Main Menu ·
Search ·Current Issue ·Contact ·Archives ·Centennial ·Letters
to the Editor ·FAQs
"Where Will Psychoanalysis Survive?"
Keynote Address by Alan A. Stone, M.D.
to the American Academy of Psychoanalysis
December 9, 1995
© 1995 Alan A. Stone
There is a famous maxim found in Burton's essay on Melancholy that states,
"A dwarf standing on the shoulders of a giant may see further than
the giant." I think most of us who became psychoanalysts in my generation
assumed that this maxim had to be true. Whether reverential as we were here
in Boston, or critical of Freud as some people were elsewhere, we all hoped
to be able to see further than the giant and to build on the foundation
Freud had begun. This of course was in those halcyon days before Prozac,
managed care, and the hermeneutic cross-roads.
The most beautiful and moving description of the collective enterprise at
that time was given by John "Jock" Murray at the Boston Psychoanalytic
Society who in presenting his interesting insights into narcissistic entitlement,
compared what we were doing to the construction of the great cathedral at
Chartres, where workers toiled for more than a century. He declared that
he would be satisfied with his career as a psychoanalyst if he had placed
one brick in the conceptual cathedral of psychoanalysis. Although Jock Murray
was more impassioned than most of my teachers in psychoanalysis I think
at some level they shared his conviction and tried to pass it on to us.
Unfortunately I and many others in my generation have lost that sense of
conviction and with it the feeling that we are part of a collective enterprise.
To us, the maxim about dwarfs standing on giants seems untrue or at least
inapplicable to psychoanalysis. Those who stand on Freud's shoulders have
not seen further, they have only seen differently and often they have seen
less. Rather than building a cathedral, psychoanalysts have built their
own churches. Consider from this perspective the two great women, Anna Freud
and Melanie Klein, who dominated psychoanalysis after Freud's death. Each
of them thought she was standing on Freud's shoulders and extending his
true vision. And their adherents certainly believed they were building Freud's
cathedral and they accommodated both their psychoanalytic practice and thinking
accordingly. Today, at least in my opinion, and I am not entirely alone
in thinking this, neither Anna Freud's Ego Psychology nor Melanie Klein's
Object Relations Theory seem like systematic advances on Freud's ideas.
Rather they seem like divergent schools of thought, no closer to Freud than
Karen Horney who rebelled against Freudian orthodoxy.
Heinz Kohut makes my point in relationship to his own work on self psychology.
Kohut, in 1971, traced his own intellectual genealogy from Freud to Hartmann
who had separated the concept of self from Freud's structural ego, to Erikson's
notion of identity, to Mahler's separation-individuation to Edith Jacobson's
The self and the object-world and to Annie Reich's clinical work on self-esteem.
Kohut at that time saw his contribution as an extension of centrist psychoanalytic
thinking--i.e. an analysis of the reconceptualized self in treating narcissistic
personality disorder where self pathology was a crucial factor. By 1977
Kohut had decided that further developments in his self-psychology had forced
him to "recognize the limits of the applicability of some of the basic
[Freudian] analytic formulations." Kohut at one place in his writings
in trying to explain the relationship of self psychology to psychoanalysis
had used an analogy from physics in which light can be understood either
as waves or particles. Freud was particles and Kohut waves. But in the end,
Kohut concluded that self psychology, rather than adding something to Freud's
psychoanalysis or being an alternative to it, was a different conception
of the human condition.
Let me emphasize to you that I am not opining about their motives or the
relative merits of Anna Freud's ego psychology, Melanie Klein's object relations,
or Heinz Kohut's self psychology. I am suggesting that whatever they may
have thought they were doing, these distinguished leaders of psychoanalysis
have not been able to stand on Freud's shoulders and achieve the production
of cumulative knowledge. Let me also make clear that it is not as I once
thought just a matter of narcissism among psychoanalytic writers who routinely
fail to acknowledge their reliance on Freud or on other psychoanalysts whose
ideas they routinely rediscover. Kohut, who failed to acknowledge Karen
Horney, was sensitive to this criticism but he pointed to what I agree is
an important problem. If he tried to take into account all of the important
contributions (e.g. Balint, Kernberg, Winnicot, Lacan, Schafer, etc.) He
would have been entangled "in a thicket of similar overlapping, or
identical terms and concepts which, however, did not carry the same meaning
and were not employed as a part of the same conceptual context."
