidence of efficacy in major depression treatment. Although the document states that it is based on empirical evidence, some of the practices that are not contained in it also have empirical evidence of effectiveness, efficiency, etc. The treatments choice recommended by NICE also depends on other factors that we will see throughout this article. The fact is that the document produced does not correspond to the empirical evidence reality found in research on the subject of treatment for major depression.

Since mid-2010, there has been a growing number of publications that corroborate to the fact that Psychoanalysis¹ and psychoanalytically based therapies are effective for this disorder as well as many others. One of these most prominent papers in the field of mental health, which is still discussed to this day, is Shedler's,¹ which basically opened the doors for more analysts and researchers to begin understanding the importance of having their results empirically based.

Four years after Shedler, Leichsenring,² in a meta-analysis research found evidence from randomized controlled studies of Psychoanalysis empirical efficacy. Among other studies, we also highlight Gaskin³ who, although states that more research is needed to have better and more robust evidence, also reveals that the evidence exists that Psychoanalysis and the models based on it achieve effects that remain even after the end of treatment. In this article, we will analyze other research studies that provide evidence relevant to the specific topic we will be addressing, at first, we only highlight that the research and evidence existed even before the protocol was published in 2022 and that they are neither scarce nor difficult to obtain from those who are used to working with research.

In an article entitled Effectiveness of psychoanalytic psychotherapies, Chrzan-Dętkośand Kalita,⁴ the authors confirmed the empirical effectiveness of psychoanalytic treatment for various mental disorders, citing randomized controlled trials (RCT), meta-analyses that corroborate to the findings in these studies, and many other elements that reaffirm Psychoanalysis as a treatment with strong efficacy evidence. The hypothesis arises, then, that perhaps, one of the problems for the non-disclosure of this scientific material may lie within the analytical communities where the institutions themselves either remain unaware of the research or, through their analysts, fail to recognize them as possible and necessary. Without research and scientific dissemination, it is unlikely that guidelines and the general population will have knowledge of and access to this treatment.

Continuing with the discussion regarding protocols for mental health treatment, in Canada there is a policy that treatment is accessible and universal. According to Moroz et al.,⁵ just like in the NHS, in addition to ensuring that a treatment is effective, cost-benefit studies must be carried out for the treatment to be included in Medicare (a healthcare system financed by the federal government of Canada). Among the practices not incorporated into Medicare is Psychoanalysis. According to the document Canada Health Act Annual Report 2019-2020, psychoanalytic practice is not a treatment covered by the country's health system, however, there is a statement in the document itself that says Psychoanalysis can be applied in institutions that have a bond with Medicare and that the treatment must be previously approved by the Minister of Health and Social Services of Canada. It is curious, therefore, that the government institution regulation the offered treatments does not recognize Psychoanalysis as one of the empirically validated treatments, although it does not prevent its practice as long as it is under state control.

Currently, in Canada, studies regarding the effectiveness of psychoanalytic treatment for various mental disorders are being carried out and their results published. According to Leuzinger-Bohleber et al.,⁶ in research published in the Canadian Journal of Psychiatry, no significant differences were found between psychoanalytic and cognitive behavioral treatments in the long term. In 2020, Abass et al.,⁷ in an article entitled Psychodynamic therapy in Canada in the era of evidence-based practice, highlights that psychodynamic psychotherapy should be included in the list of therapies considered to have empirical evidence of effectiveness and, furthermore, that patients who do not have satisfactory results with other treatments already considered “empirically proven” should be able to choose psychoanalytic treatment subsidized by Medicare. This brings us to the study published in 2015 by the Tavstock Research Center⁸ where patients who showed no improvement while primarily undergoing cognitive-behavioral psychotherapy and psychopharmacological treatment, when treated with psychoanalysis had 44% of these patients no longer meeting the criteria for a diagnosis of depression after 18 months. In the control group, only 10%. This study also concluded that the chances of a patient benefiting from psychoanalytic treatment is 40% higher those who received the usual treatment.

