Med thumb freud

For better or worse, we owe a lot to Sigmund Freud. For decades after his death in 1939, the good doctor loomed large in the offices of tweedy analysts who employed his methods to tease out deep-seated psychological issues. Among other exercises in psyche-excavation, Freudian disciples treated dreams as manifestations of suppressed wants and woes. Dreams were symbols begging for interpretation.  

The popularity of Freudian psychoanalysis began to wane in the 1970s and ’80s. Academics, in particular, saw Freud's tightest-held ideas and therapeutic methods as being empirically anemic and grounded in sexism. As reverence for Freud and his legacy slipped, more goal-oriented methods, such as Cognitive Behavioral Therapy (CBT), gained traction.

And yet, while many have gleefully exiled Freud from their offices, those trained in psychodynamic therapy insist his central ideas still form the bedrock of contemporary therapy. In fact, they claim Freud and his musings on the mind are more relevant than ever.

“There was a time when there was a lot of Freud-bashing and people didn’t appreciate him,”  said Carol Donnelly, a psychologist who teaches about schools of psychotherapy at Northwestern University. “But because of neuroscience especially, people can now see which ideas of his are valid — and that’s exciting… He’s been invited back into the family.”

The Ghost on the Couch

In The Interpretation of Dreams, first published in 1899, Freud explained dreams as a form of wish fulfillment — attempts by the psyche to express and resolve desires and conflicts that the waking mind exiles. Freudians picked apart patients’ nighttime narratives, looking for themes, characters and ideas that he considered meaningful. These deep-dives also enabled free association, in which patients prattled on about their dreams with little guidance or interruption in order to dredge up repressed formative experiences.

As psychoanalysis entered the modern age, science got involved. And Freud’s ideas didn’t hold up to scientific rigor. They lacked evidentiary basis and were, in fact, incredibly hard to test. In the 1980s, greater use of psychiatric drugs, combined with the decline of talk therapy, helped shift the therapeutic spotlight onto cognitive therapy — CBT and other types of shorter-term, goal-oriented methods that didn’t require thrice-weekly emotional purges.

[pullquote]True Freudians are still out there, earnestly explaining to their patients that the coworkers in their sex dreams are really their mothers.[/pullquote

By the 21st century, Freud was on his way to becoming a rest-stop on the highway of intellectual history. In 2007, the New York Times reported on new findings from the American Psychoanalytic Association that “while psychoanalysis — or what purports to be psychoanalysis — is alive and well in literature, film, history and just about every other subject in the humanities, psychology departments and textbooks treat it as ‘desiccated and dead,’ a historical artifact instead of ‘an ongoing movement and a living, evolving process.’”

Drifting Further Afield from Freud

But Freud wasn’t dead to everyone. There remain seasoned Freudians unwilling to relinquish the psychiatric principles by which they’ve lived and breathed for decades. In fact, true Freudians are still out there, earnestly explaining to their patients that the coworkers in their sex dreams are really their mothers. According to Scott Lilienfeld, a psychology professor at Emory University whose “eclectic” therapy skews away from Freud, northeast cities are bastions for these old-school analysts.

True Freudians are still out there, earnestly explaining to their patients that the coworkers in their sex dreams are really their mothers.

Margaret Walsh is a Freud-friendly therapist who works at the University of Michigan medical school and psychoanalytic institute. Like most therapists waving the Freudian flag in 2015, she practices psychodynamic analysis, an updated version of Freudian theory that jettisons certain outdated concepts (e.g., penis envy, Oedipal complex). They conduct dream exercises akin to free association, but dreams are no longer considered the “royal road” to examining the unconscious mind.

Dreams are of even less concern to cognitive therapists, who concentrate on addressing the issue at hand — often anxiety or depression — through behavioral modification. CBT patients learn to substitute bad tendencies and mindsets for healthy ones, eventually building coping mechanisms. Cognitive behavior therapists come equipped with an extensive toolbox, but meandering dream-chats aren’t in there.

Freud didn’t have MRIs. But he did note patients’ visceral reaction to stimuli.

Some psychodynamic adherents take issue with the cognitive camp’s preoccupation with evidence-grounded psychology. They claim that Freud naysayers point out evidentiary lapses simply to poke holes in time-tested methods, not because psychodynamic theory deserves the derision. Jonathan Shedler, a vocal psychodynamic believer, argued in an influential 2010 paper that research actually supports psychoanalysis as an effective long-term treatment for some mental disorders. CBT simply benefits from being newer, more results-oriented and quicker. But it’s not better, overall.

