Dismissing Freud 2.0


It happens every few years: historians, psychologists, journalists and investigators find “new” material to dismiss and discredit the work of Sigmund Freud. Since his passing in 1939, the man, who is often mythologized, has undergone numerous character assassinations. Many have said his work is both unscientific and offensive, while others have labeled him a racist and a sexist. Most recently, his work and its lack of empirical research, has been cause (somewhat fairly) for concern about the effectiveness of psychoanalysis. In his new book, the British author and critic Frederick Crews continues his take down of the late Freud. The book, “The Making of an Illusion,”  focuses on Freud’s shortcomings as a man and a professional, and rails against a form of treatment that created a “cult of personality” in the late 19th and early 20th centuries.

Freud’s most notable dissenters have spent years rejecting his theories on penis envy, the Oedipus Complex and the core concept of the sexual drive inherent in all humans. His experimentation with cocaine has poured into mainstream culture. But the main problem with dismissing Freud outright is the lack of understanding of the value of psychoanalysis. At its core, psychoanalysis is a talking cure (coined by Josef Breur in 1895). Patients are able to therapeutically process emotion, content, disturbances and conflicts. The contemporary relational psychoanalyst Susie Orbach said “Psychoanalysis is the study of human subjectivity. It is a clinical practice. It theorises the vicissitudes of human attachment, of the psychological development of mind and body that occur within a relational, cultural field.” She is correct. Furthermore, psychoanalysis proper is rarely practiced today because of the “need” for brief, concrete and managed mental health treatment.

Swept up in the Freudian revisionism is a more common problem, which is the dismissal of the magnitude his ideas have had on the field of psychology for 100 years. Freud’s groundbreaking understanding of transference and countertransference, along with his working model of the mind, are still understood and used today. Psychiatric assessments refer to “attitude toward writer,” which can be linked to a patient’s transferential projection onto the therapist. Because of Freud, we now understand the omnipotence of defense mechanisms and the unconscious motives of our drives.

Freud normalized sexuality for men and women. The ability to relate sexuality to early childhood experiences is a sensitive issue, but one that needs exploration in the therapeutic setting. Today, we have a greater appreciation for attachment theory, psychosocial development and the ego because of Sigmund Freud. The problem with the argument that Freud’s work was not empirical rests on the idea that therapy is strictly a science. Cognitive behavioral approaches, along with other standardized modalities are ubiquitous, but their long-term efficacy remains unknown. Behavioral interventions negate defense mechanisms, unconscious conflicts, inhibition, drive and attachment.

The mind is still a largely unknown construct. Psychoanalysis has allowed therapists, physicians and lay people to inch closer to understanding its processes. Replacing this with psychopharmacology and shallow methodologies of treatment that rely on labels and symptoms fails to grasp the rewards of the subjective therapeutic experience.



On the struggles with grief



I wish I could have done more. More for my client who suffered. More for his family who suffered. More for the pain, the emptiness, the despair. But I couldn’t. I couldn’t keep him to prolong his treatment. Not long enough to make a dent in an otherwise broken, hurt and lonely soul. I thought about him when he left. I thought about him when I slept. And now, I think about him as I type. Today was the first, but likely not the last time I will hear that a client of mine has died. My reaction was not of surprise or shock, but of sorrow. Sorrow for the man who had decided his time was up.

As therapists, we are faced with mortality. As clinicians in the field of addiction, we are faced with the cruelty and the hostage taking drugs and alcohol become. And yet, we still hold out for hope. We still strive to make a difference and we still have hope that our clients can obtain the ultimate recovery- inner peace. But like so many of the suffering, that task was not fulfilled.

I was angry when I heard the news. I was angry at myself, angry at others, angry at him. I was angry at addiction. I was angry at depression. I was angry at work. But my anger will not succeed nor flourish. My anger will be invested into what I know how to do best- work with those in need of healing. The only way I can grieve is to continue with the work I do everyday. The grieving means advocating for my clients when they cannot advocate for themselves. My anger and shortcomings will be met with a continued passion for treating those who have been unable to treat themselves.

