Past and Future of Psychoanalysis in Psychiatry

Thomas Svolos

Abstract

Over the last quarter century, biological psychiatry has replaced psychoanalysis as the dominant paradigm for psychiatry. The author presents a description of the original impetus for the discovery of psychoanalysis and argues that American psychoanalytic traditions have departed from the core principles of psychoanalysis, a departure that has contributed to the decline of the reputation of psychoanalysis. He advocates for Lacanian psychoanalysis as the tradition which best preserves the practice of psychoanalysis and argues for the importance of psychoanalysis for the general psychiatrist.

Past and Future of Psychoanalysis

I wish to speak today not about the "how" of psychoanalysis, but rather the "why" of psychoanalysis. To put this differently, I do not wish to speak today about the techniques or the various practices which constitute psychoanalysis, about the various indications for different approaches which we use in psychoanalysis, or even necessarily about the theory which informs those techniques and practices; but, today, I wish to speak about the history of psychoanalysis, about the context for Freud's discovery of psychoanalysis, about some of the changes that psychoanalysis has undergone in its more American forms and in the form which is identified today as Lacanian psychoanalysis, and - most importantly - to speak about all of this in the context in which all of this is important to the general psychiatrist.

I would like to start with a discussion of Freud and his discovery of psychoanalysis. And already, in the beginning of this discussion, I find myself adjusting the language I use. For in fact, it is probably misleading to speak of psychoanalysis has something that was discovered by Freud, but it is better spoken of as something created by Freud. In other words, psychoanalysis represents a unique form of discourse--a specific combination of theory and practice which is independent in its own right and not best understood as "part" of another discourse, such as medicine or science. In this context, psychoanalysis must be examined at the level of any other discourse, such as the discourse of religion or science. This is in contrast to the view of psychoanalysis as just another treatment modality that is used in psychiatric practice.

Critical to any understanding, any elaboration of psychoanalysis is an awareness of the context in which Freud worked.1,2 Freud was, it is well known, trained as a neurologist and, in fact, in the early part of his career, he spent less time engaged in clinical practice, but spent the majority of this time engaged in the pursuit of various research topics. The theoretical background for his work were the physiological theories elaborated at the end of the 19th century by Helmholtz, and Freud did most of his work the within the laboratories of the University of Vienna. Freud's initial goal seemed to have been a research professorship, and he was fairly prolific in his work in pursuit of that goal. He had original contributions to the discovery of the neuron; a striking contribution to the psychopharmacology of cocaine - one of the first psychopharmacologic research papers; neuro-anatomic work on various animals; and several significant monographs on cerebral palsy and aphasia - all of this alone would secure him some fame in the history of neurology for his contributions. Freud, however, was unable to obtain advancement within the medical institutions of Vienna, for the most part a result of the anti-Semitism present at the administrative level at which faculty appointments were made. For this reason, he went into private practice to support his family. Around that time at which Freud made the shift from the career of the bench scientist to that of a clinician, he was awarded a stipend to travel and work with the great French neurologist, Jean-Martin Charcot. At this point in Charcot's work, the great French neurologist was himself undergoing a change in his orientation from the study of the more classical syndromes and illnesses which constitute neurology to a study of hysteria. And Freud, who initially planned on continuing his neuroanatomic studies in Paris, became interested in hysteria as well.

Nowadays, hysteria is not a word that is well-accepted in American medical discourse. For most people, hysteria brings to mind bold images of the black and white photographs of patients identified as hysterics, photographed in the clinics of Charcot at the Salpêtrière hospital. The photographs are dramatic in that they represent the images of the most prominent neurologic symptoms that constituted hysteria as it was understood, the various motor abnormalities of the illness. These symptoms, identified and defined as conversion symptoms by Freud, are certainly the most dramatic symptoms of hysteria. Hysteria, however, was a much more complicated entity. Definitions and descriptions of it from that time vary widely. Charcot's unique contribution to the contemporary understanding of hysteria was to describe what he termed the hysterical type in all of its manifestations and to realize that patients who present with just some of the symptoms that are a subset of this hysterical type also fit under the diagnostic rubric of hysteria.