The collapse of conceptual solidarity is now felt at the very center of
psychoanalysis among the self-declared Freudians. Yeats' famous phrase is
"Things fall apart; the centre cannot hold." This is the diagnosis
of Leo Rangell and Merton Gill, two leading figures of the American Freudian
Gill, one of my first teachers and a wonderfully candid man, described the
situation as follows: "Psychoanalysis seems to be in particular disarray...while
there have always been dissenting voices and even new schools...the organized
center seems to be less a majority viewpoint..." He worried that this
was a "portent of the dissolution of the conceptual framework."
What is there about Freud's vision that has made his monumental work a limiting
factor rather than a scaffolding on which others can stand? Put less metaphorically,
why has psychoanalysis not become a cumulative discipline? I believe the
answer to this question will tell us something about where psychoanalysis
will survive. The answer which I think all of you who have reached the hermeneutic
cross-roads know, is that psychoanalysis, both as a theory and as a practice,
is an art form that belongs to the humanities and not to the sciences. It
is closer to literature than to science and therefore although it may be
a hermeneutic discipline as Schafer says it is not a cumulative discipline.
We--and I include myself--are retreating into our own subjectivity. Looking
back at what we now know about Freud I think the case can easily be made
that Freud was more an artist/subjectivist/philosopher than a physician/objectivist/scientist.
Ernest Jones in his biography created the legend that Freud, upon graduating
from the gymnasium, decided to become a medical scientist because he read
a famous essay by Goethe on nature. If Freud was inspired by Goethe's essay,
then I suggest it was because he identified with the author and not the
medical and scientific content of the essay.
During the years when Freud was working on The Interpretation of Dreams he confided to his friend W Fleiss, "As a young man my only longing
was for philosophical knowledge, and now that I am changing over from medicine
to psychology I am in the process of fulfilling this wish. By the end of
his life he felt comfortable enough to inform his readers, "My self
knowledge tells me I have never really been a doctor in the proper sense."
If not a "proper" doctor, did Freud consider himself a "medical
scientist"? In the late 1890's he wrote, "It still strikes me,
myself, as strange that the case histories I write should read like short
stories and that, as one might say, they lack the serious stamp of science."
Freud in fact had enormous literary talent and when it seemed clear that
he would never win the Nobel Prize for medicine, Thomas Mann, along with
other literary greats, actually encouraged the nomination of Freud for the
Nobel Prize in literature. Freud of course was awarded the Goethe prize.
Even those like myself who cannot read Freud's German are awed by the power
of his rhetoric in translation.
Here is a line from one of his most influential theoretical papers, "Two
Principles of Mental Functioning." Describing the momentous significance
of the reality principle replacing the pleasure principle, he writes, "The
doctrine of reward in the afterlife for the voluntary or enforced renunciation
of earthly pleasures is nothing other than a mythical projection of this
revolution in the mind." A marvelous subjective speculation--I find
it persuasive, but is it empirical? Is it based on objective data?
From Civilization and its Discontents, "The more virtuous a
man is the more severe and distrustful is his conscience, so that ultimately
it is precisely those people who carried saintliness furthest who reproach
themselves with the worst sinfulness."
And finally, "Eternal wisdom, in the garb of primitive myth, bids the
old man renounce love, choose death, and make friends with the necessity
of dying." The quote is from a piece of Freud's literary criticism;
he is discussing Shakespeare's King Lear.
This literary artistic side of Freud is by all accounts and not just Bettleheim's
even more prominent in his original German; however, Jones, Strachey and
the official British translators of Freud's work were particularly determined
to present Freud to the readers of English as an empirical scientist. William
James, who had gone to hear Freud speak at Clark University, declared him
a man of fixed ideas. And Ernst Jones worried that Freud might be written
off as unscientific and speculative by the English-speaking world. Jones
actually convinced Freud to keep some of his theories quiet at least for
a while, e.g. Freud's belief in E.S.P. and his conviction that the Earl
of Oxford had written the plays of Shakespeare.
And Jones had good reason to worry on other grounds. I quote Freud's famous
letter of February 1900 to Fleiss, "I am not really a man of science,
not an observer, not an experimenter, and not a thinker. I am nothing but
by temperament a conquistador--an adventurer if you want to translate the
word--with the curiosity, the boldness and the tenacity that belongs to
that type of being. Such people are apt to be treasured if they succeed,
if they have discovered something; otherwise they are thrown aside. And
that is not altogether unjust."
