In the age of happy pills and quick fixes, the "talking cure" still has something to offer.
How many Freudians does it take to change a light bulb? Two. One to change the bulb, and one to hold the penis ...
I mean ladder! Although Sigmund Freud isn't exactly famous for his sense of humor, he actually liked jokes ?in fact, he wrote a book about them,
Jokes and Their Relation to the Unconscious. But he probably wouldn't have liked that one. Freudian psychoanalysis was one of the great innovations of the 20th century, and only 50 years ago, it was a mainstay of mental-health care. But since then it has gone from a medical and cultural institution to the punch line of a mildly dirty joke told by psychiatry residents. The members of the American Psychoanalytic Association today treat fewer than 5,000 patients in the U.S. How did the treatment Freud called the "talking cure" fall from grace? And now that it has fallen, can it get up again?
For almost a century, Freud's followers have treated his techniques like Holy Scripture. Now they are being forced to update his theories to compete with new drugs and new therapies, even if it means using methods that would have been unthinkable to their patriarch. At the same time, post-Freudian psychotherapists are figuring out that the old master still has something to offer the science of mental health: an understanding of the human mind and its many malfunctions that's richer, fuller and more exciting than anything invented since.
In their time ?the early decades of the 20th century ?Freud's ideas radically and irrevocably changed the way we think about who we are. He both explained the human mind and made it more mysterious. One of Freud's key insights was to divide the mind into the conscious and the unconscious: he showed us that beneath the surface banality of everyday thoughts and gestures lurk subterranean caverns of forbidden longings that reach all the way back to our earliest childhood memories. Freud's therapeutic technique, psychoanalysis, was an intellectual exploration of those depths, where patients could confront their deepest, darkest desires. If they recognized and overcame those repressed desires, the theory went, they could return to the surface with a calmer, healthier mind.
By the 1920s, psychoanalysis had become wildly popular in America (a country Freud visited only once and hated). Jazz age sophisticates held "Freuding" parties at which they told one another their dreams. Samuel Goldwyn, the movie-studio magnate, offered Freud $100,000 to write a love story that Goldwyn could turn into a motion picture. (He was rebuffed.) But Freud died in 1939, and the golden age of psychoanalysis lasted only until the 1950s. By then competing psychotherapeutic theories and approaches had begun to spring up, among them ego psychology, self-psychology, the object-relations school, interpersonal therapy and existential therapy. All revised Freud, and some rejected him outright.
Cognitive therapy is one of the most virulently anti-Freudian strains of post-Freudian therapy, and it has become one of the dominant approaches to therapy today. It was pioneered in the early 1960s by the psychiatrist Aaron Beck, who was trained as a Freudian but ?in classic Oedipal fashion ?rebelled against his master. Beck dismissed Freud's ideas about the subconscious as so much scientifically unverifiable cigar smoke. In their place he crafted a quick, pragmatic therapeutic approach that dispensed with abstract theories and focused on results. Cognitive therapy attacks such symptoms as anxiety and depression by "coaching" patients on how to think about their lives more clearly.
Not only did Beck reject Freud's idea of the unconscious self, but he also abandoned the formal reserve of the classic Freudian analyst. Freud believed the analyst should be as neutral and silent as possible. That way, Freud theorized, the patient can project personalities from his or her past onto the analyst and relive past conflicts right there on the couch. Freud called this process "transference." Beck and his followers aren't interested in transference. Instead cognitive therapists talk back to their patients, pointing out their misconceptions and advising them on how to see their lives more clearly.
Cognitive therapy is everything psychoanalysis isn't: simple, quick, practical, goal oriented. "
There's this mystique about psychoanalysis," says Judith Beck, daughter of Aaron and herself a leading cognitive therapist. "Psychoanalysis is esoteric and creative and interesting, and the psychoanalyst holds himself up as the expert who interprets what the patient is saying and has all the answers. It's kind of the opposite in cognitive therapy." Cognitive therapists tend to follow the same basic script for each session, so the treatment is remarkably standardized. It's also remarkably effective; research shows that when it comes to treating depression, cognitive therapy works as well as drugs like Prozac. And though it's not quite as quick as antidepressants, the results last longer after treatment stops. One study published in the New England Journal of Medicine found that, used together, cognitive therapy and antidepressants can help 85% of patients suffering from chronic major depression.
How can psychoanalysis compete with that? Freud's methods may be intellectually exciting, but they're slow and largely unproven. A course of cognitive therapy can take as little as six to eight sessions to finish; a course of analysis often takes five to 10 years. Even its supporters admit there are few clinical studies to show that psychoanalysis actually works. After all, they argue, the ultimate goal of psychoanalysis is deeper self-understanding, and how can you demonstrate that with a study?