The list of symptoms that made up hysteria as it was understood was quite extensive and included, first and foremost, the neurologic symptoms that ranged from chronic symptoms of paralysis or paraesthesias to episodic and acute attacks of spasm in the extremities or trunk or face.3 The symptoms also included anxiety of a chronic and or episodic, panic like, nature. Mood instability and episodes of depression and excitement were also noted. Patients also had more chronic mood disturbances, with symptoms such as fatigue and abulia. It was not that uncommon to encounter various somatic symptoms, most commonly headaches or gastrointestinal pains. Anorexia nervosa and self-induced vomiting--symptoms now categorized with in the spectrum of eating disorder--were noted as well. Sometimes more dissociative and psychotic symptoms are also described. Patients with the diagnosis of hysteria were sometimes described as bright and intelligent and could be quite charming - in some descriptions - when not in the midst of an acute attack. Finally, there were many of forms of hysteria that presented a much less severe set of symptoms than those identified by Charcot and seen within the Salpetriere asylum. A fairly comprehensive description of hysteria - from a psychiatric, and not psychoanalytic, perspective - can be found in Kraepelin's textbook simply called Psychiatry, the historic 6th edition of 1899 now available in an English translation, a book that is still worthy of close scrutiny.4

One of the most interesting things about hysteria is the reaction physicians had to patients diagnosed with hysteria. In Germany, for example, hysterics were seen as particularly difficult patients. They were often identified or suspected of malingering, and their symptoms were often described as feigned by the patient in order to achieve some sort of gain. In general, according to Freud, most neurologists and psychiatrists did not particularly want to deal with these difficult patients. The comparison of these hysterics to what in a pre-scientific age were identified as witches was even made by Freud, who noted that it was only at this time that this particular type of patient was seen within a medical context.

For those doctors who did try to work with patients with hysteria, the dominant forms of treatment at the time included a variety of somatic and psychic techniques. The somatic techniques included hydrotherapy; electric therapy; surgeries such as hysterectomy and castration; medications, such as bromides and other sedatives; and, massage therapy. For the most part, while some people found these techniques of some value, most found that they were ineffective in treating patients with hysteria. It was rather the psychic techniques that were seen as the most important way of treating hysteria. These included a variety of psychological strategies that are best understood as falling under the domain of suggestive therapy. Kraepelin identifies psychic influence as the most important strategy in dealing with hysterics and suggests both gentle and bold suggestive therapy, as well as taking a position of benign neglect with hysterics. One of the most important techniques developed at the time, most prominently by Bernheim at Nancy, was suggestion - therapeutic direction and advice - introduced while the patient was under hypnosis. In fact, in 1889 Freud traveled to France to work with Bernheim. The idea behind the therapy is that rather than simply suggesting to the hysteric that her problems will go away while the patient was conscious, one would cause the hysteric to enter a state of hypnosis and, while under the influence of the hypnosis, the patient would be encouraged to make some change or another to lead to resolution of the symptoms.

Freud, however, found that he was a very bad hypnotist. He had a great deal of difficulty getting patients into a hypnotic state. What he did find, however, was that by asking the patient to enter a state of high degree of focus or concentration, he could get the patient into a hypnotic-like state. In an intermediary approach between hypnosis and psychoanalysis, Freud has described how he would press his hand upon the foreheads of his patients and ask them to concentrate on the subject of their therapy. Interestingly, working with patients in this manner, he gradually became less motivated in prescribing particular therapeutic dictums, in other words once he was able to achieve such a state, he did not direct his work to demanding or suggesting that the patient follow some request of his. Rather, he started using this state is a way of exploring the patient's history. In other words, he started being a very careful listener and directed his scientific curiosity to the history of the patients. Working initially with his elder colleague Joseph Breuer in work published as Studies on Hysteria, and later, independently, we can thus see how Freud gradually moved away from the standard hypnotic technique in two different directions.5 On the one hand, he stopped using the hypnosis to gain access to a different way of talking on the part of the patient. After, at first, using hypnosis and later the hand-on-forehead technique, he simply requested of his patients that they say what ever was on their mind at any given time. This was the technique of free association, which is the foundation technique of all psychoanalytic therapy. Freud also moved away from hypnosis in another direction. Instead of, once obtaining a particular state of mind, instead of using that particular state of mind to suggest to the patient one thing or another - some change of mood, to demand some disappearance of a symptom, and so forth; instead of using this particular state of mind to suggest treatments, he used the state of mind to explore patient's history. And, it is while in the midst of that process of exploration that Freud discovered -and here I think the word is apt - the unconscious.

