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News Gram™ June 2005

June 2005 ~ Volume 11, No. 11

Psychoanalysis is one of the most influential and exciting developments in the 20th and 21st centuries. It has become much more than a medical enterprise, becoming a cultural force that animates thinkers in disciplines as disparate as philosophy, religion, history and cultural studies. What is it about psychoanalysis that has attracted so many followers (and so many detractors)? How does it fit into the field of workers’ compensation and disability insurance? How does one learn about it?

In the last few years of the 19th century, a neurologist by the name of Sigmund Freud became interested in patients of his who had developed strange symptoms that his colleagues could not understand. These symptoms involved weakness or paralysis of the limbs, alterations in speech, trance-like states, and other conditions, all of which revealed no abnormality of the nervous system or other part of the body. Often, physicians regarded such people as fakers, malingerers or moral failures. Freud thought otherwise. Having studied with the great Charcot in Paris, he determined that these people were not pretending to be sick but were experiencing symptoms produced by unconscious mental processes.

While many people before Freud had considered the idea of the unconscious, he was the first to view it as a dynamic process that exercised profound influence on a person. For instance, a paralysis might represent an unconscious inhibition against a wish to kill one’s father. A dream that one is stepping over a black line might, through its peculiar logic, convey a longstanding desire to marry a man of a different religion, an act that would devastate her parents. Or when a man, responding to a simple question such as “How are you?” declares that “X marks the spot,” he is really referring to Karl Marx, revolution and the desire to unseat both parents from their authoritarian positions.

Freud began to investigate these strange kinds of phenomena and, to facilitate the process of learning about his patients, he had them recline on a couch and tell them to say whatever came to mind. This process became known as free association. By 1900, he published The Interpretation of Dreams, arguably his most famous work. In this early period, he also constructed what he called the topographic theory of the three layers of mental activity – the conscious, the preconscious and the unconscious. Conscious mental activity is what we usually think it is. Thought, wishes, memories and the like of which we are aware and speak. The preconscious domain consists of all those thoughts we are not currently aware of but can recall at will – phone numbers, names of people and places and the latest weather report. The unconscious cannot be brought to mind and is the largest reservoir of mental material. It exerts a force on the person and often compels him in one or another direction that he may not much like.

Symptoms are one sort of behavior brought about by unconscious processes. Such acts as checking several times to see if the door is locked before going to sleep, dressing and undressing, over and over and washing one’s hands à la Lady Macbeth, the behavioral products of the unconscious.

In psychoanalysis, the patient lays down on the couch and free associates for the better part of an hour. During this time, the analyst usually says very little, though every once in a while he may offer an interpretation of what the patient has been saying. The process continues like this four or five times a week and may extend over several years.

In the early days of psychoanalysis, the aim of the treatment was the elimination of symptoms. Gradually, though, the focus has changed and analysts are far more interested in character, the underlying psychological mainstay of a person that may be the source of great achievements, abject misery or both.

For a long time, psychoanalysis was influenced by Freud’s idea of the structural theory, the idea that we all have an id, ego and superego. The id is the repository of a person’s drives, largely sexual and aggressive. The ego is the part of the person that directs his every day life, makes executive decisions and plans for the future. The superego is the person’s conscience.

Under the sway of Freud’s ideas, analysts concentrated on what came to be known as ego psychology, an examination of how the person thinks, feels and deals with conflict. In more recent years, they have looked at the person from the perspective of narcissism, a branch of psychoanalytic thought introduced by Heinz Kohut. This area of interest has yielded rich results. Narcissism is an involved subject in psychoanalysis and is perhaps made more compelling by the general sense that ours is an age of narcissism. The Me Generation now seems to have found a way to free itself from all the gooey self-absorption that can make life so unpleasant and unfulfilling. Rather than concentrating on matters of psychosexual development, the main area of traditional psychoanalytic concern, self-psychology, as it is called, looks closely at the development and difficulties experienced by the self. The latter term is loaded with technical connotations that needn’t concern us here. What is of considerable interest, though, is that the idea of infantile conflict, a key concept going back to Freud, takes a back seat to the development of the self. The analyst tries less to interpret such patterns of events in the earliest years than to empathize with the patient in an effort to repair the damage to the self that occurred in the process of becoming an adult.

For many years, psychoanalysis dominated American psychiatry. However, its hegemony has been replaced with, for lack of a better term, what we might call the psychopharmaceutical kingship. Psychoanalysts often look dimly on this change of authority. Many think analysis will ultimately die out under the pressure of a pill-oriented culture. Others simply wait for the frustrations of pharmacological treatment to accumulate until the whole enterprise collapses. Still others seek to combine the two points of view. The friction between the two schools of thought remains part of what makes psychiatry such an interesting medical specialty.

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