In France, a country known to have a great psychoanalytical tradition, not only because of the life and work of Jacques Lacan, but also because of Daniel Lagache who, in addition to being a physician and psychoanalyst, was appointed responsible for training the first psychologists in the country after the occupation during World War II; There is at the moment great tension in relation to the topic addressed in this article. Currently, it can be said that there is an explicit conflict between entities that promote evidence-based treatments and the psychoanalytic tradition.

The major confrontation occurred around the 2000s when, according to Sauré and others,⁹ the French Public Health Council was bombarded by criticism at Psychoanalysis and analysts. Most of the criticism was related to Psychoanalysis not having evidence of efficacy and, also, starting from the growth of a biopsychosocial model for different psychopathologies, the psychoanalytic legacy and tradition in medicine, psychiatry, education and psychology began to crumble.

Based on a global proposal, following the policy of other countries such as the United Kingdom, the General Direction of Health (DGS), the National Union of Mental Friends and Family III (UNAFAM), the National Psychiatric Federation of Psychiatric Patients and Ex-Patients (Fnap-psy) among other institutions, were tasked with producing a report comparing treatments and their effectiveness in the field of mental health. This report became famous worldwide under the name Inserm Report. The objectives, research and model used in the report were in accordance with NICE in the United Kingdom and Medicare in Canada. The main idea was to offer empirically validated treatments in France and, mainly, that science in the area would point out the evidence that would decide which practices would benefit the population most and which should be prohibited. The idea of ​​this pressure, according to Sauré and others,⁹ was to prohibit Psychoanalysis and other treatments from being offered in France.

At this point, it should be noted that many analysts, who deny research in the field of mental health and say that Psychoanalysis should not be included in a treatment with evidence of effectiveness, do not even have an idea of ​​what happened in this period in France and what has been happening worldwide, in general, with regards to the non-inclusion of psychoanalytic care in public and corporate systems (health insurance).

Once again, if the accepted and offered treatments must be based on evidence, why not subject Psychoanalysis and the treatments based on it to research to verify or refute this modality of treatment? Saying that it is a pseudoscience based on authors like Popper or Hanson is not enough. Other epistemologists such as Bachelard, Kojéve, Koyré, Milner, think about science in another way. They think of a science in which it is possible to include Psychoanalysis and its treatment within the “scientific” predicate. Regardless of the philosophical line that will demarcate what we call science, Psychoanalysis is present in today's world as a treatment and, as such, must demonstrate evidence of effectiveness and efficiency to, even nowadays, be dispensed to the general population.

Psychoanalysis in Brazil, SUS and evidence-based medicine: historical relations

In Brazil, Psychoanalysis has a strong presence within the universities and perhaps holds even more power in the culture than within psychology, medicine and education departments. These three departments were responsible for the insertion, maintenance and growth of Psychoanalysis in Brazil, however, currently, there is a sharp decline in theoretical training that was provided at universities in exchange for training that was more consistent with the policy of evidence-based practices that not only advocate against psychoanalytic treatment, relegating it to a past history of psychology, which makes no sense since even Psychoanalysis is not an approach to Psychology, but, mainly, attacking analysts directly saying that it is a pseudoscience and that it is does not have empirical evidence of efficacy.

Historically, in Brazil, Freud's ideas first appeared with the psychiatrist Dr. Juliano Moreira, who in 1899 presented a work citing some of Freud's ideas. Then, Durval Marcondes, Francisco Franco da Rocha and many other doctors dedicated themselves to the study and implementation of Psychoanalysis in our country.

While Psychoanalysis was advancing in Brazil, and all over the world, other ideas about mental health treatment were gaining strength. In the same decade (1950) in which Psychoanalysis in Brazil was recognized by the IPA, the Diagnostic and Statistical Manual of Mental (DSM) was created. In the first manuals, there was a very close relationship between the DSM and psychoanalytic theories. Both in the way of thinking about psychopathologies and also in the possibility of treating the most diverse manifestations described in the DSM.