Put most simply: the unconscious must be understood as something akin to a logical place, a formal necessity - something which must exist in order to explain the symptoms which the hysteric patient was presenting. What Freud initially posited in his work with hysteric patients was that they experienced something, generally in their childhood - what we would now refer to as a traumatic situation--the intensity of which was so great that child was unable to process it in the normal manner.6 The normal ways in which experience would be processed by the nervous system -according to Freud, who at this stage in his work relied quite heavily on a pseudo neuro-scientific understanding of the mind - the normal ways in which an experience would be processed would be that the excitation introduced into the system through a sensation and perception would work itself out either through motor activity of one sort or another or through the buildup of a stream of associations of the particular trauma to other things in such a way that the intensity of the experience, which he identified within this psychic system as the affect, could be discharged. In the case of hysteria, however, the intensity of the experience - the piece of energy associated with the experience, this trauma - is, for one reason or another, not able to be discharged through motor activity or through memory associations and instead is repressed and then discharged, in a distorted form, through the generation of symptoms. The key term here for Freud is repression. A certain experience - of a childhood seduction - is too intense to be properly registered or discharged through motor activity, and the representations of that experience are repressed, repressed into the unconscious, the place from which they lead to the construction of symptoms.

We can thus describe psychoanalytic therapy, as it was initially understood, as the attempt to cure the patient through the elimination of a symptom by allowing the affect or energy associated with a symptom to be discharged in a different manner. In other words, through free association, the patient gradually begins to talk more about the symptom and, in this manner, she is able to gradually connect the symptom back to the particular traumatic event which lies at the kernel of the symptom and thus redirect the energy associated with the symptom into new associations of the symptom through the connection of the symptom to other aspects of the patient's history. This process then leads to the elimination of the symptom in the therapy, as the energy - the affect - associated with it is discharged differently.

This particular way of understanding the unconscious and psychoanalysis represents when I would term of the logic of psychoanalysis. This description of the logic of psychoanalysis is in fact the most important aspect of Freud's work. It is worth noting (though I will not dwell on this at any great length) that Freud owes this particular discovery to the hysteric patients he worked with. While there are other forms of neurosis and there are, of course, the psychoses, perversions, and various other forms of clinical structure, it was through his work with hysteria that he was able to discover the existence of the unconscious. The reason for that-outlined elegantly by Gerard Wajcman in Le Maître et l'Hystérique, portions of which have been translated as "The Hysteric's Discourse" on the website lacan.com, has to do with the particular way in which hysterics offer their symptoms to the doctor who cares for them, the particular way in which they seek a master to give them the meaning of their symptoms.7 The particular way in which the hysteric seeks a master for knowledge of the symptom, and then seeks to control this process - "The hysteric wants a master over whom she can reign," Lacan indicated in Seminar 17 - represents the key structure of hysteria that allowed for her unconscious processes to be so available for interpretation.8 It is also this opening up of themselves to their doctors which makes the patients with hysteria so amenable to suggestion, which formed the basis for the earlier treatments, as I noted above.

Freud did not remain satisfied, however, with this understanding of the formal character of the unconscious. In addition to this way of understanding the unconscious, Freud also throughout his career posited a certain specific content to the unconscious. In the earliest phase of his work associated with the origins of psychoanalysis, the dramatic sexual content of the material he uncovered in his analyses led him to initially posit that it was the sexual abuse of his patients which led to the elaboration of the hysterical symptoms - the childhood seduction theory.9 Freud, who at this stage was working with about 15 or 20 patients, had uncovered this particular scenario in all of these patients he was working with. But in a careful analysis of these particular cases described for the most part in his letters to Wilhelm Fleiss, Mikkel Borch-Jacobsen, in "Freud's Neurotica: Freud and the Seduction Theory," has demonstrated that Freud gradually began to realize that the reason for this particular history coming up again and again was that Freud was conducting his analyses at that time with a particular technique which imposed certain histories on is patients.10 In other words, the hysteric's structural position in relation to the doctor is such that even particular types of questions - ones described by lawyers as leading questions, "Have you ever experienced one thing or another?" - will be assimilated by the hysteric and weaved into the histories obtained from them.

