Freud's window on the mind: Say what you like about the father of psychoanalysis, but he was right that trying to understand life makes living a bit more bearable, says Raj Persaud

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NO ONE knows how much we spend in Britain on private psychotherapy, but some indication of its popularity can be seen in a recent survey showing that last year Italians spent more than pounds 1bn on psychotherapy - roughly the same as on sport or entertainment. In the light of the recent spate of media attacks on the credibility of Sigmund Freud, the founding father of psychoanalysis, should we be regarding psychotherapy as closer to a sport or entertainment than a serious therapeutic enterprise?

Frederick Crews, Professor of English at the University of California, initiated the current furore with a controversial article in the New York Review of Books at the end of 1993, in which he suggested Freud's interpretations were driven by ruthless self-interest rather than any objective fact.

Furthermore, says Professor Crews, Freud appears to have claimed cure in several cases, while knowing full well this was never achieved. One of his first claimed treatment successes was eventually tracked down by journalists in the Seventies, having been in and out of treatment for 70 years - Sergei Pankeev declared his treatment had been 'a catastrophe' and that he was in the same state as when he first went to Freud.

There is a widespread public belief that all modern psychiatric therapy is based on psychoanalytic principles, so unease about Freud creates apprehension over the whole psychiatric enterprise itself. Psychiatry appears to be a worthless navel-gazing exercise for the middle classes, who are too wealthy to have any real problems; while the genuinely psychotic, who wander the streets directing the traffic, appear simply too ill to be helped.

If psychiatrists really did do no more than talk to their seriously ill patients about early childhood sexuality, the profession certainly would be useless at treating mental illness. In fact, psychiatrists use a wide range of treatments, including a plethora of new, effective medications, as well as behaviour, cognitive, group, family and couple therapies. This eclectic combination of approaches (many of them blatantly anti-Freudian) ensures that psychiatry is able to help the vast majority of patients as effectively as modern cardiology and obstetrics. The comparison with other medical specialities is important, because psychiatry is a branch of medicine and is not synonymous with psychology, psychotherapy or psychoanalysis.

Of all these separate professions, only psychiatrists actually hold medical degrees and are therefore allowed to prescribe medication or other physical treatments, as well as being trained to detect the numerous physical causes of mental distress. Psychologists also hold university degrees, but these tend to focus on the emotional and social antecedents of mental states, rather than the biological, which is a larger part of the psychiatrist's medical training.

Psychologists' academic background, being rooted in scientific experiments on observable behaviour, means their treatments frequently encourage patients to be active and perform practical tasks to help themselves, rather than merely talk about them, as in most other psychotherapy.

In contrast, those who call themselves psychotherapists have received training that focuses on talking treatments by small organisations, which, rather worryingly, have thus far been left to supervise and regulate themselves largely outside academic requirements and the clinical standards of the NHS.

Psychoanalysis is only one form of these talking treatments. It derives its ancestry from Freud, and achieves change through the development of a deep relationship between client and therapist over many years of hour-long sessions, three or five times a week. In this situation good treatment is always more a case of how good the therapist is, rather than how good the theory, but because psychoanalysts disapprove of clients 'shopping around' this vital consumer's perspective has been neglected.

Within psychoanalysis itself there is a multiplicity of post-Freudian schools which disagree with Freud's assertion that unconscious sexual impulses underlie all human behaviour. Kleinians (after Melanie Klein) emphasise early childhood relationships with significant others and Jungians (after Carl Gustav Jung) accentuate the spiritual dimension of human nature.

Another reason why Freud might appear more relevant to the public than to clinicians is that modern psychiatry is supported by a gamut of sciences, including epidemiology, genetics and neuropharmacology. Freudians were always notoriously reluctant to subject their ideas to rigorous scientific testing, claiming you had to be in analysis before you could judge its validity. Yet by virtue of its sheer cost and time, this particular experiment attracted only ready converts. The philosopher Wittgenstein argued that psychoanalysis is not a science, but a mythology, since the sole criterion of a psychoanalytic interpretation's correctness is the assent of the subject - that, said Wittgenstein, is not a discovery, it is a persuasion.

But before Freud is unceremoniously dispatched to the wastelands inhabited by phrenology and neurasthenia, scientific experiments have produced strong support for some of Freud's ideas. For example, there is good evidence that a few of his theories about personality were right, and he correctly predicted that people who are obstinate will also be parsimonious and orderly - the anal character.

And there is scientific support for the idea of an internal censoring mechanism which was part of Freud's theory of repression. Researchers from University College London's psychology department developed an apparatus which allowed them to control the brightness of words presented to subjects, so that words could be displayed at a level from just below visibility. Where emotionally disturbing words, such as 'penis' or 'whore', were presented subliminally, it appeared that subjects needed the words to be brighter than usual before becoming visible. This piece of research and others like it suggest very strongly that some 'censoring' machinery is unconsciously at work in the mind.

Indeed, that some people may be able to sustain bizarre sexual practices while revealing none of this to their closest companions can only really be explained by mechanisms such as repression. The deep difficulties in understanding the paradoxical nature of human life will always force us to fall back on Freudian considerations.

Yet if psychoanalysis can reveal us to ourselves, surely it should be able to ameliorate suffering? This is perhaps where psychoanalysis is at its weakest: it is unable to comprehend the multiplicity and depth of reasons why more than six million people in the UK are estimated by GPs to be suffering from serious mental illness. This does not represent mere middle-class Viennese neurosis - 20,000 individuals die each year in the UK as a direct result of mental illness, including 4,500 suicides and 1,800 fatalities due to alcohol and drugs.

Ranged against this epidemic of despair are 5,500 British psychiatrists, medics who treat patients for seriously disturbing thoughts, moods or behaviour and who need to be armed with treatments which are proven to be effective, cheap and short. No wonder psychoanalysis never stood a chance in the NHS, and was peremptorily banished to the suburbs.

In fact, Freud never saw psychoanalysis as simply a treatment, more a method of exploring and understanding oneself, without any necessary therapeutic benefit, a bit like obtaining a scan of your brain for your own personal interest. There has always been a genuine and sincere demand by thousands who, while not psychotic, would like to learn more about themselves in order to understand the way their minds and personalities work. This has been described more negatively as pandering to the narcissistic pleasure of talking and exploring oneself with a sympathetic and inexhaustible expert companion.

More positively, even when a wealthy society can solve the material needs of thousands, and although movements such as feminism and gay rights are busy dismantling the political difficulties faced by many others, it still appears that life can remain deeply unsatisfactory, and it is through this cleft, left by economics and politics, that psychotherapy attempts to step.

What does unite all those who go to psychiatrists, rich or poor, ill or not, is a sense of confusion about self, and at its best psychiatric treatment helps by getting us to reflect on ourselves through an open- minded dialogue. But this does raise the serious question: how did we become opaque to ourselves in the first place? In western culture discussing dark or complex personal issues is frequently frowned upon by friends, colleagues or partners, and whenever people are discouraged from exploring at a profound level personal issues that confront them in life, an 'underground' or 'taboo' profession will develop to satisfy these needs.

As the first psychotherapeutic century draws to a close, we can say that one of the things Freud got right, for which he will always be studied seriously, is the idea that attempting seriously to understand oneself does appear to make modern living a little more bearable.

The writer is Clinical Lecturer in Psychiatry, Institute of Psychiatry, London University.