According to Dunker,¹⁰ up to its third edition released in the mid-70s (DSM-III), it is possible to historically identify a good relationship between Psychoanalysis and psychiatry. Consequently, the Manual reconciled both proposals. In the third version, the relationship with Psychoanalysis was extremely shaken. Twenty years after the launch of DSM-III, the fourth version of the Manual appeared, burying once and for all any possibility of dialogue with Psychoanalysis and, curiously, with many other fields of knowledge that brought elements to think, diagnose, and treat patients diagnosed through the exercise of power that the Manual proposes as a diagnosis form.

In the publication of the DSM-IV, launched in the 1990s, the proposal was that the manual should be non-theoretical, following the perspective of evidence-based treatments. In this logic, it is already possible to envision that the truth was pragmatically submitted to the idea that science should deal with practices based on evidence, in the final analysis, the truth is what “science” claims to be. Psychopathologies began to be understood from a biological perspective, even if, to give two examples, biological markers that prove, for example, the organic causality of depression or bipolar disorders are not found, this idea is supported and emphasized in the media that the DSM program is atheoretical.

Not just mental disorders, but the creation of guidelines by the APA followed in partnership with the pharmaceutical industry and with the newly formalized policy of evidence-based medicine. Historically, the 1990s were also marked by the beginning of the sale and massive dissemination of Prozac as the medication that would end the Depression. Aligned with the vanguard of the biologizing policy, many treatment models began to gain ground, among them Cognitive Behavioral Psychotherapy which, in its core, was born in a time and environment in which Evidence-Based Medicine was developing.

The Evidence Based Medicine proposal emerged in the mid-1990s as the heart of the medical residency program coordinated by Dr. Gordon Guyatt at McMasters University. However, according to Sur & Dahm,¹¹ since 1969 there was a research project that attempted to articulate medical theory with clinical practice and also respond to a deficit that existed in medicine in that there was no training based on scientific evidence. so that doctors could carry out clinical practice.

According to Faria Lima and Filho,¹² one of the reasons for evidence-based medicine to take shape around the world from the 90s onwards was the strong funding from the Rockefeller Foundation and the Cochrane Collaboration, both aligned with research in the field of neurosciences and of pharmacology. In particular, the Rockefeller Foundation has been funding projects and research in the field of mental health for many years. In 1953, he financed the MKULTRA project in partnership with Central Intelligence Agency (CIA) from the United States. This program aimed to carry out research in the field of psychiatry, using humans as guinea pigs. We will not go into details of this research, but one of the MKULTRA objectives was to achieve mental control over individuals subjected to torture and experiments with psychotropic drugs.

According to Offerman,¹³ prior to the MKULTRA program, it also prominently financed the Aktion T4 program that exterminated people considered incurably ill. Aktion T4 was a eugenics and euthanasia project developed in Nazi Germany in which thousands of people were killed for having a “[...] life unworthy of being lived”. Patients were, for the most part, exterminated for having any type of disease that doctors considered incurable, especially the mentally ill and babies up to 3 years’ old who had traits of idiocy or Down syndrome.

Although they were different times, this same foundation was responsible, in the 90s, for the implementation of evidence-based medicine (EBM) in large university centers and in agreement with government agencies in several countries, mainly the United States. According to Faria et al.,¹² from the 1990s, EBM soon reached worldwide coverage, especially with the International Network of Clinical Epidemiology (Inclen), supported by consistent and massive investments from the Rockefeller Foundation by White and with Cochrane Collaboration, international movement founded by Iain Chalmers in 1993 to share scientifically validated clinical information.