Freud then went on to alter his understanding of the dramatic stories he was hearing in his analyses. Some of what he noticed again and again he ascribed to the suggestive influence of the questions and the very technique he was adopting. Another key shift was his realization that much of what he was hearing may have represented infantile fantasies - wishes from an earlier time in the histories of his analysands, which because of the nature of memory from that time can get remembered as if they actually happened. The key shift in his approach, however, derived from his work on his self-analysis. Writing to his colleague Fleiss on October 15, 1897, Freud states, regarding his self-analysis:

A single idea of general value dawned on me. I have found, in my own case too, being in love with my mother and jealous of my father, and I now consider it a universal event in early childhood, even if not so early as in children who have been made hysterical. If this is so, we can understand the gripping power of Oedipus Rex, in spite of all the objections that reason raises against the presupposition of fate; and we can understand why the later "drama of fate" was bound to fail so miserably. Our feelings rise against any arbitrary individual compulsion, such as is presupposed in Die Ahnfrau, and the like; but the Greek legend seizes upon a compulsion which everyone recognizes because he senses its existence within himself. Everyone in the audience was once a budding Oedipus in fantasy and each recoils in horror from the dream fulfillment here transplanted into reality, with the full quantity of repression which separated his infantile state from his present one.9
Freud went on to replace the theory that hysteria was caused by a childhood seduction - the theory that the repressed was a certain trauma experienced in reality - by a theory in which the critical element of repression - and not just in hysterics but all individuals - relates to a series of fantasies from childhood about the child's relations with his parents.

If I might be allowed to state this in a different way, the crucial thing to realize is that Freud noted that a failure occurring at some level of registration of memory - repression - leads to a logical process which results in the generation of a symptom. Now, this particular discovery of his represents when I would consider the heart of the psychoanalytic discovery, the key to the entire psychoanalytic enterprise. Freud did not rest content with this discovery of the logic, of the formal character of the unconscious. He felt a need to specify the particular content of the unconscious, of that repressed material, a specific content with a general or universal value. His first attempt at defining that content, the seduction theory, he abandoned, feeling that, among other reasons, he imposed that content on his patients. His second theory, the Oedipus complex, however, he held to for the remainder of his career.

If the discovery of the logic of the unconscious development represented psychoanalysis, this content which Freud imposed upon it, be it the seduction theory or the Oedipus complex, represent what I will term Freudianism and it is Freudianism that is, I believe, the proper target of attack that many have had on psychoanalysis over the past quarter-century.

If psychoanalysis represented a certain process of discovery and elaboration, Freudianism was one of imposition. As we have seen, Freud regretted a certain imposition imposed on is patients with his earlier seduction theory. Later in his work, we can see how he used the Oedipal complex to impose brutal and at times even strikingly preconceived, ready-made interpretations on his patients. The case of Dora, of which Freud himself later had reservations on particular technical aspects, represents a striking example of this.11 And furthermore, in the hands of lesser analysts than Freud, what can be seen often is a certain loss of the quality in psychoanalysis by an abandonment of the more difficult project of psychoanalysis in the name of Freudianism.

When I would like to argue for is a psychoanalysis - a theory and a practice - which holds to the great discoveries of psychoanalysis and which avoids the paths of Freudianism. To do such is a tricky matter. We can look at the work of Melanie Klein and later object relations theory as an attempt to hold true to psychoanalysis and abandon strict adherence to the Oedipal complex. The assertion of the critical role of the pre-Oedipal time and the significance of the mother-child dyad either replace or complement the Oedipal complex, the content driven domination of interpretation by the Oedipal complex, according to Klein or object relations theorists. But if we take an exemplary case, such as Klein's case of the boy named Dick in "The Importance of Symbol Formation in the Development of the Ego," we see that instead of replacing the Oedipalization of the unconscious with an exploration of the unconscious, Klein simply redefines a general content to the unconscious and interprets from that point, in a manner no less brutal than Freud.12 For Klein, avoiding Freudianism does not rehabilitate psychoanalysis, but simply replaces the universal Oedipal content with a universal pre-Oedipal content.