My client’s passing is a reminder of the tremendous difficulties we face as soon as we walk into work. We work with chronic and persistent drug abusers and mentally ill men and women. We work with altruists, sinners and criminals. We work with the sad and the angry. The confused and the hopeless. And on this day, I am mourning the loss of the sad. I am mourning the loss of the angry. I am mourning  the loss of the confused. I am mourning the loss of the hopeless. And I will continue to work alongside the individual who needs help.

Does therapy work?



What is the objective of therapy? Are we seeking to rid our demons? Is therapy a room that allows for free thought and open dialogue in 45 minutes? While the objective(s) of therapy may be tough to pin down, the measures of success are even harder. With new treatments and approached to therapy such as cognitive behavioral and dialectical therapies being crowned “evidence-based,” there is little room for more long-term, in-depth psychotherapies. If success is measured solely by self reporting, a red flag should go off.

In this regard, I will outline certain criteria that I think measure success and reflect a positive therapeutic experience.

First, real success and improvement in one’s life relies on the patient’s willingness to explore his or her unconscious. This is where our drives and impulses rest and contain our real desires. It is the most primitive element of the human mind, but arguably, the most rich. A therapist should be able to detect what defense mechanisms a patient is using and help enhance and improve one’s presenting defenses. As I have mentioned in earlier posts, defenses such as splitting, denial and projection are very primitive, while defenses such as humor and altruism are very mature.

Second, success can be measured by a patient re-examining his or her past and tolerating the uncomfortable feelings and thoughts that arise. A therapist should not coddle a patient and restrict self-exploriation. While it is not always helpful to reach into the past and dig up painful memories, it is important to understand why someone is behaving and interacting in a certain way. Often times, the past dictates our present and future. Along these lines, it is important to talk about family, childhood and relationships and come to terms with past decisions and events. Vivian Gornick, in his book review of Becoming Freud, writes, “the best one can hope for in analysis is reconciliation, not cure.”

Arguably the most important and telling evidence for significant improvement is analyzing one’s interpersonal relationships and skills. Sure, a patient or client can say they feel happy, energized and motivated to be in a relationship or rekindle an old flame, but it is more important to walk the walk than talk the talk. In contemporary psychoanalytic terms, this constitutes object relations. It is important to understand what types of people one is drawn to, if the relationship can incorporate sex and intimacy and if vulnerability can be tolerated. Along these lines, one’s ego functions (insight, judgment, etc.) are developed.

For families in therapy, I would argue that the three most important functions to focus on are the roles, boundaries and alliances that make up a family unit. These criteria are the backbone of family structural therapy. While some of its tenants might seem old-fashioned and clash with a post-modern family, such as traditional family roles and norms, they can still be applied and used to understand and help a family. Everyone reading this can identify with and relate to a family member who is seen as the boss, the alliance between the father and daughter and the porous boundary where a parent tries to be your friend.

These outlines can be helpful when evaluating the treatment. They all take time. Today’s treatment approaches rarely allow for such exploration and processing. Our fast-paced world is not always welcoming to introspection. We miss out on truly measuring our own success and well-being.

So, then, what is the purpose of therapy?

Therapy’s focus and objective should be to create a safe environment for a patient to make sense of his or her life and to become one’s true self and not what is projected outward. On a more practical level, a patient should develop and use more sophisticated and mature defense mechanisms to deal with life’s everyday hurdles. These objectives can be daunting and time-consuming, but they will pay off in the end.



Why “sober coaches” can be harmful

Today’s rehab industry is booming with personalized care that provides horse-back riding, spa treatment, gourmet foods and the like. For upwards of $50,000 per month, it better. While this style of treatment does not sit well with me, I am even more surprised by the new profession of  “sober coaches.” No, a sober coach is not someone you would meet in an AA or NA meeting, but instead, someone who often times attends social functions with you, attends the gym with you and even lives with you! Talk about boundary issues. In this morning’s New York Times, Marisa Fox exposed the world of “Mothers Finding  Helping Hand In Sobriety Coaches.” In her article, Fox focuses on successful women in cities like New York, Boca Raton and the beachfront communities of California who have experienced both alcohol and drug addiction, and have turned to sober coaches for help.