Based on public documents accessible by citizens, the power of this policy that was also introduced in Brazil can be seen. Today, for a treatment to be accepted by the SUS, studies of effectiveness, cost-benefit, accessibility, etc. are necessary. According to Uziel "[...] at technical area of ​​the Ministry of Health, the Health Technology Assessment (HTA) seeks scientific evidence to assess several factors related to new and existing technologies: efficacy, effectiveness, safety, risks, costs, cost-effectiveness, cost-benefit and cost-utility, equity , ethics, economic and environmental implications.”. According to the author, there is a national policy for the implementation of health technologies that is supported by a philosophy that aims to elevate the evidence-based medicine model as the only reliable and acceptable model for treatment. Regarding some of these aspects, we highlight the research by Altmann et al.,¹⁴ who evaluated the reduction in the cost of health expenses in patients who were treated with psychotherapy. Also Saaskia de Maat et al., who evaluated the reduction in costs with medication, hospitalizations, use of the health system, among others, when patients were treated with psychoanalysis and psychoanalytic-based psychotherapies. Finally, Berghout found that psychoanalytic treatment, when compared to psychoanalytic-based psychotherapy, can be more expensive, however, in the long term.

According to documents from the Ministry of Health, for a practice to be incorporated into the SUS, “[...] there must be proof of the effectiveness of the treatment recommended to the patient, in addition to the medical intervention being recommended by the National Commission for the Incorporation of Technologies into the Unified Health System (Conitec), the Unified Health System (SUS) or by an internationally renowned health technology assessment body, as long as they are also approved in Brazil.” However, there is a distortion of this proposal when incorporating Integrative and Complementary Health Practices (PICs) into the SUS.

If, for SUS to offer a practice, it must be empirically validated, the rule does not apply to PICs. While the SUS maintains a rigorous check of what should or should not be offered, on the other hand, based on important public discussions and political pressure, practices that are not recommended or empirically validated are included in the SUS. To give an example, Family Constellation integrates PICS as a psychotherapeutic modality, however, according to technical note nº 01/2023 from the Federal Council of Psychology (CFP), this type of treatment is not recognized and should not be applied by a psychologist, since it does not have efficacy studies, it goes against the ethics of psychology professionals and in its theoretical framework proves to be inconsistent with the laws in force in our country. According to the CFP "In December, the XIV National Forum of Female and Male Judges on Domestic and Family Violence against Women (Fonavid), held in Pará, published in its Belém Charter a statement that guides judges from all over the country not to use Family or Systemic Constellation practices in the context of domestic and family violence against women."

It is not our responsibility here to criticize PICs as a whole, but to reflect on the way in which certain practices are or are not incorporated within the SUS and become available for treating the Brazilian population. With this example, we can see that a practice, to be offered in a given country, involves political, economic and scientific aspects.

Returning to our question regarding Psychoanalysis, whether in Brazil or in the rest of the world, it seems to be inscribed in a kind of limbo, perhaps a place, not being recognized by SUS as a scientific practice, just as it is not recognized by the NHS, Medicare, Inserm, among many others, even though there is a history and, currently, more and more research confirming its effectiveness and efficiency.

Empirical research and Psychoanalysis: in search of a space

It can be stated that the question regarding the place that Psychoanalysis occupies, and could occupy, is, in part, related to the history of Psychoanalysis itself and its research method, but also, and perhaps mainly, with the lack of research analysts who dare to discuss with other health fields in general about the effects of our practice. On this last point, it is believed that the problem is related to the training that is provided to analysts today. Whether in Psychoanalytic Schools or Universities, the eminently theoretical part of training in Psychoanalysis seems to have forgotten that Freud proposed that Psychoanalysis was, at the same time, a treatment, a type of research and, as a consequence, a scientific theory.

Lacan,¹⁴ attentive to Freudian purposes, in his text “Act of Foundation” reaffirmed his commitment to research from the first paragraphs. In “Italian Note”, Lacan¹⁵ stated that no one should be allowed to practice Psychoanalysis, and if they did not contribute to training, research, transmission and teaching.

