Why Freud Matters Now, More Than Ever

Part of my work each week is spent supervising third and fourth-year psychiatry residents in their psychodynamic clinical training. Given the era of scientific reductionism we currently inhabit, particularly within medicine, training budding psychiatrists in a treatment style descended from Sigmund Freud's psychoanalysis can sometimes be...well...a tough sell.

Freud in 1885 at the start of his career.

Source: Public Domain / Wikimedia Commons

For those who could use a brief refresher, a precursor to what would later be known as "psychoanalysis" was developed by Josef Breuer, Freud's mentor, in the 1880s in Vienna, through his work with the now-famous patient zero of psychoanalysis, Bertha Pappenheim (a.k.a., "Anna O."). Freud formally published the accounts of Breuer's treatment of Pappenheim in his 1895 book, Studies on Hysteria, before going on to refine psychoanalysis in the decades that followed, writing volumes of books and journal articles on both the process of psychoanalysis, as well as his theories on the human mind, personality, and psychopathology.

Psychoanalysis gained brief popularity in the United States in the early 20th century and became the standard of care in both psychiatry and psychology, particularly in coastal American cities with large Jewish populations. Given the social and intellectual influences of Jewish culture on the development of psychoanalysis (both Freud and Breuer were Jewish, as were many of its early pioneers), psychoanalysis meshed seamlessly into urban cultural centers around the world that had large numbers of educated, Jewish professionals. But psychoanalysis, which was never very popular in the American heartland, started losing popularity in the mid-20th century, even in coastal cities, when more straightforward and shorter-term treatments were developed, like behavior therapy (BT) and cognitive-behavioral therapy (CBT).

Since then, efforts have been made to reform psychoanalysis to fit with the expectations of modern American psychotherapy patients, and by the mid-20th century, a slew of new therapeutic styles was born that retained core aspects of psychoanalysis, while shortening treatment models and updating Freud's theories of human behavior: these offshoots of psychoanalysis are collectively referred to as the psychodynamic treatment styles. For those who may be interested in a short primer on psychodynamic therapy and the ways that Freudian-style treatments have been updated to fit our postmodern era, I highly recommend Jonathan Shedler's (2010) paper, "That Was Then, This Is Now: An Introduction to Contemporary Psychodynamic Therapy," which I offer every year to the residents I supervise.

In addition to competition from more direct, shorter-term treatments, like BT and CBT, psychoanalysis also began to fall out of favor in the mid-20th century with the rise of feminist critiques of some of Freud's more controversial theories of human behavior. Today, the majority of mental health practitioners, including those who are trained in psychoanalysis, view Freud's controversial theories as regressive and believe that most feminist critiques of Freud, particularly those about penis envy and female hysteria, are valid and justified. However, as Donna Stewart, M.D., professor and chair of women’s health at the University Health Network, explained in an article on the subject (Cherry, 2020), we must remember, "Freud was a man of his times."

All too often when we examine the ideas of people in history, we do so without an appreciation for the context of the times and places in which they lived. Though Freud and some of his theories are considered by some to be regressive today, he would have likely been considered a progressive within the milieu of the 19th-century bourgeoise, Jewish, Viennese enclave in which he developed those theories. For those who may be interested in learning more about the world that created Freud, I invite you to check out the Netflix series bearing his name, which provides important context about the time and place in which he lived.

As a result of all of the above headwinds, today Freud and his collection of theories are more likely to be taught in cultural studies programs than in the myriad disciplines of mental health. To me, this is unfortunate because a cultural studies survey of Freud is likely to ignore the important ways in which his theories translate into meaningful insights and growth in therapy. As someone who has been trained in, and has clinically implemented, Freud's theories, I believe that he understood the inner workings of the human mind better than anyone since the Buddha.

Freud's famous couch in his London office museum

Source: Huffstutter / Wikimedia Commons

There are too many revolutionary concepts to cover than what can be discussed in this article, but if there is one that is most important, one that subsumes all the others, it is Freud's notion of the unconscious. Freud's understanding of, and focus on, the unconscious distinguishes him from all other clinicians and philosophers of mind that came before, and from those who have since tried to replace his psychoanalytic approach with others that are more straightforward, direct, and concrete.

Being more concrete, approaches like BT and CBT are easier to teach, easier to standardize, and easier to manualize for use in clinical research trials. A simple literature review on psychotherapy outcomes is all that's necessary to highlight how much more frequently BT and CBT have been researched than psychoanalysis and psychodynamic therapy. This has led to BT and CBT earning a reputation as the "evidence-based treatments," par excellence, for mental health disorders. It's a reputation that's validated by considerable evidence, and in my individual experiences I have found BT and CBT to work well for a panoply of psychological conditions, however, Jonathan Shedler provides a convincing refutation of the evidence supporting BT and CBT's dominance over psychodynamic treatments in his 2018 paper, Where is the Evidence for "Evidence-Based" Therapy?

Freudian Psychology Essential Reads

The Birth of Psychoanalysis, and the Erasure of a Life

Failed Resolutions and Broken Promises

In line with Shedler's research, I would also note that just because psychoanalytic and psychodynamic therapies are harder to standardize and harder to reliably research, it doesn't mean that they are less effective than BT and CBT. In my experience, psychoanalytic and psychodynamic approaches tend to work better than BT and CBT when the clinical issue in question is unclear or complex, as is the case with existential depression or existential anxiety; non-biological sexual dysfunctions; myriad relationship problems; or bizarre behaviors that seem to have no clear cause. In these cases, a survey of the unconscious is sorely needed and can be assessed by examining one's defense mechanisms, as well as the transference/countertransference dynamic, and sometimes even one's dreams.

In contrast to BT and CBT, psychoanalysis and psychodynamic therapy are more of an art than a science, and for that reason, they are often devalued in today's STEM-obsessed world. But today's world is also filled with many things that science has difficulty predicting and explaining, including mass shootings, teen suicides, political extremism, and susceptibility to conspiracy theories, among others. It is here where the art of psychotherapy from a Freudian style may be of the most value, and the reason why Freud matters more now than ever.

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In Part 2 of this series, I explain how investigating the unconscious can help us understand why we repeat the same relationship mistakes; fall into certain behavior patterns; and self-sabotage right before we succeed.