Sunday, May 20, 2007

A Brief History of Psychotherapy: Freud

When I originally conceived of this series, I thought it would be a brief set posts. I can already see that I was overly optimistic. There's an awful lot of material here. So, at this point, I'm not sure of how many posts it will take to complete this project.

Freud, Charcot, and Hysteria

Most people believe that psychotherapy began with Freud. Actually, Freud himself (Himself?) began as a student of the French neurologist, Charcot, who was investigating the phenomenon of hysteria. In this disorder, patients, mostly women, would manifest symptoms of physical disorders (such as paralysis or blindness) with no known physical causes. (Space prevents me from dealing with the feminist issues here.)

Charcot discovered that hypnotizing his patients and encouraging them to talk about their symptoms would result in their remission. Freud was very impressed with this and began trying Charcot's technique on his own patients. He began a brief collaboration with Josef Breuer, and in 1895, they published Studies on Hysteria, probably the first book ever published on psychotherapy.

Freud apparently was either not a very good hypnotist or not a very enthusiastic hypnotist and soon abandoned hypnotic induction. He kept everything else in place; the patient would lie down on a couch in a dimly lit room and begin talking about her symptoms. There is an apocryphal story that Freud initially used to question his patients to clarify what they were talking about. On at at least one occasion, the patient said, "Don't interrupt me when I'm talking," and Freud learned to be quiet and listen during free association. This is the form of classical psychoanalytic practice: a period of free association followed by interpretation of the material by the analyst.

Freud's initial work led to the publication of The Interpretation of Dreams in 1899. (The publisher later dated the book for 1900, probably to identify it with modernity.) This book, along with his later book, An Outline of Psychoanalysis, (published in 1940) contain the best material on Freudian psychoanalysis.

Personality and Behavior

Psychoanalytic theory is highly complex and was constantly evolving under Freud; I cannot do it justice here. Nevertheless, to understand why Freud did what he did, you have to understand some part of his theory of personality.

For Freud, personality reflected the interaction of forces inside the psyche. These intrapsychic forces interacted and opposed each other. The healthy psyche was one where the forces balanced each other out and energy was expended in rational behavior. These forces interacted within and between three major structures in the psyche: The id, or unconscious mind; the ego, the conscious, rational part of our minds; and the superego, essentially our conscience, although Freud thought of it as the internalized parent.

The id is driven by instincts to either create or destroy. The basic physiological instinct associated with creativity is, of course, sexual reproduction. Aggression is the basic physiological instinct associated with destruction. Because the id is the only source of energy, it is always the central player in our behavior.

The ego and the superego obtain energy from the id through symbolization. The id is unable to tell the difference between reality and the symbol; that is the job of the ego. Hence, the ego would direct the individual to engage in behaviors symbolically related to these instincts. Anything, from playing a musical instrument, to telling a joke to a friend, to doodling on a piece of paper would accomplish this.

It is the job of the superego to control the impulsive, reckless, and immoral behavior of the id. In the healthy individual, the ego is the negotiator between them; in the unhealthy individual, the ego is the battlefield between them. When the superego is in control, the individual is rigid, compulsive, and intolerant. In this three-way interplay, the symptoms of mental illness emerge.


It is important to understand that treatment actually evolved before the theory did. Freud thought that his treatment worked. After being analyzed, symptoms of hysteria seemed to go away. Hence, psychoanalysis is really an explanation for why treatment worked.

Treatment, for Freud, was a matter of balancing intrapsychic forces. For doing this, he had three primary tools: Free association, dream interpretation, and analysis of the transference relationship. Free association gives us the classical image of the patient on The Couch.

Free association. Free association, as described above, provided the primary data for analysis. It was assumed that if the patient was talking about it, it was important. The juxtaposition of different ideas gave a clue about unconscious connections between them. Symbolization was manifested both in free association and in dreams, and proper interpretation was crucial to treatment.

Dream interpretation. Freud regarded dreams as the "royal road to the unconscious." He found that patients often discussed dreams during free association and became convinced that dreams represented unconscious processes. By analyzing the dream symbols, the analyst developed insight into the patient's problems.

Transference. Transference refers to the manner in which the patient responds to the analyst. Does the patient idealize the analyst, or does the patient "forget" about appointments? Freud concluded that the patient "transfers" his or her feelings about the parents onto the analyst. This, of course gives clues about early family relationships that are so critical to the development of the individual. To this end, Freud argued that the analyst should be as bland as possible.

Countertransference is the other side of the coin and refers to the feelings of the analyst toward the patient. While this gives insight into the analyst's state of mind, it also helps the analyst understand how the patient affects other people. If, for example, the analyst feels angry at a patient, it may suggest that the patient is behaving in a hostile manner toward the analyst. That provides much data for the analysis.

Analysis. Using these tools, Freud investigated the unconscious life of the individual. By uncovering unconscious conflicts and developing insight, Freud believed that he could strengthen the ego and redirect the emotional energies in a healthier manner. This always involved understanding the internal symbolic world of the individual, and the symptom was always linked symbolically to the underlying trauma. If, for example, a patient complained of hysterical blindness, Freud assumed it was because they had seen something awful. Hence, it was necessary to uncover the traumatic event the patient had seen, to relieve the symptoms. Generally, for Freud, the traumatic event involved childhood trauma.