Returning to the axis of this research, the proposal to consider whether or not Psychoanalysis can be empirically verified involves a certain type of paradox. The discussion of whether or not Psychoanalysis should be a practice in which it is possible to have evidence of therapeutic efficacy for some analysts can be summarized by the position of Carvalho¹⁷ The psychoanalytic clinic is not based on evidence of reality, but on the ex-existence of reality. And if the impossible is the real, its efficacy cannot be gauged by the EBM criteria, which are incapable of evaluating the change in the jouissance position that the speaking being occupies in the Other, when moving from impotence to impossibility and turning the symptom into an invention.

This position, although not unanimous among psychoanalysts, is an easily understandable majority position when analysts state that there is no way to empirically verify what is produced in an analysis, and that it would be impossible to repeat the result of a treatment. In this aspect we do not disagree with this position, however, we also remember the statement, once again, that for Freud¹⁸ Psychoanalysis should be a treatment that brings the patient well-being. “Psychoanalytic therapy was created from and for patients with a lasting incapacity to live, and its triumph is that it makes a satisfactory number of them capable of living their existence in a lasting way.”

Still on this aspect, Oliveira¹⁹ published an article in the journal of the Associação Brasileira de Psiquiatria that will substantiate that Psychoanalysis “[...] gained new contours and generally abandoned scientificity as its central point.”. This position marks an attempt to think of Psychoanalysis not as a science, but as something else and, therefore, Psychoanalysis cannot be thought of as a pseudoscience since it would not be in the field of science. It should be noted that the highlighted term is a science, since there is no science, but distinct possibilities of thinking about science from different authors, thinkers, philosophers and researchers.

In this sense, Oliveira's thinking¹⁹ may be one of several possibilities for thinking about Psychoanalysis, but this way of thinking would be more of a way out on a tangent than a way of answering questions about the effectiveness and efficiency of Psychoanalysis as a treatment. and, consequently, its inclusion and presence as a recommended treatment in the guidelines.

Lacan,¹⁵ in “Freud's Trieb...” resumes the discussion on the last page of his text by asking his interlocutor what would be the objective of an analysis beyond the therapeutic. Also in “Aggressivity in Psychoanalysis” Lacan²⁰ stated that “[...] the analyst healed through dialogue, and cured equally great madness [...]”. These excerpts from both texts are resumed in order to pick out in Lacan's work some elements that allow us to state that, even for Lacan, healing, therapy, and improvement in the patients' life conditions were always present in Psychoanalysis as a treatment. However, the therapeutic effect should never be confused with the analytical objective.

It is exactly at this inflection that a supposed paradox begins to emerge. Would an analytical treatment be possible without the objective being therapeutic and, even so, if empirical, measurable evidence of its effectiveness was obtained? In “The quarrel of diagnoses” Soler²¹ stated that “[...] Psychoanalysis is a therapy, but not like the others. In effect, we do not sell psychotherapy – if you will allow me the expression -, but we accept therapeutic demands and, therefore, we treat therapeutic demands.” (p.24). With this, we can understand that psychoanalysis does produce therapeutic effects, either as a consequence of the analyst's interventions when the anguish decreases or in the intervention in cases of patients with suicidal ideation, as stated by Briggs and collaborators,²² or else as secondary gains of the treatment aimed at the subject, through speech and not directly at the positive therapeutic effects.

Returning to Carvalho's¹⁷ position, it may be possible to understand what is analytical as something beyond what tests, exams, and “references” can verify. In this sense, Lacan even states that the end of an analysis is when something unprecedented is verified, when an analyst is produced.

While the therapeutic may appear in the imaging examination, decreasing the activity of the prefrontal cortex in patients with major depression who underwent psychoanalytic treatment, as verified by Buchein et al.,²³ for analysts, it is more important to verify what is produced in the analysis as an effect of the clinical device engendered by Freud. However, we think it is not possible to remain in analysis without the therapeutic effects being perceived and spoken by the analysand.