Freud in a much later conversation with Jones allegedly said that, "As
a young man I felt a strong attraction toward speculation and ruthlessly
checked it." This "ruthless" suppression of speculation is
seldom to be found in the collected works of Sigmund Freud. Fifteen years
ago I spent most of a year reinterpreting Freud's first dream, the dream
of Irma's injection in The Interpretation of Dreams along lines suggested
by Levi Strauss. This endeavor required me to read carefully all of the
available biographical material, the letters of Freud together with all
of his published work in the early years of 1895-1896. What one discovers
is that Freud had a new hypothesis every day. It is astonishing to see how
little evidence he needed; a single patient hour was enough to launch a
whole new theory of mental illness.
Freud was no more a scientist than Marx. I say this not in disrespect; both
men were geniuses. Freud's Three Essays on the Theory of Sexuality is a work of genius which one can still read with amazement. Freud considered
it the core of psychoanalysis. These essays provided the twentieth century
with a revolutionary reconception of the human condition: Psychosexual development
and the Oedipus complex. The work is in some sense empirical and yet Freud
provides almost no evidence and no direct observational data for his sweeping
conclusions. The unspecified and perhaps unrecognized premise of the work
is that the author deals here with the universals of the human condition
and every reader, like Freud, has the necessary empirical evidence available
and need only be willing to consider his or her own subjective experiences.
Although the method is not recognizable as science I know of no other work
in psychiatry or psychology so powerful, so lucid, and so immediately convincing.
Inventing two technical terms, sexual aim and sexual object, Freud deconstructs
the centuries-old conception of the sexual instinct and in the process illuminates
the related significance of sexual foreplay and perversions. It was Freud
who brought the sexual outcasts back into the family of humanity and showed
us the common themes in all the complicated dances of our erotic life. These
ideas for me unequivocally establish Freud's revolutionary genius but I
find no scientific method or science in this great work. Indeed these essays
were too convincing. They are filled with what we now recognize as horrifying
mistakes (fixed ideas) about female sexuality that were taken as scientific
truth by psychoanalysts. As a result we made several generations of educated
women feel sexually inadequate and misled them about the possibilities of
sexual gratification. I shall return to these essays below when I discuss
Freud in his later works exemplifies what I have called the non-cumulative
style in psychoanalysis. Explaining in his brief preface to The Ego and
the Id why he had not acknowledged others in this monograph, Freud wrote,
"If psychoanalysis (by which he means his own writings) has not hitherto
shown its appreciation of certain things this has never been because it
overlooked their achievement or sought to deny their importance, but because
it followed a particular path which had not yet led so far. And finally
when it has reached them things have a different look to it from what they
have to others." What he describes is not the collective and cumulative
enterprise of science built on the shoulders of those who go before. This
is Freud advancing the human project of self understanding more than any
other person in this century--but with the unique subjective vision of the
artist and not through the objective methods of science. Freud did not even
feel the need to build with consistency on his own ideas. The complete psychological
works to use Kohut's phrase, is a "thicket of similar overlapping,
or identical terms and concepts which, however, did not carry the same meaning
and were not employed as part of the same conceptual context." Scholars
like Rappaport, Hartmann, Bibring and Kernberg labored in vain to bring
some semblance of order to what I think were flashes of inspired speculation.
I believe that at times Freud recognized that what he was doing was very
close to literature. He wrote about creative writers, "One may heave
a sigh at the thought that it is vouchsafed to a few with hardly an effort,
to salvage from the whirlpool of their emotions the deepest truths, to which
we others have to force our way." And again, "Imaginative writers
are valuable colleagues. In the knowledge of the human heart they are far
ahead of us common folk, because they draw on sources that we have not yet
made accessible to science." Clearly Heinz Kohut knew this as well.
He wrote, "The artist stands, as it were, in proxy for his generation:
not only for the general population but even for the scientific investigators
of the socio-psychological scene." Freud best described what psychoanalysis
is about from this perspective in his paper on his interpretation of Michelangelo's
Moses. "Works of art do exercise a powerful effect on me, especially
those of literature and sculpture less often of painting. This has occasioned
me, when I have been contemplating such things, to spend a long time before
them trying to apprehend them in my own way, i.e. to explain to myself what
their effect is due to. Some rationalistic, or perhaps analytic, turn of
mind in me rebels against being moved by a thing without knowing why I am
thus affected and what it is that affects me. This has brought me to recognize
the apparent paradoxical fact that precisely some of the grandest and most
overwhelming creations of art are still unsolved riddles to our understanding.
