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
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.
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."
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
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."
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
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
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
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,
"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
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." ▪