Although Carvalho's position is an important defense of Psychoanalysis, the dialogue with other knowledge tends to become weakened. It is as if Psychoanalysis needed to maintain two separate models, that of science with research in the field of neurosciences and such, where it is possible to verify and measure its effects, and that of Psychoanalysis, in which effectiveness is verified in terms of achieving the proposed objective of Psychoanalysis.

In “Nota Italiana” Lacan²⁴ problematizes this question in a somewhat complex way. While the path to verifying the therapeutic effects can be verified by projective, psychometric tests, biological markers among other tools, the analytical effects, on the other hand, should be sought from certain devices internal to the School and training institutions. According to Lacan²⁴ there will only be an analyst, in other words, the expected effect of a psychoanalytic treatment that also includes the therapeutic one, if the analysts are able to verify that the analyst's desire has been produced. It would be up to analysts, based on the theories that support their work, to deliberate on this issue.

This somewhat complex discussion leads us to think about what happened in the 2000s in France and throughout Europe in general, especially with regards to the treatment of Autism. If Psychoanalysis can be effective in terms of the analyst's production at its end, would it also be effective as a treatment practice that is possible to verify positive therapeutic effects?

According to Sauret; Askofaré and Macary-GAripuy⁹ in the 2000s in France there was a movement to prohibit psychoanalytic treatment for autistic patients. Such prohibition would occur from political pressure with the intention of enacting a law for this purpose. According to the authors, “The most recent peak of this confrontation was reached with the double proposal of a member of the National Assembly right wing, Daniel Fasquelle, who sought to prohibit not only psychoanalytic treatment of people with autism, but also teaching and research psychoanalysis at the university”.

Movements like this did not occur only in France. In Germany, university courses chairs reserved for Psychoanalysis suffered a significant decline. As we have seen, in the guidelines of Canada, the United States and the United Kingdom, Psychoanalysis does not even appear as an empirically validated method. The fact is that Psychoanalysis, as a treatment, either responds to the inquisitors of our time, or it will be doomed to an ever greater upsurge all over the world. And in this regard, it is necessary to clarify that answering those who question is not necessarily subjecting Psychoanalysis to the expectations of the biomedical model, but rather, as Lacan (1975) states, finding elements in the sciences so that Psychoanalysis and the analyst, when using them, can be renewed.

In this perspective, some contemporary works such as that of Gary Ahlskog²⁵ are included, which propose a dialogue between Psychoanalysis and Neuroscience to think about trauma, treatment, and many other aspects of both psychoanalytic theory and Neuroscience itself. Establishing dialogues means, in principle, recognizing both fields, their limits and possibilities. It is not a question of thinking about a “Neuropsychoanalysis” as proposed by Solms,²⁶ other eminent authors and researchers or a new modality of Psychoanalysis, but rather, of verifying what of psychoanalytic theory neurosciences can validate and what of Psychoanalysis can serve as guiding research in the field of neurosciences.

Another reason for the resurgence of Psychoanalysis is the financing of research theoretically linked to evidence-based medicine. This research is based on the theory that mental disorders are organic and biochemical dysfunctions, and that treatment is only through certain methods aligned with this reductionist policy. With more funds for research, treatments end up having an immensity of published articles. However, as much as such articles flood the scientific field of mental health, not all scientists and researchers agree with their quality, as stated by Shedler.²

According to Wooding and Pollit,²⁷ the United States of America (USA) is the largest producer of research and articles worldwide. To give you an idea, in 2016, approximately 36% of the articles published in the field of mental health worldwide were linked to the US, with the US government and institutions linked to it being the main funders of this research.