A work of art of this kind needs interpretation, and until I have accomplished
that interpretation I cannot come to know why I have been so affected."
Freud managed to see in Anna O, in Elizabeth von R, in the Rat Man, and
most importantly in himself the same kind of mystery or riddle he saw in
Michelangelo's Moses. There are, I think, interesting consequences in recognizing
or if you prefer positing that Freud was more artist/subjectivist/philosopher
than scientist. For one thing, it immediately suggests why it is impossible
for us to see further by standing on his shoulders. It is difficult to imagine
anyone claiming that because he stands on Shakespeare's shoulders he can
see further than Shakespeare. Merton Gill, who died in 1994 at age 81, had
spent his entire life trying to advance Freud's vision, believing that psychoanalysis
was a scientific enterprise. He was one of my first teachers and a wonderfully
candid man. In his last book published in the year of his death he was forced
to acknowledge that psychoanalysis has remained "to a remarkable degree
the work of one man, Sigmund Freud." Further in the book he writes
that "systematic research [i.e. the kind of scientific work Gill had
himself attempted] has brought no new "advances" in psychoanalytic
practice or theory" and in a final cri de coeur he echoes Freud's
scientific critics, "Let me repeat: We may be satisfied that our field
is advancing, but psychoanalysis is the only significant branch of human
knowledge (and therapy) that refuses to conform to the demand of Western
Civilization for some kind of systematic demonstration of its contentions."
Gill steadfastly refused to make the hermeneutic turn with Roy Schafer and
to accept that psychoanalysis was an interpretive discipline rather than
a natural science. Plato, Hegel, Kant, Michelangelo, DaVinci, Shakespeare,
Dostoevsky and Sartre helped to shape Western Civilization and its conception
of the human condition without any systematic proofs of their contentions
and so, I suggest, did Freud. I do not think Merton Gill would have taken
much comfort from this thought. In his common sense way he intuited that
without its putative scientific roots, psychoanalysis as he knew it would
be crippled. Ricoeur recognized that psychanalysis needed both its drive
energic leg and its interpretive hermeneutic leg. That conception of psychoanalysis
embodied in the work of Sigmund Freud held the enterprise together. Even
those who disagreed with Freud were anchored and placed in relation to Freud.
Now the center does not hold--without the claim of science there is no privileged
If psychoanalysis and Freud belong to the arts and humanities, or as Schafer
says to the hermeneutic disciplines, then that is the domain in which Freud
and psychoanalysis will survive. As academic psychology becomes more "scientific"
and psychiatry becomes more biological, psychoanalysis is being brushed
aside. But it will survive in popular culture where it has become a kind
of psychological common sense and in every other domain where human beings
construct narratives to understand and reflect on the moral adventure of
life. As a token form of empirical evidence for this proposition we conducted
a computer search of the Harvard Catalogue identifying courses that mentioned
either Freud or psychoanalysis in their course descriptions. Not counting
my own two courses, there are 40 listed. All of them are in the humanities,
particularly literature; no course is being given in the psychology department,
and next to nothing is offered in the medical school.
Most of my comments thus far have addressed psychoanalytic theory. I turn
now to the even more vexing predicament of psychoanalytic treatment and
psychoanalytic therapy. Here I shall discuss two sets of ideas. What happens
to psychoanalysis if one loses confidence in its supposedly scientific account
of human development. And what happens to an analyst like myself who becomes
disillusioned with Freud. Part of what I am going to say is personal. I
realize that I cannot speak for other analysts; however I take comfort in
a statement of Carl Rogers, who once said that what you often think is singularly
unique about yourself is the thing that you have most in common with others.
There are lots of reasons for the faithful like myself to have become disillusioned.
Freud has become a four-letter-word in many intellectual circles and any
psychotherapist, no matter how distinguished, can be disparaged as "Freudian"--Leo
Rangell, an eminent centrist and former president of the American Psychoanalytic,
described learning this painful lesson when a potential patient of the kind
that once flocked to him decided not to pursue treatment because she had
heard he was Freudian. Rangell bitterly complained about his analytic colleagues
who were deserting the sinking ship and positioning themselves to avoid
being stigmatized as Freudian. I think many of us have been affected by
these experiences, but even more important for me is my disillusionment
with Freud, the man, and with Freud's moral authority.