Others in the same camp see neuroscience as providing the formerly missing evidence needed to bolster Freudian theory. “Today, some of what’s really interesting about psychology — consciousness, emotions and dreams,” said Northwestern’s Carol Donnelly, “is finally the stuff of neuroscience. Neurobiological explanations can impose boundaries on what we should dismiss and embrace [from Freud.]”

Lighting Up the Mind

How exactly does neuroscience give credence to Freud’s model of the mind?

Let’s say that, in a neuroimaging study, scientists ask subjects to smell something — a noxiously sweet cherry lip gloss. Then, using functional magnetic resonance imaging (fMRI), they see if their brain activity changes in response to the odor. If there’s more activity in regions associated with emotional processing and episodic memory, researchers might conclude that there is nostalgia associated with that smell (even if they aren’t consciously aware).

Freud certainly got a few things right. Discussing dreams can have some value.

Freud couldn’t look at brain activity on fMRIs, but he did take note of patients’ visceral reaction to stimuli. He talked with them at painstaking length — and asked probing questions — to uncover emotional resonance to triggers.

It’s by no means a given that uncovering the neurobiological underpinnings of emotion will help Freud stage a comeback. Both diehard cognitive therapists and those with more eclectic or integrative training — a little of this, a little of that — are skeptical.

Emory’s Scott Lilienfeld, for one, suggests that neuro-psychodynamic therapists are merely using neuroscience to retrofit broader-strokes ideas — ideas that, while most often attributed to Freud, aren’t unique to him. For instance, Freud spoke often (and loudly) about defense mechanisms and repressed desires, but so did other thinkers. The outdated convictions that truly distinguished Freud will never find vindication in neural firing patterns.

And that’s the problem, said Lilienfeld. “Neuroscience dovetails with broad notions Freud put forth, but whether that vindicates Freud per se more than any other model of human nature — well, I’m not convinced.”

Lilienfeld further pointed out something missing from the argument that neuroscience will save Freud: heuristic value, or the extent to which a theory predicts something new. “What did Freud predict,” Lilienfeld asked, “that we wouldn’t otherwise have foreseen, if not for neuroscience?’”

Finding Room for the Good Doctor

Bringing Freud back requires finding new support for outdated ideas, such as his thoroughly debunked belief in infantile stages of psychosexual development and, again, his unwavering dedication to correlative dream interpretation.

Right now, this doesn’t jive with current science. Lilienfeld explained, “Neuroscience data poses some real problems there, because most suggests that dreams are triggered by automatic perceptions and memories originating way back far in the brainstem, and that our higher brain tries to make sense of them after the fact… I don’t think any of that provides support for the idea that dreams are disguising content with a symbol.”

Lilienfeld isn’t so staunchly pro-cognitive therapy that he can’t recognize Freud’s contributions to the field. He concedes that Freud certainly got a few things right, and that discussing dreams can have some value.

“When people go through depression, dreams tend to be depressive. And when I’m doing therapy, I occasionally will discuss dreams — having dreams about certain key themes in life, may reflect something about psychological state as it is.”

Still, in the end, Lilienfeld doesn’t think acknowledging Freud’s psychological contributions proves that Freudian theory, as a school of thought, was right. In his view, it’s time to accept that we’ve scattered Freud’s theoretical ashes — and move on.

Others are more kind to the good doctor’s influence and legacy. Robert Galatzer-Levy, a psychiatrist at the University of Chicago, makes the point that the past’s perfectly fine practices may become outdated but not necessarily invalidated.

“It’s true that almost no one practices analysis exactly as Freud did a hundred years ago, but then no one does physics the same way that Einstein did a hundred years ago or Newton did 300 years ago,” he said via email. “Yet their ideas and theories remain a central part of physics, and Freud’s ideas a central part of psychoanalysis.”

And anyway, not every Freudian needs neuroscience. Margaret Walsh believes Freudian theory is a necessary component of emotional introspection that’s missing from cognitive approaches. She laments the exclusion of Freud from training programs.

“You go through [academic] programs, and hear Freud’s dead,” she said. “Then, students start seeing patients and self-gravitating toward old Freudian ideas. There has to be some integration, because you can’t approach people in a clinical setting cognitively only.”

One selling point of cognitive therapy is its efficiency — programs may finish in as little as six or eight weeks. But cognitive behaviorists who see patients on an ongoing basis, Walsh contends, draw on Freud. Some of today’s buzziest mental health topics, such as attachment theory and post-traumatic stress, are, in many ways, refurbished versions of what lay at the core of Freudian theory.

“Same concepts, new language,” Walsh said.

It’s hard to imagine Freud would disagree. As Carol Donnelly noted, Freud treated the past as fundamentally stitched into the present. Patients undergoing psychotherapy cannot uncouple their former and current selves — and neither should today’s psychoanalysts.