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Friday, May 20, 2011


So what about little girls? Well, Freud concluded that they go through an analogous development conflict, competing sexually with the mother for the father. Freud himself spoke only about a female Oedipus Complex, but Freud’s pupil and later competitor, Carl Jung, dipped back into Greek tragedy [an endless source of archetypal imagery] and coined the term “Electra Complex” for this stage in the development of the little girl. Since I am way past the outer limits of my grasp of psychoanalytic theory, I am going to move and, and leave it to interested readers to explore all of this themselves [or, if they choose, with a significant other, playing doctor. Hem hem.]

Let us move on to a few words about the superego, which plays so important a role in the healthy development of a mature man or woman and can wreak such havoc if things go wrong. As the child develops, in the third year or so and beyond, it begins to internalize the voice, indeed the very being, of the parent. This process of internalization is one of the strange primary thought processes of the unconsciousness that I mentioned earlier, along with projection, displacement, and splitting. The primitive mind, if I may speak that way, does not distinguish between imitating another person and incorporating that person into itself. [Literally incorporating – i.e., eating.] One consequence of this incorporation or internalization is the development of a conscience – an inner voice, originally that of the parent, that in healthy development becomes an authentic part of the child. If you spend a good deal of time with little children, you can actually watch this process of internalization as it is taking place. I recall seeing a little boy [not one of my sons, as it happens], doing something that he had been told many times not to do, and saying out loud, as he did it, “No. No. Don’t do that.” The voice was that of his parent, and he was, as it were, on his way to developing a conscience. He had internalized the voice, but not yet the ability to obey its injunctions.

I was giving a lecture at Hampshire College many years ago [probably thirty or so], and during the question period, a young man asked me how I would go about raising my own children to be anarchists. I said that I would provide a very structured environment with clear rules about what they were and were not permitted to do. He expressed astonishment, obviously expecting me to say that I would raise them without any rules and without myself acting as an authority figure. I explained that what I wanted was for my sons to internalize a strong, independent voice that would, when they grew up, tell them to act autonomously and without regard to the authority claims of the state or any other group of persons. That, after all, is what it is to be an anarchist. How to accomplish this? By presenting them with such a voice and encouraging them to internalize it.

A too harsh, endlessly critical internal voice can become a punitive superego that cripples the individual with constant immobilizing feelings of guilt. It says a good deal about the social world in which Freud practiced that this was one of the most common neurotic formations he encountered. In these laxer, more self-indulgent times, one can grow quite nostalgic for the days of punishing superegos.

It is worth pointing out here that psychoanalysis was not conceived by Freud to be a technique for the treatment of all mental illness whatsoever. Neuroses are a particular form of emotional illness. Strange as it may seem to say, they actually require a well formed ego for their occurrence. But there are many other kinds of mental illness – psychoses, they are sometimes called. Paranoid schizophrenia, bi-polar disorder, profound depression, among others. Psychoanalysis was not designed by Freud to treat such ailments, and in fact cannot do so.

Needless to say, I have only scratched the surface thus far in my attempt at an exposition of the core ideas put forth by Freud, but since this tutorial is pushing 17,000 words, I think the time has come to speak about some of the developments in psychiatry post-Freud, to acknowledge and comment on some of the criticisms of Freud and psychoanalysis, and then to offer a summary estimation of Freud’s legacy.

As we have already seen, some of Freud’s followers, including his own daughter, tried to extend his analytic techniques to the treatment of children. In theory, this ought not to work, because the aim of analysis is to bring to the surface repressed wishes that date from childhood and are interfering with adult functioning. But one could certainly hope that very early interventions might forestall precisely the fixations and repressions that lie, according to Freud, at the root of adult neurosis. I confess that despite myself having been the subject of an experimental teenage analysis [see my autobiography for details], I do not know how these efforts in general panned out.