All of which is not to say of course that Oedipal and to a certain extent pre-Oedipal phenomena do not exist. Though some have argued that the Oedipal complex does not exist in any form - contemporary or historical - , that it is simply a fiction of Freud's, I feel that a more complicated relationship between the Oedipus complex and social and historical formations remains to be elaborated, though Paul Verhaeghe's essay "The Collapse of the Function of the Father and Its Effect on Gender Roles" and "Whither Oedipus?", a chapter in Slavoj Zizek's The Ticklish Subject, are suggestive of the direction such an analysis might take.13,14 Of course, Oedipal structures are encountered often in clinical work, and they have a clinical significance. But we must follow the example of Jacques-Alain Miller in his "Petite introduction à l'au-delà de l'Oedipe" and explore a psychoanalysis beyond this.15

I will indicate here what I believe to be the one of the most significant components of such a practice. It is, namely, a refusal of the analyst to occupy a certain pre-established position in his work with analysands. For example, standard advice in some schools of psychoanalysis is for the analyst to take a position of paternal authority - to play the role of the father - to bring the analysand through the Oedipal complex that he did not properly traverse. In other words, if symptoms are due to a failure in the confrontation of the patient with the Oedipal complex, leading to repression and symptom formation, then the analyst must take on the role of the father, regress the patient in the therapy to the time of the Oedipus complex, and maneuver the patient through it. Another form of standard advice is for the analyst to take on the role of the mother and to give the patient a certain attachment security that he was unable to find in his childhood. By then allowing the patient to attach properly to the analyst, the analysand will be able to subsequently attach well to other individuals in his life. In contrast to this advice, I believe that the analyst must take the position of nothing. The analyst must decentralize his role in the relationship with the analysand, and allow the analysand to make of the analyst what he will. With this technique, the unconscious of the analysand will reveal itself, instead of the theories of the analyst. This refusal of mastery and of knowledge on the part of the analyst is much harder to achieve than most realize.

This is, in many ways, the obverse of the practice of ego psychology. One might even, in fact, identify ego psychology - which is the dominant psychoanalysis understood by most in American psychiatry when referring to psychoanalysis - as a Freudianism without psychoanalysis. There is no better way to describe Heinz Hartman's project of creating a general psychology that would be derived from psychoanalysis than the notion of Freudianism I introduced above. Several aspects of ego psychology are worth reviewing, but I will restrict my comments to a therapeutic issue. In ego psychology, the general direction of therapy is oriented around the goal of the analysand identifying with the stronger ego of the analyst. Within that particular framework, the goal of the analyst is to strengthen those particular parts of the ego that the analyst identifies as most appropriately in tune with reality. It is up to the analyst to identify said reality and to direct the analysand in that direction. The particular reality referred to here is the analyst's. And the analyst positions himself in the position of the Father in order to maneuver the analysand through the Oedipal complex that he was unable to maneuver through previously. Whatever the nature of the identifications and desires of the particular analysand, the truth of them is only established through the lens of the Oedipus complex.

Now, the attack on psychoanalysis that we have witnessed over the last quarter century is best understood as an attack not on psychoanalysis - as I describe it here - but on that particular aspect of its legacy known as Freudianism. It is, therefore, not surprising that the assault on the psychoanalysis, which has come from many directions - biological psychiatry, feminism, critical theory - , has been most strongly felt in this country, where the dominant school of psychoanalysis is ego psychology, that school of psychoanalysis which I have identified as that which draws the most from the Freudianism.

And it has been in France and Western Europe where psychoanalysis has suffered the least from these assaults. I would assert that the reason for this is that practice in these countries has been the psychoanalysis associated with work of Jacques Lacan. Lacanian psychoanalysis is best understood as drawing its strengths from the logic of psychoanalysis itself--and a development of psychoanalysis as an autonomous discourse--to the exclusion of Freudianism. In fact, in Seminar 17, L'envers de la psychanalyse, Lacan sets his project has identifying the desire of Freud and elaborating a psychoanalysis without that desire.8

If there is to be a return to psychoanalysis in this country, it will be in as much as this psychoanalysis turned to stays true to psychoanalysis to the exclusion of Freudianism.

Now, why is this of importance to the general psychiatrist? Why would the general psychiatrist care about such squabbles between different schools of psychoanalysis?

I want to answer this question in several different ways.

