Bob Pyles wrote this article for Psychiatric News, the newsletter of the American Psychiatric Association. For his audience he emphasized the APsaA's collaborative work with medical organizations (the American Psychiatric Association and the American Academy for Psychoanalysis). He wishes TAP's readers to know the great value that the APsaA places on work with other colleagues — Division 39 of the American Psychological Association, the National Membership Committee on Psychoanalysis in Clinical Social Work, and the Independent Psychoanalytic Societies.
“The intention is to furnish a psychology that shall be a natural science: that is, to represent psychical processes as quantitatively determinate states of specifiable material particles, thus making those processes perspicuous and free from contradiction.”
Could this be a quote from the mission statement of the Steering Committee on Practice Guidelines? Or from Steve Hyman, describing new research initiatives for NIMH? In fact, this is the opening line from the introduction of the Project for a Scientific Psychology, written by Sigmund Freud in 1895.
The Project was one of Freud's many attempts to explain psychological phenomena in physical science terms. Though the limited knowledge of the day thwarted these efforts, to the end of his life Freud retained the deep conviction that ultimately new knowledge would bring the integration of physical science and psychological phenomena.
Because the development of psychoanalysis overshadowed his earlier career, it is often forgotten that Freud began his work as a research neurobiologist. Working under the renowned Viennese physiologist, Ernst Brucke, in the famed “Helmholtz school of medicine,” Freud published a number of papers on neuroanatomical research, including three papers on the structure of the medulla oblongata, and others on new techniques for staining nerve tracts and for tracing embryological nerve fiber origins. In addition to his daring, as well as controversial, studies on the medicinal properties of cocaine, his published lecture on “The Structure of the Elements of the Nervous System” has been considered by many to contain a clear anticipation of the later neurone theory.
His writings established him as a specialist on the subject of cerebral paralyses in children, and his 1891 monograph “On Aphasia” is still considered a classic today. Freud's roots as a distinguished biological and neuroanatomical research scientist are enumerated in detail in Frank Sulloway's Freud, Biologist of the Mind. Sulloway points out that Freud began his psychoanalytic work relatively late in life, and after fifteen years of biological research. In fact, it was only when Brucke himself, in 1882, sensibly pointed out to Freud the inevitable financial difficulties that the latter would have to face if he were to continue with a research career in biology that he finally — and reluctantly — turned to the practice of medicine. Sulloway notes,
… the later Freudian theories derive their roots from this work not only in fundamentals but also in detail. The impact of these intensive … years cannot be overemphasized. … In many respects Freud seems to have undergone a profound reorientation as he turned from being a neuroanatomical researcher to a clinical neurologist who experimented with psychotherapy, finally becoming the first psychoanalyst.
True to his scientific training, Freud based his psychoanalytic theories squarely upon careful and detailed clinical observation. In contrast to some of his followers, Freud never hesitated to discard and replace formulations in the light of new clinical data. He considered himself a scientific “conquistador,” developing revolutionary and effective treatment methods for conditions that had proved impervious to known approaches. This new “humanitarian” psychoanalytic discipline quickly replaced the existing Kraepelian descriptive psychiatry, which seemed rigid and unresponsive by comparison.
Psychoanalysis and psychodynamic psychotherapy within a relatively few years became the “gold standard” by which all other treatments were measured. The success of these treatment techniques in dealing with “battle fatigue” in both World War I and World War II further validated psychoanalysis as an essential clinical approach, as well as a general theory of mind. The years following World War II were truly the halcyon days of psychoanalysis in this country, with virtually unlimited numbers of candidates wishing to be trained and psychoanalytic ideas being fully integrated into the culture. Psychoanalysts were regularly the heads of major departments and training programs in medical schools and universities.
Ironically, that very success may have contributed to the sense that psychoanalysis could afford to be a field unto itself. Ties to the community and other professional groups such as the APA and the AMA languished. What can only be described as a certain hubris on our part may have played a major role in our later difficulties.
The object lesson here is to some degree the nature of science; especially to the point, however, is how the perception of science is distorted through the organizational lens. Inevitably the seeming objectivity of science is altered and shaped by the underlying value system of the group. What is considered to be “scientific” is exceedingly changeable and often constitutes a rationalized and self-serving mechanism for group protection.
This was certainly the case for American psychoanalysis. The isolation occurred for what seemed to be sound scientific and clinical reasons. The view of transference and counter-transference, which evolved after Freud, dictated that treatment could only take place under carefully controlled conditions, free from external influence. In fact, it is clear in retrospect that these convictions were determined by the sense of threat experienced by analytic institutes. The subsequent reaction of trying to protect psychoanalysis by “circling the wagons,” albeit for “scientific” reasons, proved highly destructive.