A second variation in therapeutic technique – group therapy – was prompted by the sheer cost of psychoanalysis. The legendary financial burden of analysis is a simple consequence of its time-intensive nature. An analysis lasting only three years [never mind Woody Allen and the problem of interminable analysis!] takes, let us suppose, between five hundred and six hundred hours [four times a week, forty-eight weeks a year]. What is a reasonable price per hour? Well, a psychoanalyst, we may suppose, can see patients seven or eight hours a day, five days a week, forty-eight weeks a year [just try to think about what a crushing burden of focused attention that requires], which is to say about 1700 hours a year. Now, Wikipedia tells me that psychiatrists are among the lower paid specialists in the medical profession. The median annual compensation for psychiatrists is $214,740. For cardiac surgeons it is $533,084, for orthopedic surgery $605,953. You are much better off replacing hip joints than trying to relieve people of their neurotic hang-ups. A psychiatrist working 1700 hours a year has to charge a tad more than $125 an hour to hit the median compensation. But that means that our patient completing an analysis in three years [and whom do you know who ever managed that?!] is looking at almost $75,000 for the total treatment! Even with spectacular medical coverage, this pretty well limits psychoanalysis to members of the upper middle class.

But group therapy, though much cheaper, cannot by its nature employ the techniques of free association and dream interpretation that Freud believed to be the royal road to the unconscious. Group Therapy, like once a week counseling, is inevitably limited to adult adjustments designed to manage, but not to get at the causes of, debilitating behaviors. It may be quite helpful with the problems that arise along life’s way, but if Freud was right, it cannot treat neuroses, any more than physical therapy can take the place of hip joint replacement.

A far more promising development has been the extensive use of psychotropic drugs to treat psychoses [not amenable, remember, to psychoanalysis] and also less serious psychological problems, like depression, and even some problems, such as Attention Deficit Disorder, which almost seem to have been invented to fit newly marketable drugs. Let us recall that Freud himself was committed, as a trained neurologist, to the operating assumption that every psychological disorder is rooted in some dysfunction of the nervous system, and indeed that every aspect of human personality, healthy or otherwise, must be grounded in the nervous system. There is no longer any doubt that certain diseases, such as bi-polar disorder, are the result of some neuro-chemical imbalance in the body. People who are “on their meds,” as popular slang has it, function effectively in the world and lead reasonably satisfying lives. When they go off their meds, their disabling psychosis returns. If one thinks back to the horrific treatments that neurologists employed in an earlier, darker day [hydrotherapy, electric shock therapy, even pre-frontal lobotomies], one can get some sense of the magnitude of the medical triumphs that have brought relief to large number of psychiatric patients.

The use of mood-altering drugs in less serious cases raises some very, very difficult questions which I can adumbrate here but hardly answer definitively. I have in mind particularly the tranquilizers and anti-depressants that are now among the most widely prescribed drugs in America. [By some counts, antidepressants top the list of prescribed drugs, although other lists put Vocodin, a painkiller, at the top.] There is no doubt that antidepressants alter the way people feel and therefore the way in which they can function effectively in real-world situations. They do so by altering the balance of certain chemicals in the body or by altering the effectiveness with which certain chemicals function in parts of the brain or elsewhere in the nervous system. So far so good. But the taking of such a medication does not bring with it any cognitive insight into the emotional sources of a debilitating psychological state, and it is precisely that sort of self-understanding that psychoanalysis is intended to achieve.

This raises a very difficult and troubling question. Is the insight achieved by psychoanalysis merely a byproduct of an inferior mode of treatment now superseded by drug therapy, or is it a valuable cognitive and emotional achievement that ought to be preserved despite the possibility of obtaining cheaper and faster relief from painful symptoms? One is reminded of Voltaire’s sardonic observation that “you can kill a flock of sheep with witchcraft, provided you also feed them arsenic.” [The great English economist, Joan Robison, to her eternal discredit, invoked that famous quote in claiming that nothing in Marx’s excoriating critique of capitalism had anything at all to do with the Labor Theory of Value.] Are the explanations provided by psychoanalysis nothing more than the witchcraft accompanying the “arsenic” of alterations in body chemistry?

To some extent, I think, this question can only be answered empirically. If drug therapy relieves anxiety or depression, but does not stop patients from making the same self-defeating decisions or from engaging in the same dysfunctional behaviors that sent them to a doctor’s office, whereas analysis succeeds in interrupting those repetitive behaviors, then we would have to conclude that psychoanalysis achieves something that drug therapy cannot. On the other hand, if patients treated with tranquilizers, anti-depressants, or other mood altering drugs function just as well as those who go through lengthy and expensive psychoanalyses, then perhaps we should conclude that the wisest course is to give them the drugs and suggest they read some books if they are looking for self-understanding.

I confess that I believe analysis achieves something that drug therapy cannot. Whether it is worth the time, effort, and money is a separate matter, and one that is not, perhaps, really a medical question at all.

1 comment:

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