Let me try to explain why Freud's moral authority is important to me. One
of the most instructive readings of Freud is Philip Rieff's Freud: The
Mind of the Moralist. Rieff's central idea about morality as it relates
to psychoanalytic theory might be expressed as follows. Human beings typically
cling to some childlike illusory ideal, some version of the parent as god-like
redeemer and moral authority. When they come into analysis they project
that illusory ideal onto the analyst. This parental ideal is implicated
in the person's deepest moral convictions, which are typically unexamined.
During analysis the patient will work through this attachment to the ideal,
reconsider his moral convictions, face up to reality and necessity and relinquish
his illusions including the illusion of ultimate moral authority as symbolized
by the idealized parent. Life without illusions is the goal of this moral
dimension of Freud's psychoanalytic therapy as understood by Rieff. But
this therapeutic goal would seem to require that the illusory ideal that
has been projected onto the analyst be relinquished. If it is not then the
analyst remains as the idealized parent.
There is an enormous psychoanalytic literature that touches on this problem.
Some of the most interesting is by Kohut. I can only briefly characterize
some major trends. I and several of my psychoanalytic colleagues have met
once a month for 30 years to discuss our cases. At the core of our interest
and what got us started was Strachey's paper on the mutative interpretation.
What is it that allows our patients to change for the better? During the
intervening years as we have presented our work to each other the psychoanalytic
literature has moved away from the view that therapeutic change comes about
only or primarily as a result of insight. It is now widely accepted that
the interaction between analyst and patient is critical and therefore analytic
neutrality becomes in some way problematic. If one is not to be neutral
what should one "say and do." Franz Alexander pioneered the corrective
emotional experience but presented it as a form of behaviorist manipulation
with the analyst playing various roles. Nonetheless interpretations of the
transference relationship were increasingly considered more important as
mutative factors. Analysts like Merton Gill argued that here and now Transference
Interpretations were more important than reconstructions of childhood experience.
Even in centrist circles analytic neutrality has been reconstructed in terms
of empathy, emotional connection, support, acknowledgment, and caring. Our
small group has I think followed these developments.
But all of these new interactive modes, which are thought to be necessary
for therapeutic change, in my opinion intensify and leave hanging the question
of what happens to the idealized transference--the analyst as the moral
authority the ideal parent. I have for myself concluded that most people
who are pleased with their analysis have never resolved the idealized positive
transference. I have also concluded that the major occupational hazard of
psychoanalysis is the analyst cultivating and believing in that idealizing
role. Nonetheless I believe that this idealized transference is one of the
necessary mutative ingredients in psychoanalytic psychotherapy.
The analyst is loved, admired, gains power over the patient, is accepted
as a authority in the moral adventure of life, and that is one of the most
important aspects of how the patient is changed. Although I am sure many
of you would qualify and refine aspects of what I have just said I would
hope there is a general consensus that positive transference, as Freud recognized,
produces the power of suggestion which is the catalyst of change. These
transference considerations are why we have professional boundaries.
Now it will not be too much of a leap for those of you who are analysts
if I were to say that we analysts idealize our own analysts and that this
is an element in our institutional politics and divisiveness. For most of
my life I have had some sort of idealized transference to Sigmund Freud.
I have read and reread the collected works for 45 years and taught them
for almost as long. As one might feel toward an idealized psychoanalyst
I was able to overlook the negative things I learned along the way including
Freud's own boundary violations. Long ago on reading that Freud had himself
analyzed Anna Freud--I somehow dismissed it as necessary under the circumstances.
What somehow broke through this idealization was my discovery of the Horace
The details of the Horace Frink affair have been authenticated by Professor
Gay of Yale, the author of the definitive biography of Freud. Frink had
trained in psychiatry under Adolph Meyer at Johns Hopkins. He later settled
with his wife and children in New York, where he began to practice psychoanalysis
without any real training as was the custom at the time. Among his patients
was a woman who was a New York socialite married to a fabulously wealthy
man. Frink began to have an affair with her which he interrupted to go to
Vienna for an analysis with Freud. Frink had one distinction of importance
among analysts in New York at the time--he was not Jewish. Reminiscent of
his early elevation of Carl Jung, Freud had the idea of installing Frink
as the head of the New York/American Psychoanalytic Association, much to
the chagrin of analysts like Abraham Brill who had much better credentials.