By developing insight and uncovering repressed trauma, energies attached to inappropriate objects can be released and appropriately redirected by the ego. Freud used the term, catharsis, to refer to re-experiencing the emotions related to the trauma. Release of the tensions associated was called "abreaction."


For those who know something of Freud, you will note that I have said nothing about his theories of development. I have done that deliberately. I am more interested in focusing on psychotherapy than on personality development or psychopathology. I will only say in passing that Freud was very right to observe that a child is not a small adult. His scheme of development was very wrong.

Freud remains a controversial figure today. We continue to argue about his strengths and weaknesses. (A good discussion of the strengths and weaknesses of classical psychoanalytical theory is contained here.) In relation to psychotherapy, I think it is safe to say, he made several significant errors.

First, Peter Kramer, in his book, Freud: Inventor of the Modern Mind, argues that a great error of Freud was his belief that the symptom is a symbol. For Freud, the symptoms were always related to the underlying psychodynamics of the individual. We know now that is not true. Depressed people show similar symptoms regardless of their underlying dynamics. So, for example, if a person experiences panics when out of the house, Freud would have assumed that the person experienced some trauma outside of the house. The goal of treatment would involve uncovering that trauma and unlocking the emotions associated with it.

Freud's second error was that he didn't understand the role of the situation, and saw behavior as a function of the internal dynamics of the individual. Freud did not recognize that individuals acquire maladaptive behavior through experience. A child growing up in an abusive environment learns to be a perfectionist because it helps reduce the abuse. It's not because of a rigid superego.

Third, Freud did not understand the influence of culture. We know that as culture changes, symptoms of mental illness change. Freud saw a lot of hysterical blindness and paralysis. We see almost none of it today. In fact, I have been in practice for over 30 years, and I have yet to see an individual with hysterical blindness. Similarly, Freud saw the role of women as being biologically, not culturally determined. He would be amazed to see women working along side of men, much less fighting in the military.

Finally, Freud hoped that someday psychoanalysis would be subjected to scientific evaluation. But, psychoanalysis is not a scientific theory, especially as science is practiced over 100 years after The Interpretation of Dreams was written. Psychoanalysis is too complex and it makes too many conflicting predictions. There is also a paucity of systematically collected data. But, that does not mean Freud has nothing to offer us.

As I said previously, Freud was a visionary. His ideas are so ingrained in us today, that we cannot conceive of a world without the idea of unconscious motivation. For me, Freud, beginning with almost nothing, made three significant breakthroughs.

First, through his concept of transference, Freud uncovered the therapeutic relationship. Today, we understand that the relationship between the therapist and the patient is the primary vehicle for change. The therapist and the patient must have a relationship of mutual trust and respect if the patient will explore material that is potentially shameful and anxiety-provoking. The modern view of the therapeutic relationship is broader than Freud's, but there is no doubt that he originated the idea.

Second, Freud recognized that something is going on in people's minds that they are unable to talk about. Most modern therapists do not talk about investigating the unconscious, but they do recognize that there are things going on the person's head that are relevant but difficult to identify and change.

Finally, and most importantly, Freud recognized that speech is a very powerful tool. The term, "talking cure" came from one of Freud's patients, and it is a very apt description. Without Freud, there would be no psychotherapy today.

Coming Soon

Today, it is safe to say that there are few orthodox Freudians left. In fact, early in the twentieth century, contemporaries of Freud began to elaborate and diverge from his thinking. By the 1950's psychoanalysis had evolved significantly from it's roots. My next post will trace that change.

Sunday, May 13, 2007

A Series of Posts on Psychotherapy

I'm going to begin a series of posts on psychotherapy, which are long overdue. When I started blogging, I anticipated writing a lot about the science of psychotherapy, but I haven't followed through with it; I've been having too much fun with other things.

Two events have come together to get me started. First, at Aardvarchaeology (on ScienceBlogs), there was a recent post entitled, Is Psychotherapy Superstition? in which the author, Dr Martin Rundkvist, seemed to be confused about what psychotherapy is. Furthermore, some of the commenters on the blog seemed totally unaware of the evidence for the effectiveness of psychotherapy.

