Freud’s therapeutic work and his writings are correctly described as psychoanalysis, because this is the term he coined for them. The first one or two generations of his adherents and followers are also rightly described in the history books as psychoanalysts. This is what Freud called them, unless they made a formal break with him, as some of them did, and it is what they called themselves.
Some psychotherapists today still call themselves psychoanalysts. But it is now over 80 years since Freud’s death and if the term psychoanalysis is today intended to mean a psychotherapy that is shaped exclusively by the ideas and practice of Freud, such a thing no longer exists. Everyone who now calls himself a psychoanalyst is, in practice, implementing a form of therapy that is influenced by Freud and also by other people in addition to Freud. In other words, he is practicing a form of psychotherapy that can be accurately described as more, or less, psychoanalytic.
For this reason many psychotherapists like myself who acknowledge a major debt to Freud’s work, but who wish to emphasise at the same time that other influences are also important to their idea of therapy, call themselves simply psychoanalytic therapists.
In cutting our way through the jungle of terms that has come to plague the contemporary field of psychotherapy, the attempt to draw a distinction between psychoanalysis and psychoanalytic therapy is no longer of value. From the point of view of a member of the general public trying to figure out what kind of therapy he can expect from a given practitioner, psychoanalysis and psychoanalytic therapy may be treated as the same thing. Some therapists using these terms will try to adhere more closely to a model of therapy associated with Freud, and others will be less concerned with this. But until you meet the therapist you will not be able to tell from the title he chooses what is his practice in this regard. Except when referring specifically to historical events and the development of psychotherapy in the past, I shall therefore for the remainder of this essay ignore any distinction between the two terms.
The most important distinguishing characteristic of psychoanalytic therapy is that it places emphasis on treating emotional problems by looking at the biography of the person as a whole. The symptoms of the individual are taken to be the outcome of his whole history, development and life circumstances.
One of the words that regularly occurs in Freud’s writing is context – Zusammenhang, in German. Freud is looking for contexts within which the symptoms of the patient make sense. In other words, he is looking for connections within which the symptoms form part of a comprehensible story. What this means in practice is that we connect symptoms with events and experiences in the individual’s life by postulating emotions and motives that plausibly link them.
For example, if a young man falls physically ill with chronic debilitation, headaches and vomiting, and it emerges that he has spent the last several years caring for a mother who has been suffering from a terminal illness, then it is possible he has fallen ill, at least in part, because he has had to deal for so long with the conflicts between his feelings that have arisen as a result of such a demanding way of life.
Furthermore, if, when we speak in confidence to the man, he tells us he has had to postpone for some years his marriage to his fiancée, then we may have further reason for believing the man’s physical symptoms are in part at least a reflection of the stress he has experienced. His symptoms, in other words, are the way that the emotions he may have not been able to admit to himself, or convey to his mother, have found to express themselves.
Freud writes, in Studies On Hysteria, from 1895:
I am struck by the fact that the case histories I write read like short stories and that they dispense with what one might call the serious stamp of the scientific … However, a searching presentation of the mental processes that one is used to getting from the creative writer permits me, with the application of a few psychological formulas, to achieve a degree of insight into the development of a hysterical illness. [SH 131]
The work that Freud regarded as his most original and significant contribution was his book on dreams. This he entitled the Interpretation [Deutung] of Dreams, rather than the Explanation [Erklärung] of Dreams. Psychoanalytic therapy, and this is true of psychotherapy and counselling in general, is an interpretive discipline, we are concerned with the meaning of symptoms. And “meaning” here refers to the connections that a symptom has with the lived experiences, intentions, concerns, anxieties, hopes and aspirations of the patient.
This is why narrative is such an important part of psychotherapy. We treat symptoms by making stories that make sense of them. And, surprisingly enough, because we are creatures who live so much by stories, making good narratives out of our emotional problems has a powerful therapeutic effect on them.
What the work of psychotherapy reveals to us is that removing symptoms often turns out in practice to be less urgent a matter than discovering what is their meaning in the narrative flow of our lives. It turns out that we develop emotional symptoms not, as with symptoms arising out of our physical nature, because something has gone wrong in our make-up, but because something has happened to us whose meaning we need to find out. The emotional symptoms we develop are a way of forcing us to find this meaning. In other words, unlike physical symptoms which arise because we are not well, emotional symptoms arise as an adaptive, and ultimately creative, measure for dealing with life itself.