After several months of Frink's training analysis in Vienna, Freud instructed
him to send for the patient with whom Frink had been having the affair.
Freud told this woman that unless she divorced her husband and married Frink,
Frink would most certainly become a homosexual. The woman agreed to Freud's
drastic remedy and over her husband's bitter objection was divorced and
married Frink, her analyst; The exchange of letters between this husband
and Freud I found appalling. Frink's wife also accepted Freud's verdict.
Unfortunately Frink subsequently began to display unmistakable symptoms
of serious bipolar disorder, his socialite wife abandoned him, and he eventually
returned to Johns Hopkins as a patient. All of this was revealed a few years
ago when one of Frink's daughters found her mother's correspondence.
You might say that my reading about the Frink affair was to some extent
a mutative experience. It certainly made me question Freud's moral authority.
Am I alone in feeling this sense of disillusionment, or am I correct in
thinking that others do as well and that is part of our current predicament.
Everywhere I go and talk to other analysts there is the scent of scandal
hanging over our idealized leaders.
I think most of you will agree with me that in some sense what all schools
of psychoanalytic therapy have in common is a developmental historical account
of the individual. We may disagree about which events are critical, but
we agree that the individual's history is important in understanding and
treating the individual's psychopathology. "The history of desire in
the person" seemed to me a good way to think about psychosexual development
and to begin to think about all object relations. I was prepared to believe
those who claimed that psychoanalysis was more like history than like science
and that the task of psychoanalytic therapy was to reconstruct that history.
Out of that enterprise of understanding the individual's history will come
an important therapeutic element--a believable self-description. The appeal
of Freud to the twentieth century is that his theories of individual development
gave men and women, to a lesser extent, revealing and believable self-descriptions
that helped them make sense of their personal history. Here is Freud describing
his own personality and why he was not cut out to be a physician: "I
have no knowledge of having had in my early years any craving to help suffering
humanity. My innate sadistic disposition was not a very strong one, so I
had no need to develop this one of it derivatives. Freud's self description
comes right out of the three essays and his theory of psychosexual development.
An even more dramatic example of what I mean--because it comes form unexpected
quarters--is to be found in Jean Paul Sartre who made elaborate and brilliant
arguments against Freud. For example, criticizing Freud's theory of unconscious
repression, he described it as a lie without a liar. He may have constructed
his whole theory of Bad Faith to rebut Freud. But when it came to giving
a self description of his own life, he reported that a psychoanalyst had
told him that because his father died when he was an infant, Sartre did
not have a superego. This wild interpretation delighted Sartre, he wrote
that other men went through life weighted down by their fathers "like
Aeneas carrying Anchises from the walls of Troy" but he, the philosopher
of radical freedom, had no such burden.
The construction of narratives as self descriptions, though usually in much
more subtle and convoluted ways, is what much of psychoanalysis is about.
Freud generated self descriptions based on developmental events and psychosexual
stages like those he described in Three Essays and The Ego and
the Id. That is how we came to understand our sexual preferences, our
foibles and our character. Now the important challenges for psychoanalytic
therapy as posed by our critics are first that these developmental events
have no important causative relationship to the phenomena of psychopathology.
Second, that the self descriptions generated by our explanatory theories
are both irrelevant and unverifiable.
Early in my career as a psychiatrist and a psychoanalyst I believed that
every form of mental illness be it psychosis, neurosis or personality disorder,
could be understood in terms of psychoanalytic developmental stages. If
one wanted to understand psychopathology better one had to learn more about
infant and child development. This idea was basic and it was unquestioned,
the secrets to understanding psychopathology were to be found in studying
infant and child development. That is what Anna Freud, Ernst Kris, Beata
Rank, Margaret Mahler and other s devoted themselves to. And other analysts
tried to improve psychoanalytic theory based on these observations. Ideas
about the relationship between child development and psychopathology were
never questioned, although there was always of course the matter of genetic
Our problem is that based on the scientific evidence now available to us,
these basic premises may all be incorrect. Our critics may be right. Developmental
experience may have very little to do with most forms of psychopathology,
and we have no reason to assume that a careful historical reconstruction
of those developmental events will have a therapeutic effect. I know that
it is difficult to assimilate this idea; it certainly is for me. Recently
in reviewing a new psychoanalytic textbook on affect I read, "There
is growing consensus that adult psychopathology can be understood with reference
to normal child development." I nodded inwardly in agreement, but then
I stopped in my tracks and thought about those words more carefully as I
ask you to do. There is certainly no longer any consensus that schizophrenia,
bipolar disorder, depressive disorders or substance abuse can be understood
with reference to normal child development. In fact most research psycho
pathologists would say that child development explains very little about
most so-called Axis 1 disorders. There is of course one very important exception--post-traumatic
stress disorder; but the trauma is not crucially related to childhood development.