But try telling that to an insurance company. Another reason cognitive therapy has been so successful ?Judith Beck estimates that there are 5,000 cognitive therapists nationwide ?is that it's the perfect therapy for the age of managed care: quick, cheap and backed by statistics. Classical Freudian psychoanalysis demands four or five sessions a week, and a session with a qualified psychoanalyst can easily run you $125, if not twice that amount. Few insurance companies will pay for a treatment that costs $30,000 a year and has hardly any clinical outcome studies to back it up. Insurers would rather pay for a cognitive therapist ?or for that matter, a psychopharmacologist, especially since the introduction of Prozac in 1987. Prozac and the other selective serotonin reuptake inhibitors are widely used to treat disorders like depression and anxiety, which were once the bread and butter of psychoanalysis. Of the 14 million patients treated for depression in the U.S. every year, around 80% take some form of antidepressant medication.
That's how Freud has gone from being the founding father of psychotherapy to a poor, eccentric cousin on the fringes of psychotherapeutic practice. "Classical analysis is a very, very small percentage of what is practiced in this country," says Dr. T. Byram Karasu, editor in chief of the American Journal of Psychotherapy. "It's almost a negligible fraction." Judith Beck believes psychoanalysis will die out in our lifetime. "Managed-care companies and insurance companies," she says, "are finally waking up and looking at research, and finding that it's not effective." Practically the only place patients actually lie down on couches anymore is in Woody Allen movies and New Yorker cartoons.
In the hope of finding a place in modern mental-health care, however, its practitioners are trying to change with the times. One way they're doing that is by dropping the austere, formal pose of the classic Freudian analyst. "The image of Sigmund Freud sitting there smoking on his pipe is nothing like the modern 21st century analyst," says Kerry Sulkowicz, chairman of the committee on public information at the American Psychoanalytic Association. In modern psychoanalysis, that formal reserve is disappearing, and the analyst's personality comes much more into play in treatment. "The process is far more transparent today," says Sulkowicz. "An analyst may say, 'I'm choosing to remain silent to allow your thoughts to bubble up.' Analysts are much more up front. That never would have happened in Freud's day." Many analysts have even given up the beloved couch in favor of face-to-face conversation. "I don't know if that's gotten out to the general public," says Dr. Elio Frattaroli, a psychoanalyst who practices in Pennsylvania. "We made a lot of mistakes by being too much in our heads."
Psychoanalysts are also learning to borrow from other disciplines. According to a survey conducted by the Journal of the American Psychoanalytic Association, more than 18% of patients undergoing psychoanalysis in America also take some form of psychoactive medication. Some psychoanalysts even borrow techniques from cognitive therapy. "The analysts have moved more in the direction of understanding cognitive distortions," says Dr. Glen Gabbard, a psychoanalyst and professor of psychiatry at Baylor University. "If you look at good therapists on videotape, you'll find that the cognitive therapists and the analysts do many things in common." Many psychoanalysts also offer patients a treatment known as psychodynamic therapy, which requires less of a time commitment. It's like psychoanalysis lite: the same techniques are used, but the patient comes for only one or two sessions a week. "The current state of psychoanalysis is such that Freud would probably not recognize it," says Gabbard.
But old-school Freudian psychoanalysis has its true believers, and not all of them are doctors. Some are patients. "It's allowed me to figure out some pretty basic things about myself and why certain situations keep coming up," says a graduate student in her 30s in Brooklyn, N.Y., who went into analysis after a difficult breakup. "A lot of the jokes about analysis talk about blaming your parents, but being in analysis is more about learning to take responsibility for yourself and to take care of the people around you. That kind of control only comes from understanding your past." After four years of analysis, she is more productive, less moody, less angry and less depressed. "It was one of the best decisions I ever made."
Whatever else may have changed, the intellectual adventure of psychoanalysis, the delving into the depths, is still part of the Freudian tradition, and that's not going to disappear. Psychoanalysis is based on the fundamental belief that we aren't just a collection of neurotransmitters to be fixed with a pill, or a set of cognitive skills to be coached back into shape like a slumping quarterback. To Freudians, the mind is a complex and mysterious thing, and symptoms like depression and anxiety are the language in which deep inner conflicts express themselves. "Now most psychiatrists have scorn for psychoanalysis," says Frattaroli. "In this age of the quick fix, the idea is to get rid of the symptom with a pill or some sort of therapy. But one of the problems with the current thinking is the belief that symptoms are bad. In psychoanalysis, symptoms are messages from the subconscious that something is out of balance. They have meaning. The symptom points to something deeper, and if you just get rid of the symptom, you're not solving the underlying problem."
In other words, the future of psychoanalysis depends on who, deep down, we really think we are. With or without clinical studies, the idea that the mind is a deep, mysterious place is too powerful to go away by itself. But to keep psychoanalysis alive, psychoanalysts will have to learn to innovate and evolve. A sense of humor might not be a bad place to start.
by Janice Horowitz and Andrea Sachs/New York