Doctors and psychiatrists tend to disregard perspectives like this, or at best they regard them as outside their sphere. In the main, they want to treat our emotional symptoms as if they were of the same nature as our physical symptoms, that is, as signs of an underlying system failure that needs to be repaired. But this approach, although it certainly has its place in treating emotional problems, especially those that are clearly rooted in neurological malfunction, is much less helpful in addressing those of our symptoms that we develop in the course of the battle of life itself.
Freud had a lot of experience in the medical science of his own day and though he insisted that psychoanalysis was a part of science, he was not afraid to propose accounts of things that did not look the way medical science was expected to look. Freud understood, in a way that many of his critics down through the years have not, that the shape a science takes will depend on the thing it is studying.
In 1925 looking back on his development of psychoanalysis at the turn of the century, Freud wrote: “Even the psychiatrists, to whose attention came the most unusual and surprising mental phenomena, showed no inclination to examine their details and trace their contexts. They were satisfied with classifying the variety of the manifestations of illnesses and where possible with tracing them back to sources in somatic, anatomical or chemical disturbances. In this materialist or better mechanistic period medicine made great advances, but it also overlooked in a short-sighted way the most important and difficult of the problems of life.” [The Resistances against Psychoanalysis, 1925, SD 227]
Nothing could be more mistaken than the idea that Freud was trying to force the science of the mind into the pattern of a science designed for something else, like biological evolution, or physics. Yet this is what Freud’s critics – and indeed many prominent psychoanalysts also – have often claimed. For a relatively early example of this argument, out of scores of other works that could be cited, see Thomas Szasz’ famous The Myth of Mental Illness, first published in 1961. Szasz argues, rightly, that psychotherapy is an essentially interpretive discipline, rather than a medical discipline. And this is why he asserts that mental “illness” is a “myth”. But he asserts, quite wrongly, that Freud saw psychoanalysis as an application of the physical sciences that underlie medicine.
On the contrary, it is plain to anyone who takes the trouble to read him that trying to force the human mind into a scientific medical straight-jacket is exactly what Freud was not doing. Indeed this is exactly why he was so successful, where almost everyone else who attempted to develop a science of the mind ran into the sand. What he was doing was using some of the expressions of the physical and biological sciences as symbols and metaphors for mental processes. I have looked at the precedents for this in the classical German literature in which Freud was steeped in my own study, The Last Resistance, from 2002.
As Philip Rieff remarks, “Far from being a residual idea left over from his biological training, as the neo-Freudians have maintained, Freud’s theory of instinct is the basis for his insight into the painful snare of contradiction in which nature & culture, individual & society, are forever fixed.” (Freud: The Mind of the Moralist, The University of Chicago Press, 1959, Third Edition 1979, pp. 33-34)
This is exactly right. Many people both inside and outside psychoanalysis have encouraged us to jettison the metaphors Freud employs from the biological and physical sciences, on the assumption that some kind of purer or clearer discipline will result. But without these metaphors psychoanalysis is impoverished because we start to lose sight of precisely the kind of inescapable conflicts that Freud draws to our attention.
We may with as much justification regard a careful analysis of someone’s unconscious motives as scientific as we may, for instance, a careful piece of historical, biographical, social, or legal, research. All investigation like this, when it is properly conducted, involves a mixture of close attention to the empirical evidence, and the development of hypotheses that describe human motives.
But to expect the science that develops from this kind of analysis to look like physics, or animal ethology, or to regard it as a failure because it does not look like these disciplines, is purely superstition. There is more to science than the physical and animal sciences.
At the same time, one must be careful not to fall into the opposite error, which is even more widespread, of thinking that the sciences of human life are in some radical way disjoined from the physical sciences and involve some entirely different logic and reasoning. We must acknowledge the unusual place of the human mind in nature, while also recognising that its place is in nature. It was Freud’s success in doing just this that explains the continuing fecundity of his ideas.
But not everyone has been able to maintain this difficult balance. In the middle decades of the twentieth century, for instance, the medical psychiatrists of the United States embraced psychoanalysis with an enthusiasm that reflected a mistaken understanding of its true nature. In the years after World War II a training in psychoanalysis was a pre-requisite for any career in American medical psychiatry and no one was allowed to practice psychoanalysis who did not have medical qualification. What these doctors failed to see, for some decades, was that psychoanalysis could not be integrated with the rest of their medical training, because it represents a different kind of intellectual discipline. When this truth finally did dawn, particularly in the 1970s and 1980s, they abandoned it entirely, as if it had failed to keep some promise ti had made to them. Nowadays any American psychiatrist who has an interest or training in psychoanalysis and who hopes to make any kind of career will keep this quiet. And in general on this side of the Atlantic also, people with a medical training and background now no longer play any major part in the world of psychotherapy.