Let me delineate the exact parameters of what I am trying to say. Psychoanalysts
can no longer assert that what they learn about their patient's childhood
will help them to explain the etiology of the patient's psychopathology,
or even of the patient's sexual orientation.
Many psychiatrists now argue with better evidence than we have that child
development has little to do either with any Axis 1 disorder or with personality
disorder. The problem in psychoanalytic reconstructions of childhood events
in their view is not that we have difficulty in finding the crucial causative
event or the crucial sequence of events, but that those events are irrelevant
to explaining psychopathology. Again the exception to all of this about
which I am not gong to speak is post-traumatic stress disorder.
The task of constructing self descriptions in psychoanalytic therapy also
encounters the problem of memory. Years ago Selma Fraiberg presented a follow-up
of a child analysis case. The main issue over three years from age 6 to
9 was the little girl's masturbation. The analysis, by all of Mrs. Fraiberg's
criteria, went well and the follow-up at age 12 was a pleasant reunion.
As the little girl got up to leave she said in an embarrassed tone, Mrs.
Fraiberg, there is one thing I never told you in my analysis, it is about
my masturbation. The young girl remembered nothing about what had been the
central concern during three years of child analysis. This report made a
great impression on me. How could the child have been helped if she had
forgotten the very thing Mrs. Fraiberg considered central to the analysis.
And what about our own efforts to help patients reconstruct memories from
even earlier time.
Everything we have learned in recent years about memory has emphasized its
plasticity, the ease with which it can be distorted, and the difficulties
of reaching a hypothetical veridical memory. Much of what psychoanalysis
considered infantile amnesia may be a function of the reorganizing brain
rather than the repressing mind. All of this makes the task of constructing
meaningful histories of desire in the individual more daunting. This is
the post modern world where everything is paradox and hermeneutic uncertainty.
If there is no important connection between childhood events and adult psychopathology,
then Freudian theories lose much of their explanatory power. If memory cannot
be trusted to construct a self description, what does one do in therapy?
Each of you has to solve these problems in your own different ways; there
is no unifying paradigm. I can tell you briefly what I do.
I certainly have not given up on psychotherapy but my focus is almost entirely
on the here and now, on problem solving, and on helping patients find new
strategies and new ways of interacting with the important people in their
lives. I still believe that a traditional psychoanalytic experience is the
best way to explore the mysterious otherness of one's self. But I do not
think psychoanalysis is an adequate form of treatment. There is certainly
no reason for psychoanalysts to withhold medication from their patients.
If I can call on Freud after criticizing him so harshly as a moral authority.
I would suggest that he would have welcomed Prozac, Ativan, and all the
rest. Despite his disclaimer, he himself tried to find such substances that
would relieve human suffering.
Freud's famous conclusion was that when our patients' neuroses are cured
by psychoanalysis they have to deal with ordinary human suffering on their
own. Perhaps it will be no further offense to Freud for me to suggest quite
the opposite. When a patient's symptoms are treated he may then need a psychoanalyst
to help him deal with his ordinary human suffering. That is the therapeutic
domain in which the art of psychoanalysis will survive.
Alan Stone '50, a graduate of the Boston Psychoanalytic Institute and a former president of the American Psychiatric Association, is Touroff-Glueck professor of law and psychiatry in the Faculty of Law and the Faculty of Medicine at Harvard.
The original address from which this piece derives
A one-webpage version of this article, suitable for printing out for personal use
For information regarding copyright restrictions, please contact Jim
Nourse, Dr. Stone's assistant, at [email protected]
See Letters to the editor for comments on this piece, or to enter your own thoughts