First, I would like to make several comments about the condition known as borderline personality disorder. I will first note that this particular condition - and I hesitate to use this psychiatric term - is notably hard to categorize. Patients identified with borderline personality disorder present with a staggering array of symptoms. Those symptoms can include mood instability, anxiety, difficulty with interpersonal relations, episodes of psychotic-like or dissociative symptomatology. Often, the histories include dramatic stories of trauma or childhood abuse. Many psychiatrists and psychotherapists suspect that patients they treat with borderline personality disorder are at one time or another malingering. There are those who view borderline personality disorder as on a continuum with other conditions, such as dissociative identity disorder, post-traumatic stress disorder, or psychosis. A great many different specific ways of describing the disorder has been advanced, and I would refer anyone interested in a brief summary to the writings of Gabbard on the topic in his Psychodynamic Psychiatry.16 There is one thing, however, that is somewhat clearer. Many psychiatrists and therapists involved in the treatment of patients with borderline personality disorder identify this as a very difficult condition to treat. Some psychiatrists and psychotherapists even try to limit the number of patients with this condition who they will see because of the high degree of frustration they feel in working with patients with borderline personality disorder.

I introduce this discussion to highlight the great similarity between our contemporary accounts of borderline personality disorder and the historical accounts of hysteria. With the singular exception of the more specific neurologic symptoms, there is a remarkable similarity between the two diagnoses. Even more interesting than the similarity in specific symptom clusters is the similarity in the context of the diagnosis. By this, I mean that in both cases the disorder is extremely difficult to pin down in an exact way like other clinical categories contemporary to it. In both cases patients with the condition are often suspected of malingering. In both cases, many physicians responsible for treating patients with the condition find working with such patients to be difficult. This is particularly notable, because borderline personality disorder is generally not categorized by psychiatrists as a severe mental illness, much in the way that hysteria was not viewed as a severe neurologic or psychiatric disorder.

Perhaps more interesting than the similarities are in fact the differences. The most dramatic of those are the neurologic symptoms previously seen in hysteria. The explanation for this is to be found in the relationship between the patient with hysteria and the treating doctor. Hysteria must be understood as a psychic structure, a particular logical structure of the unconscious. Patients with hysteria exhibit a particularly strong sensitivity to the others around them. Thus, when patients with hysteria stand before a priest, their symptoms take on a religious character. When seen by neurologists, the symptoms produced become more neurologic. And, finally, when those with the structure see psychiatrists, the symptoms are psychiatric.

Hysteria has in fact not disappeared. It has simply adopted another form by virtue of the context in which it is described. To understand in greater detail the logic of these transformations, we must turn to psychoanalysis. And if there is any hope for that resolution of the painful symptoms of the patient with borderline personality disorder, of today's hysteric, if there is a hope of cure and not simply the important - though limited - goals of decreased hospital time or adverse behaviors, I believe it is to be found through psychoanalytic treatment.

Another reason for the psychiatrist to be aware of psychoanalysis is that I believe that it may offer an explanation for our most effective psychiatric treatment. Let me take the case of depression. As we all know, an individual with an uncomplicated episode of depression - a first episode - who presents to his doctor and is prescribed an anti-depressant medication will be cured of his depression about 70% of the time. Interestingly, if that same individual presented to his doctor and was prescribed a placebo medication he would stands a 50% chance of cure for his depression. In my way of looking at this, the medication itself - the particular drug with its binding affinities and psycho-pharmacological profiles, it's receptor specificity and effects on brain function - the particular medication itself accounts for less than one the third of the cure. In other words, more than two-thirds of our cure for this particular patient is not due to the medication but to something else that happens. Something happens when someone realizes he is in pain, he suffers, and goes to another seeking care, relief from his symptoms. That something else, which represents the bulk of the general psychiatrist's ability to help others, is the transference. Knowing about the transference - knowledge obtained through psychoanalysis - can help the work of any doctor.

