MS-2 · psychiatry

Freud

In this morning’s (21st century, electronic) New York Times: Psychoanalytic Therapy Wins Backing.

We’ve had a series of psychotherapy lectures recently: psychoanalytic, psychodynamic, cognitive/behavioral.  I am still not sold on the whole thing.  I have no doubt that it works, especially for chronic mental illnesses, but I am not convinced that it is medical.

Perhaps part of the reason I feel that way is that I was introduced to psychoanalysis in a literary rather than a medical context.  The Unconscious, id/ego/superego, the Uncanny — all that works really well for approaching certain works of literature.  Fairy tales are the prototypical example, with their seemingly innocuous working through of cannibalism, patricide, and sexuality.  And there’s no doubt that Freud himself was a revolutionary figure, willing to address sexuality at a time when it was taboo.  In broad terms, I would say that his realization that past events influence the present is absolutely true.  But here’s the thing: psychoanalysis (as opposed to some of the other forms of therapy we’ve learned about) is so subjective that I don’t see anything medical about it.

Really, all my feelings come from Dora, a case study by Freud that I read in my capstone literature seminar.  It goes like this: “Dora” comes to Freud at age 18 or 19 with a persistent cough.  He starts analyzing her, exploring her dreams and memories, and learns that about five years before, while on vacation with her family and her father’s business partner’s family, the business partner attempted to molest Dora.  Freud then determines that Dora’s father is having a secret affair with the business partner’s wife, and therefore Dora feels that she and Frau K have been traded between the men.  Dora has a dream about a fire and a jewelry box, from which Freud decides that she is harboring latent attraction for (1) Herr K, (2) her father, (3) Frau K, (4) Freud himself.  When he tells her all this, without suggesting any cure for her cough, Dora breaks off treatment.  At this point, Freud starts lamenting the loss in absurd, high-flown, quasi-poetic phrases about how he has been abandoned.

And I’m sitting in class, book in hand, thinking “Counter-transference much?”

The problem with psychoanalysis, as I see it, is that it is inherently not falsifiable.  If you tell the patient that they are in love with their mother and want to kill their father, and they deny it, you can always say “Aha!  You are simply repressing those memories.” And because the whole point of psychoanalysis is to have one person interpret another, there can be no independent verification of the results.  Everyone acts differently with different people, and a second analyst might come to a completely different conclusion, based on slight modifications in the patient’s demeanor and their own prior experiences with other patients.

I guess I just don’t understand the need to medicalize psychoanalysis.  Obviously, it works well for some people — that was known even before this meta-analysis.  But there is lots of other stuff outside the medical paradigm that works as well or better than scientifically-oriented medicine.  Social work, for instance.  No one would deny that, say, cancer patients who receive social work counseling in addition to to chemotherapy do better than those on chemo alone.  But that doesn’t make social work part of medicine.  So why is psychoanalysis part of psychiatry?

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