In the current scenario, we consider that dialogue is essential for the defense and advancement of our field of work. Dialogue with other knowledge in the field of mental health, as Freud, Lacan, Winnicott, Dolto, and many others did, so that Psychoanalysis remains alive and not a fact for history because, as we have seen so far, without due investments in research and in the training of clinicians committed to the analytical cause and in the transmission of Psychoanalysis in today's world, Psychoanalysis will never be recognized as an effective treatment, not being offered to citizens, becoming in fact a chapter in history.

Regarding the issue of investments in research, as we have seen previously, the influx of massive investment in the field of mental health within the United States is not something to be ignored. In the country where the Rockefeller Foundation invested in secret programs (MKULTRA) with the CIA; when, at the end of the 1980s, Prozac appeared, elaborated in the Elli Lilly laboratory, which is also North American. Later, in the 90s, the ideas of evidence-based medicine arrived and influenced the division of the APA that organized and edited the DSM. According to Faria and others,¹² these ideas were heavily funded by Rockefeller and Cochrane funds. Still in the 90s, in the Times magazine, one of the much discussed covers (to this day) was in which the editors stated that “Freud is dead”.

By historically tracking the advancement of therapies aligned with the biomedical discourse, APA, evidence-based medicine and with the internal policy of building and disseminating the DSM, we found that from the 90s onwards they gained ground in the field of mental health.

In Brazil, according to Dias and Muhl²⁸ the pharmaceutical industry lobby in our country can be understood from a process that [...] it occurred concomitantly with the expansion of another model of care aimed mainly at the private sector and related to the transformations of practices in psychiatry around the world ― markedly, in the process that has been developed since the 1970s, and whose great promoter is the North American Psychiatric Association, deeply articulated with the pharmaceutical industry.

In addition to the problem of financial interference and massive lobbying work by pharmaceutical industries that finance research and develop medicines, there is an agency of mental health professionals who work to carry out propaganda regarding what is effective and what has no proven effectiveness. According to doctor and researcher at Georgetown University Center, Adriane Fugh-Berman, in an interview with journalist from the Cremesp bioethics center Concília Ortona:

Because they work in an area little used to the universe of sales, doctors have difficulty noticing when articles published in prestigious scientific journals include subliminal messages, whose intention ranges from supporting the effectiveness of drugs that have not yet been released, to creating or exaggerating 'disease states'. Such texts are prepared by ghost-writers – 'ghost writers' – at the service of laboratories, responsible for writing articles to be signed by colleagues from academic circles.

Today, in its fifth version, according to Dunker,¹⁰ the construction of the DSM is based on the premise that mental disorders have an organic causality. This statement can never be empirically proven and, currently, with the advancement of epigenetic theory, this hypothesis is gradually being discarded, as we can see from the research of Schiele and collaborators²⁹ and also Wang et al.,³⁰ for these authors, and many others who are involved in research in this field, psychopathologies are not a cause-effect explanation, but rather a relationship between each person and their history, the environment, life and even intrauterine events. This thought is also found in a footnote of Freud's text (1912) called “The dynamics of transference”.

Going against reductionism is Psychoanalysis, which understands, like many neuroscientists, that mental disorders, for the most part, without discarding the organic aspect that is on the scene, are the effect of the interaction relationship between the body and what Freud called of soul (Seele), a concept that goes back to the German romantic tradition. In this case, an entire theoretical construct specific to Psychoanalysis is necessary to recognize the illness and also to verify that the treatment was effective in meeting its objectives.

There would only be a problem if the effects produced with psychoanalytic treatment could not be measured empirically as they are with other treatments in the field of mental health. That analytical effects such as the verification of the Ex-sistence of the Real, the production of the analyst¹⁵ or the suspension of repression³¹ are only verifiable through the elaboration and theorization of the clinic in Psychoanalysis, this does not prevent that the positive therapeutic effects as possible alternative solutions for the most varied mental disorders, the stabilization of a patient diagnosed with bipolar disorder, or the remission of a panic/anxiety condition after a certain period under analysis, to give some examples.