Second, I put off a post on a story in last week's New York Times Magazine by Bruce Stutz, who decided to withdraw himself from Effexor. Stutz initially went on Effexor after becoming depressed during difficult period in his life. He stayed on the drug for several years, and was advised to stay on it the rest of his life. He decided that he didn't want to and weaned himself off, but experienced severe withdrawal symptoms in the process:

Over the next several days they (low doses of Effexor--F.O.) came in handy, especially at night, when I would wake up feeling dizzy, almost seasick, disoriented and in a heavy sweat, the pillow soaked. One night, awake and not eager to go back to lying restlessly in bed, I went online, typed in “Effexor withdrawal” and found bulletin boards full of pained, plaintive and sometimes angry posters who had quit taking their medication and were suffering a broad but surprisingly consistent range of symptoms: dry mouth, muscle twitching, sleeplessness, fatigue, dizziness, stomach cramps, nightmares, blurred vision, tinnitus, anxiety and, weirdest of all, what were referred to as “brain zaps” or “brain shivers.” While there were those who went off with few or no symptoms at all, others reported taking months to feel physically readjusted.
Stutz eventually did wean himself off Effexor, and has not had a recurrence of depression. He puts his finger on the issue:
If my psychiatrist had told me, “I think you can do this without taking any drugs,” would I have done just as well? If I had been told how difficult it would be to get off the drug, would I have so readily started on it? Even the doctors and researchers who most believe in the effectiveness of antidepressants acknowledge that the “chemical balance” paradigm, the magic-bullet paradigm, makes things seem simpler than they actually are. For some, these drugs may be a lifesaving treatment. But for most of us troubled or even temporarily anguished by life’s difficulties, does our long-term reliance on these drugs become more of a convenience than a cure, allowing us to simply keep going in the midst of very difficult circumstances? And once we start taking them, how do we find the wherewithal to stop?
To make a decision between drugs alone, psychotherapy alone, and both combined, patients need to understand what psychotherapy is. It is not a panacea, as it was once advertised. It's not for all people, or even for all depressed people. Prospective clients of a psychotherapist need to understand what they are getting into. So, there are three topics I want to address in this series.

First, I'll talk about what psychotherapy is and is not. To do that, I have talk about the history of psychotherapy and how we got to where we are today. Next, I'll give a brief description of research in psychotherapy, and finally, I'll talk about how therapy and medication work together in treatment.

I hope this will give readers a better idea of what to expect if they seek psychotherapy and a better ability to understand some of the stories about the effectiveness of therapy that emerge in the press. All treatments for physical and mental illnesses involve decision making. The more you understand the options, the better.

Sunday, May 06, 2007

The Tyranny of the Shoulds

I was reading the New York Times, as usual, and stumbled across two articles I knew I should blog about. The first was Bruce Stutz's account of his withdrawal from Effexor, an antidepressant drug. Effexor is a very popular drug, especially among primary care physicians, and it can be very hard to get off. His story is, at points, gruesome. But it speaks for itself, and right now I have nothing to add. I will soon, though, so stay tuned.

The second story is much funnier and more enjoyable. It's an article in the Book Review, entitled, Why Not the Worst? In it, the author, Joe Queenan, writes about his love of bad books and compares himself to others who are obsessed with quality:

Most of us are familiar with people who make a fetish out of quality: They read only good books, they see only good movies, they listen only to good music, they discuss politics only with good people, and they’re not shy about letting you know it. They think this makes them smarter and better than everybody else, but it doesn’t. It makes them mean and overly judgmental and miserly, as if taking 15 minutes to flip through “The Da Vinci Code” is a crime so monstrous, an offense in such flagrant violation of the sacred laws of intellectual time-management, that they will be cast out into the darkness by the Keepers of the Cultural Flame.
Queenan goes on:
Some people would identify a passion for bad books as a guilty pleasure, but I prefer to think of it as a pleasure I do not feel guilty about, even though I probably should. Bad movies, bad hairdos, bad relationships and bad Supreme Court rulings merely make me chuckle. Bad books make me laugh. And if they ever stop writing books with lines like “Being a leader of the Huns is often a lonely job,” I want to stop breathing on the spot.
So, what does this have to do with psychology?

Queenan is attacking what Karen Horney (pronounced HORN-eye), an early neo-analyst, called "the tyranny of the shoulds." In this, Horney anticipated the cognitive-behavioral therapies of Albert Ellis and Aaron Beck.

Horney recognized that we carry around many beliefs about what should or should not be. Some shoulds are about what happen to us. We believe, "I should be successful," or "My spouse should know what I want without my saying so." Unfortunately, that's just not realistic.

We have every reason and right to want things. But, "should-ing" is based on the unrealistic belief that the world must grant us what we want, just because we think we're right. When the world doesn't cooperate with that belief, we get angry or depressed.

Some shoulds address standards for our own behavior. For example, "I should read only good books." These shoulds make us rigid and rob us of our pleasures. Why not enjoy a bad book occasionally? Queenan's observation, "I prefer to think of it as a pleasure I do not feel guilty about," is a wonderful rejection of those shoulds.

When I hear a client bring up their shoulds, it is my job to attack those beliefs and replace them with more flexible beliefs. Some clinicians use Socratic questioning to attack peoples shoulds. For myself, I've found that far too often, Socratic questioning turns into the Possum Lodge Word Game. Instead, I like to hit people between the eyes with a one-liner.

Needless to say, I'm always on the lookout for a good one-liner. Now, I can't wait to say to a client, "Don't think of it as a guilty pleasure, think of it as a pleasure you don't feel guilty about."

Friday, May 04, 2007

Comments are now being moderated

I've been getting spammed by an idiot pushing drug paraphernalia. So, until he or she gets tired and goes away, I'm moderating comments.

Sorry for the inconvenience.