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"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 center.
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 psychoanalytic therapy.
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 text.
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 Frink affair.
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 predisposition.
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.
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