In the last nine years, the American Psychoanalytic Association has undergone a dramatic renaissance. A serious and searching self-assessment has led to profound change. Open and vigorous explorations about a variety of treatment approaches have led to healthy clinical flexibility. Determined outreach efforts have re-engaged us with our professional and public communities. Numbers of members and trainees, as well as analytic groups, are increasing. Our public information effort has led to numerous articles in major newspapers. Our political advocacy initiatives are increasingly effective on Capitol Hill. Our eighty-eighth
annual meeting this past May in Washington, D.C., was attended by more people than any spring meeting in the history of our Association. We feel that we are on our way.
I thought it might be useful to go into some detail about our own organizational vicissitudes because I am concerned that the APA may be undergoing similar struggles. The organizational symptoms seem similar: a declining membership, many fewer trainees, and a certain sense of disenfranchisement among certain groups, particularly psychodynamically oriented psychiatrists. The economic pressures posed by managed care and extensive funding by drug companies both for drug-oriented research and for organizational activities may have given a certain “tilt” to the organizational value system.
Two especially striking examples that may indicate a certain narrowing of organizational vision are the DSM and practice guidelines projects. Both appear to be based on a very limited definition of what constitutes “data”; consequently both have limited clinical usefulness. As Wilson points out in his 1993 article “DSM-III and the Transformation of American Psychiatry: A History,”
There are three interrelated ways in which the psychiatric gaze has been narrowed. First there have been the loss of concept of the depth of mind, a loss of the concept of the unconscious. We are now teaching our residents to focus on the superficial and publicly visible. Second, the consideration of time has become sharply limited. The biopsychosocial point of view, within which I include psychoanalysis …, emphasized the unfolding of a life over time … the development of person and the place of his or her symptoms within this development. With the advent of DSM-III, time has shrunk from a lifetime to a moment, from the extended evaluation to a 45 minute cross-sectional interview. Finally, and most importantly, there has been a constriction in the range of what we as clinicians take to be clinically relevant and a narrowing of the content of clinical concern. Personality and ongoing development, character, unconscious conflict, transference, family dynamics, and social factors are aspects of a clinical case that are de-emphasized, while the careful description of symptoms is often taken to be adequate or proper assessment of the patient. Further, the emphasis on careful description fosters confusion of the easily observable with the clinically relevant.
Photo by Mervin S. Stewart
Similarly, the practice guidelines project has largely excluded clinical wisdom and experience and has focused instead on a kind of data most easily obtained by short-term treatments, such as drugs and cognitive behavioral therapy. Both DSM and the guidelines would seem to herald a return to the earlier Kraepelian exclusively descriptive model. Both also appear to represent a definition of “science” that is as limiting in one direction as the exclusive focus on psychodynamic data was in another. Could this represent the kind of “circling of the wagons” that proved to be so alienating and isolating for American psychoanalysis?
It is extremely encouraging that APA, under the leadership of Allan Tasman and Steve Mirin, is currently undergoing a major re-evaluation of its mission and its responsiveness to members. Dan Borenstein will continue and expand this effort. At this time of crisis, challenge, and opportunity, it is critical to all of us to have a vital, vigorous, and broadly inclusive APA. It is also critical that APA, the American Psychoanalytic Association, the American Academy for Psychoanalysis, and other like-minded mental health groups work closely together to achieve our mutual goals.
The true legacy of Freud is not embodied in a particular theory but in his unflinching, honest, and open search for the unvarnished truth. The message for us to carry into the future is that deviating from this principle makes for bad science and unhealthy professional organizations. Freud saved psychiatry from a rigid, mechanistic model by emphasizing the healing power of the doctor-patient relationship. Currently, we are in imminent danger of returning to that one-sided model. If we can regain our balance, we have the unprecedented opportunity of realizing Freud's dream of understanding how mind and brain operate as one. This is where the spirit and vision of Freud should carry us into the twenty-first century.
We have seen Freud in the nineteenth century. The effect of Freud in the twentieth century might best be summarized by two recent events. The Freud exhibit, which began at the Library of Congress and has since traveled to other cities, has drawn many thousands of visitors and generated reams of articles. Significantly, Time Magazines feature on the 100 most influential people of the twentieth century began with Freud.
What about Freud in the twenty-first century? There is little question that psychoanalysis and psychodynamic therapy as clinical disciplines are not only surviving but beginning to flourish again. As for Freud's ideas, his dream of a true integration between mind and brain, of a psychology thoroughly grounded in neurobiology, is his challenge to us for the twenty-first century. In Freud's day, lack of knowledge made his noble attempt in the Project impossible. Now, due to advances in both neurobiology and psychology, we have the historic opportunity to achieve a true biopsychosocial understanding of the human mind. All we need is the courage and the breadth of vision.
And Freud? I think he would say it's about time.