Each week, part of my job is to supervise third and fourth year psychiatry residents in their psychodynamic clinical training. Given the era of scientific reductionism that we are currently living in, particularly within medicine, training aspiring psychiatrists in a style of treatment derived from Sigmund Freud’s psychoanalysis can sometimes be… well… hard to sell.
Freud in 1885 at the start of his career.
Source: public domain / Wikimedia Commons
For those who need a brief reminder, a precursor to what would later be known as “psychoanalysis” was developed by Josef Breuer, Freud’s mentor, in the 1880s in Vienna, through his work with the now famous patient zero of psychoanalysis, Bertha Pappenheim (aka “Anna O.”). Freud officially published accounts of Breuer’s treatment of Pappenheim in his 1895 book, Hysteria studiesbefore continuing to refine psychoanalysis in the decades that followed, writing volumes of books and journal articles on the process of psychoanalysis, as well as its theories of the human mind, personality, and psychopathology.
Psychoanalysis gained brief popularity in the United States in the early 20th century and became the standard of care in psychiatry and psychology, especially in coastal American cities with large Jewish populations. Given the social and intellectual influences of Jewish culture on the development of psychoanalysis (Freud and Breuer were Jewish, as were many of its early pioneers), psychoanalysis became seamlessly integrated into urban cultural centers around the world that had a large number of educated Jewish professionals. . But psychoanalysis, never very popular in the heartland of the United States, began to wane in popularity in the mid-twentieth century, even in coastal towns, when simpler, shorter-term treatments were introduced. developed, such as behavioral therapy (BT) and cognitive behavioral therapy. (CCT).
Since then, efforts have been made to reform psychoanalysis to meet the expectations of modern American patients in psychotherapy, and by the middle of the 20th century a multitude of new therapeutic styles were born which retained the fundamental aspects of psychoanalysis, while by shortening treatment models and updating Freudian theories of human behavior: these offshoots of psychoanalysis are collectively called psychodynamic treatment methods. For those who might be interested in a short primer on psychodynamic therapy and the ways in which Freudian-style treatments have been updated to fit our postmodern era, I highly recommend Jonathan Shedler’s article (2010), “That Was Then, This Is Now: An Introduction to Contemporary Psychodynamic Therapy”, that I offer every year to the residents I supervise.
In addition to competition from more direct and shorter-term treatments, such as BT and CBT, psychoanalysis also began to fall out of favor in the mid-twentieth century with the rise of feminist critiques of some of the most controversial theories of psychoanalysis. Freud on human behavior. Today, the majority of mental health practitioners, including those trained in psychoanalysis, view Freud’s controversial theories as regressive and believe that most feminist critiques of Freud, especially those on penis envy and female hysteria, are valid and justified. However, as Donna Stewart, MD, professor and chair of women’s health at the University Health Network, explained in an article on the subject (Cherry, 2020), it must be remembered that “Freud was a man of his time”.
Too often, when we examine people’s ideas in history, we do so without appreciating the context of the times and places in which they lived. Although Freud and some of his theories are considered by some to be regressive today he would probably have been considered a progressive in the midst of the nineteenth-century bourgeois, Jewish and Viennese enclave in which he developed these theories. For those who might be interested in learning more about the world that created Freud, I invite you to check out the Netflix series about him, named after him, which provides important context about when and where he lived.
Because of all the headwinds above, Freud and his set of theories are more likely to be taught in a cultural studies curriculum today than in the myriad of mental health disciplines. To me, this is unfortunate because a cultural studies inquiry into Freud is likely to overlook the important ways in which his theories translate into meaningful insights and growth in therapy. As someone who was trained in Freud’s theories of the human mind and implemented them clinically, I believe he understood the inner workings of the human mind better than anyone since the Buddha.
Freud’s famous sofa in his office-museum in London
Source: Huffstutter/Wikimedia Commons
There are too many revolutionary concepts to cover than can be discussed in this article, but if there is one that is most important, one that subsumes all others, it is the Freudian notion of the unconscious. Freud’s understanding and attention to the unconscious sets him apart from all other clinicians and philosophers of mind who have gone before him, and from those who have since attempted to replace his psychoanalytic approach with simpler ones. , direct and concrete.
Being more concrete, approaches such as BT and CBT are easier to teach, easier to standardize, and easier to manualize for use in clinical research trials. A simple review of the psychotherapy outcome literature is all that is needed to highlight how much more frequently BT and CBT have been studied than psychoanalysis and psychodynamic therapy. This has led to BT and CBT gaining a reputation as the quintessential “evidence-based treatments” for mental health disorders. It’s a well-deserved reputation, as BT and CBT certainly work well for an array of psychological conditions. Earlier I noted that I was trained in psychodynamic therapy, but I was also trained in BT and CBT, and in the multimodal style that I practice in, I often use techniques from BT and CBT where appropriate , and they perform quite well in those specific areas. situations.
However, just because psychoanalytic and psychodynamic therapies are more difficult to standardize and reliably research does not mean they are less effective than BT and CBT. In my experience, psychoanalytical and psychodynamic approaches tend to work better than BT and CBT when the clinical problem in question is not clear or complex, as is the case with existential depression or anxiety. existential; non-biological sexual dysfunctions; a myriad of relationship problems; or bizarre behaviors that seem to have no clear cause. In these cases, an investigation of the unconscious is essential and can be evaluated by examining its defense mechanisms, as well as the transference/countertransference dynamics, and even sometimes its dreams.
Unlike BT and CBT, psychoanalysis and psychodynamic therapy are more art than science, and for this reason they are often devalued in today’s STEM-obsessed world. But today’s world is also filled with many things that science struggles to predict and explain, including mass shootings, teenage suicides, political extremism and susceptibility to conspiracy theories, among others. It is here that the art Freudian-style psychotherapy can be of the greatest value, and why Freud matters more than ever.
In Part 2 of this series, I will review some of the specific components of the Freudian model of the mind and highlight what makes them extraordinary.