¹In this article, we have chosen to capitalize the term Psychoanalysis to emphasize its central role in the discussion. Thus, the term will be frequently employed to address Psychoanalysis as a science; as a clinical practice or a subject of study.

Many researchers and psychoanalysts have focused on the issue of the verifiability of the therapeutic effects of a psychoanalytic treatment. Dunker¹⁰ states that “[...] as psychotherapy, Psychoanalysis presents results superior to the general average of its competitors for most diagnoses – including autism and psychosis [...]”. This position is intrinsically related to Freud's position who, since 1905, defended the idea that Psychoanalysis should be a treatment and that its results should be verified in improving the quality of life of people who were subjected to this treatment.

It is not uncommon for Freud, during his work, to address the issue of the therapeutic effects of a psychoanalytic treatment. In addition to the five major clinical cases that serve as a model for thinking about different points of theory that at the time were not very well established, it is relatively easy to find, in Freud's extensive work, demonstrations of the effect of an analytical treatment. Either in “About Psychotherapy”; going through “Introductory Conferences”; until one of his last texts called “Compendium of Psychoanalysis”. In this theoretical journey, Freud demonstrated that therapeutic effects respond to analytical effects. Especially in “The psychoanalytic technique”, a chapter included in the “Compendium” that clearly brings therapeutic gains as the analytical work is carried out in transference.

Lacan, in turn, categorically stated that there are therapeutic objectives to be achieved in analysis, but there is another, the analytical objective, the arrival point that will be the analyst's production. This question is taken up again from this text to highlight the intrinsic relationship that both Freud and Lacan found and transmitted from their texts that therapeutic effects are achieved in analysis, but also that it is not about guiding the treatment for such effects, but to guide the analytic objective.

Regarding measurable therapeutic effects, currently many research institutions, some even run by psychoanalysts, are carrying out meta-analysis research, randomized controlled research, research with neuroimaging exams, with biomarkers, etc., and the results have contradicted several authors who insist saying that Psychoanalysis is not an effective treatment and should not be recommended by health services.

According to Leichsenring and others³² psychotherapies, like any other treatment, must have their effectiveness proven based on solid scientific evidence regarding the results of the treatments offered and psychoanalytic psychotherapy and, consequently, Psychoanalysis, must also answer the questions posed by professionals in the field of mental health. This thinking led researchers to carry out a meta-analysis to find research that corroborates the effectiveness of psychoanalytic psychotherapies. According to the authors, strong evidence was found that psychoanalytic-based psychotherapy is effective for the treatment of various mental disorders and that, only when compared with medication in the treatment of cocaine users, it proved to be inferior.

To verify new research and assess whether there would be more evidence regarding the effectiveness of Psychoanalysis Leichsering et al.,³³ carried out new research entitled The status of psychodynamic psychotherapy as an empirically supported treatment for common mental disorders – an umbrella review based on updated criteria. Once again, the authors confirmed what had already been established.^34–38 Psychoanalysis and psychotherapies derived from it, such as psychodynamic psychotherapy, psychoanalytic psychotherapy and long-term psychodynamic psychotherapy, are effective treatments and the effects of the treatment last for a long time even after the end of the treatment.^39–40

Many other works have been published on this topic. According to Liellingren, from 1967 to 2022, 298 randomized controlled studies were carried out and published, the gold standard in the field of health. In the last 10 years alone, more than 120 articles have been published pointing out effectiveness, efficiency, cost-benefit, comparisons with other practices/treatments, etc.^41–45 However, due to the limits of this article, it is not possible to present all the research found here, even so, we have presented a series of articles that prove the effectiveness of treatment in Psychoanalysis and place it in the category of a practice in which there is evidence empirical evidence of effectiveness and efficiency, although investments and research are much smaller than in other practices, they exist and are published in various high-quality journals around the world.

None.

There is no conflicts of interest.

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