I wish to offer one final reason why psychoanalysis is important for the general psychiatrist. This reason - listening - must be put in the context of the differences between these two practices. As practiced today, psychiatry is in the main a practice of assessment, of diagnoses, of treatment planning, and of suggestion. Many psychiatrists trained today learn only the diagnosis of the DSM.17 It is the goal of the DSM to eliminate the transference from the doctor-patient relationship and reduce the assessment to the collection and collation of easily identified and verifiable symptoms and signs of the patient. In this regard, we could say that the structured clinical interview advanced as part of the DSM project, while primarily used as a research device, must be understood as the ultimate form of contemporary diagnostic assessment. It represents a way of talking with the patient that reduces the assessment to a form of notes taking. Once the information is gathered, a certain set of signs and symptoms are tabulated by their presence or their absence, and the data collection - to use that very unfortunate term for the clinical interview that contemporary psychiatrists are trained to use - is then fed into an algorithm, either those at the back of the DSM or those which are subsequently a memorized and internalized by psychiatrists, and a diagnosis is generated. Once the diagnosis has been identified, a treatment plan is put forth in accordance with a set structure for such diagnoses. This treatment planning and prescription of medication as part of the treatment planning, with psychotherapy to be handed off to an ancillary health provider - this view of therapy of many psychiatrists akin the to the role of physical therapy as seen by orthopedic surgeons - , represents the entirety of many psychiatrists' practice.

Psychiatrists need to understand that time spent in an assessment with the patient after the diagnosis has been established is not wasted time. For many, once it is clear what the diagnosis is and what the subsequent treatment plan will be, the work is over. For many, an office visit for medication check should be limited to the shortest amount of time it takes to reassess symptoms, reassess for side effects, evaluate for new medical problems or changes in social and occupational functioning. For many psychiatrists, they are doctors just like any other doctors, with the exception of the fact that they have a tarnished, Freudian past. For many, they are the internists of the brain, prescribing chemicals to balance and restore the homeostatic basis of brain function. If psychoanalysis is to have any lessons for the psychiatrist, it is that of listening. Psychoanalysis is a practice of patience, not of patients - with a "T" - to hustle through the office as quickly as possible, but of waiting. It is a practice of slow listening, of directing attention to what is said, and not to the anticipation of a particular answers. Those who come to psychiatrists are a particular type of patient with demands and needs different from patients with the laceration or the cough. That particularity requires time to articulate. Psychiatrists can learn that from psychoanalysis.

References

1. Freud S: On the history of the psycho-analytic movement (1914), in Complete Psychological Works, standard ed, vol 14. London, Hogarth Press, 1957, pp 7-66

2. Gay P: Freud: a life for our times. New York, WW Norton, 1988

3. Freud S: Hysteria (1888), in Complete Psychological Works, standard ed, vol 1. London, Hogarth Press, 1966, pp 41-59

4. Kraepelin E: Psychiatry: a textbook for students and physicians (1899). Canton, MA, Science History Publications, 1990

5. Freud S and Breuer J: Studies on hysteria (1893-1895), in Freud S: Complete Psychological Works, standard ed, vol 2. London, Hogarth Press, 1955, pp 1-309

6. Freud S: The neuro-psychoses of defense (1894), in Freud S: Complete Psychological Works, standard ed, vol 3. London, Hogarth Press, 1962, pp 43-61

7. Wajcman G: Le maître et l'hystérique. Paris, Navarin, 1982

8. Lacan J: Le séminaire, livre 17: l'envers de la psychanalyse, 1969-1970. Paris, Éditions du seuil, 1991

9. Freud S: The complete letters of Sigmund Freud to Wilhelm Fliess, 1887-1904. Cambridge, MA, Harvard University Press, 1985

10. Borch-Jacobsen M: Neurotica: Freud and the seduction theory. October 1996; 76:15-43

11. Freud S: Fragment of an analysis of a case of hysteria (1905), in Complete Psychological Works, standard ed, vol 7. London, Hogarth Press, 1953, pp 3-124

12. Klein M: The importance of symbol-formation in the development of the ego. International Journal of Psychoanalysis 1930; 11: 24-39

13. Verhaeghe P: The collapse of the function of the father and its effects on gender roles, in Sexuation. Edited by Salecl R. Durham, NC, Duke University Press, 2000, pp 131-156

14. Zizek S: The ticklish subject. London, Verso, 1999

15. Miller J-A: Petite introduction à l'au-delà de l'Oedipe. La revue de l'ecole de la cause freudienne 1992; 21:7-11

16. Gabbard GO: Psychodynamic psychiatry in clinical practice: the DSM-IV edition. Washington, DC, American Psychiatric Press, 1994

17. American Psychiatric Association: Diagnostic and statistical manual of mental disorders, ed 4. Washington, DC, American Psychiatric Press, 1994

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