After reading the article, there are several takeaways worth noting that shed light on the current state of therapy (and more specifically, alcohol and drug treatment). One of the mothers who is discussed throughout the article is Tamara Mellon, one of the founders of the Jimmy Choo shoe company. Ms. Mellon, according to the article, works with a London-based psychotherapist on her addiction. What raised a red flag was her comment “he’s the most enduring relationship I’ve had. I’m his one and only.” Often times, many patients have similar feelings toward a therapist. This is not to say the therapist has the same views. In therapy, the views she just expressed would be analyzed (transference) and hopefully explored. After all, this apparent paternal or even erotic attraction to the therapist is a significant factor in treatment. But, how can her overt expression of affection be explored in person when she is in New York and her therapist is in London? Also, has the therapist sent cues or signals (consciously or unconsciously) that would lead a patient to feel such a connection? We don’t get that answer in this piece and my guess is, this theme is not brought up in session (most addiction-based treatment modalities do not have components of psychoanalytic or psychodynamic theory).

There also seems to be a lack of clear boundaries with the sober coaches mentioned in the article. One patient, a female marketing executive in California, reported that “for three months, [her] sobriety coach slept in a spare bedroom, and got [her] to work out, to go to meetings, and even traveled with her.” This seems to demonstrate not only a potentially unethical relationship, but also, a sense of reliance on a therapist to help one navigate everyday life.

For some, rehab can feel like a “protective cocoon” as the marketing executive stated. For the women mentioned in the article, sober coaches can assist in transitioning to living outside of rehab. But, my skepticism for these professionals still outweighs their positive influences.

For many, drug and alcohol use is a replacement or substitute for companionship, relationships and connection. During my time working with addicts in recovery, their description of the bond and love for use can often times mirror the way non-addicts talk about a girlfriend or boyfriend. When talking about her clients who are mothers,Patty Powers, who is a recovering heroin addict and is now a recovery coach, said “they’re starved for companionship.” My intrigue into this statement is: What’s going on in the home? In the marriage? We cannot and should not treat addiction without a full understanding of family dynamics. Issues of boundaries, roles and alliances must be explored.

As I have noted before, these new trends in treatment and therapy do not offer the most in-depth, comprehensive approaches. Sober coaches, as outlined in this morning’s article, seem to cater to a select clientele who are looking for companionship as part of treatment.

Knowing what the therapist thinks can be harmful

Beth Israel Deaconess Medical Center in Boston is testing a new model that allows patients to have access to therapists’ notes . This access, which is briefly discussed in this morning’s New York Times article titled “What The Therapist Thinks About You,” should not be welcomed with open arms. Although note taking during sessions seems to be dwindling, therapists often take notes to help form hypotheses and theories about a patient. These observations are not concrete facts. Often times, what the patient reveals during a session to a clinician is sensitive material regarding family members, partners and employers.

A few months ago, a client asked me to see his chart, and by law, I was obligated to show him my notes. He was diagnosed with a “minor depressive disorder” due to his bereavement over the loss of his wife. A usually reserved and conforming man, he quickly elevated his tone and assured me that his depression should be upgraded to “major.” I told him that he should not focus on the words “minor” and “major” and that this was simply a psychiatric  diagnosis, not a measuring stick or evaluation on his grieving process. By viewing his chart, more damage was done to the clinical relationship. Did my client now view me as undermining his grief? Was he now unwilling to share his feelings and thoughts out of fear of being prejudged? Perhaps. Ultimately, the notes were for internal purposes.

Cynics and critics of therapy (especially long-term, psycho-dynamic therapy) will complain that the therapist does not want to show the patient his notes because it will disrupt the perceived power struggle and hierarchy in the session. This is nonsense. Therapists who do not wish to reveal their notes are doing so to protect the client. Imagine being a patient and reading that you experience delusions, fear of abandonment or repeated failures in a relationship. These observations can lead a patient to storm out of the office and never return. Worse, it might lead the patient to never seek treatment again in the future.

Open access to information has become so liberal that now we are willing to sacrifice the science and art of therapy for pure transparency. Therapy now revolves around a culture of over-litigious rules and constant fear of being sued. Therapists should not have to sugarcoat their notes to stay employed.

Finally, despite the push to align the field of therapy with the medical model, therapy in itself is part science, part art, part philosophy and part interpretation. A client or patient’s reaction to viewing his or her medical chart does not have the same effect as viewing one’s therapy chart.