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Professional News
Freud's Influence Has Waned But Many Ideas Hold Sway
Psychiatric News
Volume 41 Number 16 page 9-37

The office of Fred Hilkert, M.D., contains an etching of Sigmund Freud, a 19th-century divan, and an antique Greek bell krater (a container used for mixing wine and water). The ashes of both Freud and his wife were comingled in such a krater, the Washington, D.C., psychiatrist explained to Psychiatric News. The krater symbolizes what Freud felt was his greatest discovery, the Oedipus complex, derived from the play by Sophocles, "Oedipus Rex."

Although most American psychiatrists probably do not have such tangible reminders of Freud in their offices, few would dispute that Freud's concepts are still packing a powerful punch today, 150 years after his birth, regarding the practice of psychoanalysis, the practice of psychodynamic psychotherapy, and even the practice of psychiatry in general.

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Even if Freud contended that the Oedipus complex was his greatest discovery, American psychiatrists are more likely in 2006 to rate his unveiling of the unconscious as his most momentous contribution to psychoanalysis, psychodynamic psychotherapy, and psychiatry in general.

"There are certain core concepts that Freud developed and that still hold," Regina Pally, M.D., a clinical professor of psychiatry at the University of California at Los Angeles, said in an interview. "The major one is that there is an unconscious mind that influences our thoughts, emotions, and behavior... .And neuroscience, my particular interest, has confirmed that the unconscious is the majority of mental life, and that it runs the show."

"Freud is an icon," Sandra Walker, M.D., a Seattle psychiatrist primarily in private practice, told Psychiatric News. "[His] ideas about the mind have had a lasting and indelible effect.... So in terms of psychoanalysis and psychodynamic psychotherapy, psychiatry, and in many other areas of life, his ideas about the unconscious, about the repression of unconscious conflict, are commonplace."

"We are motivated by many unconscious forces that are very important," Harold Blum, M.D., a clinical professor of psychiatry at New York University and executive director of the Sigmund Freud Archives at the Library of Congress, asserted. "For example, look at the number of people who confess to crimes they have never committed. Unconscious guilt, and the need to confess, we have learned directly from Freud."

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Not long ago, a patient said to Glen Gabbard, M.D.: "I can't talk to you anymore." Gabbard, chair of psychoanalysis and professor of psychiatry at Baylor College of Medicine, asked why not. "You are exactly like my father!" he replied. "You are going to humiliate me if I tell you what is bothering me."

"This is a prime example of Freud's concept of transference," Gabbard said, "where he saw me as his father, and it kept him from talking openly." and transference, like the unconscious, is high on the list of Freudian ideas that American psychiatrists still consider highly relevant to their practices.

In fact, since transference usually occurs at an unconscious level, Pally pointed out, patients may view not only their psychiatrists, but also their spouses, bosses, coworkers, and even their children as important figures from their childhood without being aware of it. And a big part of therapy, she added, may consist of helping patients realize that they possess such views and that such views might be maladaptive for their current lives.

Transference, psychiatrists tend to agree, can likewise offer important clues as to why patients do not adhere to their treatment regimens.

"You can prescribe medication for a borderline psychotic patient, but that doesn't mean that [the patient is] going to comply," said Blum," and the reasons for the noncompliance are not strictly organic or related to the medication. They may be related to antagonism toward the doctor or profession or displaced from a host of other issues onto the treatment situation."

Transference can impact areas of medicine other than psychiatry, psychiatrists point out.

A third-year medical student rotating through a psychiatry clerkship," Bob," had been working with a hospitalized bipolar patient nearing discharge. Then Bob missed a day with the patient because of illness. When he returned, she was unusually irritable and depressed and claimed she was not ready for discharge. She started talking about a history of being rejected by boyfriends, and finally the light went on for Bob: she viewed his absence as one more rejection, and her take on the matter was a perfect example of what psychiatrists call "transference."

Shortly after that, Bob described his experience to Lisa Mellman, M.D., a senior associate dean for student affairs at Columbia University College of Physicians and Surgeons. She reminded him that "although we are trained in psychodynamic teaching to recognize transference, transference is ubiquitous, and your patients will engage in it regardless of the specialty you choose to practice."

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A third Freudian concept that American psychiatrists today tend to consider crucial for their work is the mind-body relationship.

"The mind-body dilemma—psychiatry remains preoccupied with the issue, and so did Freud 100 and some years ago," Steven Levy, M.D., vice chair of psychiatry at Emory University, said.

"Freud's early studies on hysteria were very rich accounts of how emotional conflicts can influence bodily processes," said Pally." So while I might not see patients suffering from the same bodily symptoms that Freud did, like psychogenic blindness or paralysis, I can see that conflicts can lead to digestive problems, headaches, and what have you."

In fact, an experience Pally had with one patient illustrates how helping patients divest themselves of unconscious conflicts can also relieve them of bodily symptoms. The patient, "Leila," had not been able to grieve fully the loss of her mother early in childhood, but eventually, with psy-chotherapy, Pally helped her do so. And after that, Leila told Pally about the disappearance of a skin problem she long had had. "Yes, just like that," said Pally, "even though we really hadn't talked about it."

Indeed, numerous other Freudian concepts are still resonating with American psychiatrists today as well—for example, countertransference; projection; dream interpretation and free association unmasking unconscious conflicts; the influence of early experiences on lifelong patterns of behavior; and the impact of fantasy, both normal and pathological, on mental life.

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Just as American psychiatrists are apt to concur that a number of Freud's concepts are still swaying analysis, psychodynamic psychotherapy, and psychiatry in general, they also tend to concur that his ideas will continue to pervade these fields.

"Certainly, Freud's concepts will continue to have a dominant influence on psychiatry during the next few years," Robert Michels, M.D., a university professor of medicine and psychiatry at Cornell University, predicted.

"Oh yes, Freud will continue to have a prominent influence," Gabbard added, "because he basically tells us that if we sit with [people] long enough and listen to them, they will start to reveal some of the conflicts that cause misery in their lives."

"I think Freud will be there for the foreseeable future, unless our genome changes!" Blum asserted. "This is part of the way we are, we have an unconscious mind as well as a capacity for consciousness and self-reflection."

Yet, "as people understand more about the mind, cognition, experience, affect, attachment, all of those things that are psychoanalytic...," Walker predicted, "I think we will understand Freud's ideas in different ways and more sophisticated ways." ▪

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