Twilight of the Idols, or: Are Freud and Psychoanalysis still Relevant?

As a therapist, I am sometimes asked whether psychoanalysis is still relevant to modern psychotherapy. Critics have argued that psychoanalysis is methodologically flawed, contaminated by suggestion, and unscientific. For a period it became very popular to espouse such views, denouncing Freud as a charlatan and questioning the legitimacy of psychoanalysis.

The sheer range of sources offering this same position can give one pause. Those principally opposed to psychotherapy will encourage people out of treatment by deriding psychoanalysis specifically, saying something to the effect of: “You don’t need to spend years on a couch talking to a psychoanalyst, just get a hobby.” However, even otherwise skilled psychotherapists will sometimes assure patients that what they do is "evidence-based unlike Freud’s wild speculations." It is unusual to hear such a diverse range of voices speaking in unison and so it can lure, and has lured, many into believing that psychoanalysis is nonsense.

However, Freud was an extraordinary theoretician and psychoanalysis is both a highly effective treatment in its own right, and the foundation for other "competitor" approaches, often claimed to be superior. In this post, I explore some of the startling successes and unbelievable excesses of psychoanalysis that caused it to become the most celebrated psychotherapeutic model of its time as well as one of the most ridiculed models of the present age.

A Brief History of Psychology

Physical medicine began around the time that humans began – from then on, we needed ways to repair our injured bodies. Improvements were fairly rapid due to the immediate resolution to many problems. Cauterization, for example, has been known to close wounds since antiquity, and, in an amazing recent discovery, the earliest evidence of surgical amputation was recently discovered in a 31,000 year-old skeleton in Borneo.[1]

Even with that extensive history, it took medicine until the early 1900s for medical education to become standardized. In 1910 Abraham Flexner issued the hugely influential Flexner Report, detailing the low criteria for admission and graduation at medical schools, their non-standardized curriculum, and their teaching of questionable and even defunct medical sciences. He called on them to abandon these questionable theories and adhere to the science of the day.

Although the ancient Egyptians described conditions resembling hysteria; [2] Hippocrates theorized about the causes and treatments of “melancholy”; and extreme psychological conditions, often classified as “madness”, were observed throughout the world, the understanding of mental health and illness generally lagged behind physical medicine. The belief that mental illness is a product of supernatural causes persisted for centuries. It wasn't until the mid to late 19th century that Théodule-Armand Ribot in France and Wilhelm Wundt in Germany that human psychology began to be studied scientifically. However, even then "scientific" treatments for psychological ailments often involved being confined to an asylum, mandated bedrest, dietary restrictions, and exposure to different climates.

A Major Leap Forward

Although Freud is often derided, his contributions to the field were immense. Late in his career, he was invited to write an encyclopedia article explaining the contribution of psychoanalysis – his life’s work – to a broader audience. This is what he wrote:

“The assumption that there are unconscious mental processes, the recognition of the theory of resistance and repression, the appreciation of the importance of sexuality and of the Oedipus complex – these constitute the principal subject-matter of psycho-analysis and the foundations of its theory.” [3] (p. 247).

Freud’s first point – “The assumption that there are unconscious mental processes” – is paradoxically such a large contribution that it is easy to overlook. In the mid and late 19th century the predominant view was that consciousness was synonymous with "mind" and that the notion of an unconscious was a silly theory. The eminent English neurologist, John Hughlings Jackson, for instance, wrote "“I take consciousness and mind to be synonymous terms; if all consciousness is lost all mind is lost. Unconscious states of mind are sometimes spoken of, which seems to me to involve a contradiction”; [4] William James, sometimes called the "father of American Psychology", famously wrote that the unconscious is a “pure mythology”; [5] and the hugely influential German philosopher and psychologist, Franz Brentano concluded a chapter devoted to examining arguments for the existence of unconscious mental states thusly: “The question ‘Is there unconscious consciousness?’ in the sense in which we have formulated it, is, therefore, to be answered with a firm, ‘No’”.[6]

Although several argued that it did (including one of my favorites, Friedrich Nietzsche), it was Freud who ultimately convinced the scientific world of the existence of the unconscious, which now serves as the basis for all cognitive neuroscience.[7]

Consider what a monumental shift that is. That would be like changing biology’s subject matter from the study of living things to include inorganic things as well. Not trained in the history of science, neuroscientists and cognitive scientists who focus on unconscious processes can sometimes forget this central contribution.

A Terrible Idea... Rescued

Part of what makes it so easy to forget, however is Freud’s third “contribution” – the sexual theory of neurosis. As is well known, Freud postulated that all neuroses – that is, all disorders that are not psychotic disorders (so, anxiety, depression, phobias, etc.) – are the result of a sexual source, very often one’s own mother. He could not have been more clear about this: children sexually desire their own parents. This theory is so laughably false that scholars have devoted book length treatments to trying to understand why society could have bought in to this. (For a recent, and compelling, treatment of this topic, see: [8-9])

However, in the 1950s the researcher John Bowlby re-examined the theory. He observed that babies and young children are not longing for their parents sexually but longing for touch, connection, and soothing. If you look around the animal kingdom you’ll notice that whereas deer are walking within hours and hyenas are already hunting at one year, human babies can’t do much of anything. There are interesting evolutionary reasons for this, but developmentally it means that human babies need auxiliary emotional regulation devices to help them figure out when to worry, to be relaxed, to be afraid, to be happy. These auxiliary regulation devices are called parents. The way they do this is by holding, swaying, caressing, hugging, singing, and cooing with their kids.

Bowlby’s attachment theory has received volumes of supporting research, but one notable area of evidence came from Mary Ainsworth's Strange Situation experiment. Ainsworth devised a brilliant experiment to observe how toddlers react to their parents’ presence in low and high stress environments. She found that, children’s early relationships with their parents inform how they behave toward others and their environment. These insights were quickly folded into psychoanalytic thinking focusing on the relationship between children and other people called object relations.

Object relations is a branch of psychoanalysis that treats the objects (that is, people) in people’s life as the most essential features to their psychology. The insights from object relations and attachment theory – in particular the notion that relationships formed in childhood create an unconscious “schema” or “working model” for how others value you, what traits are appropriate to value, what counts as love, etc. – form the basis of, or inform, other psychotherapies including internal family systems (IFS), schema therapy, interpersonal therapy (IPT), and even Cognitive Therapies.

How Cognitive is Psychoanalysis? How Psychoanalytic is Cognitive Therapy?

Aaron Beck, the founder of cognitive branches of psychotherapy that emphasize the distortions in one’s beliefs and attitudes that make one depressed (or anxious, or angry, etc.), is often thought to have formulated his theory after being dissatisfied with the inabilities of psychoanalysis to treat his patients. However, that is not what Beck himself has stated:

"It might be a point of curiosity therefore for you to know that my psychiatric training was completely and exclusively psychoanalytic […] I would consider my theoretical work as derivative from ego psychology rather than from cognitive psychology or learning theory. At the present time in fact I am trying to reformulate many of the basic psychoanalytic concepts into cognitive terms." ([10], p. 2).

Beck considers his theory a reformulation of, rather than a rejection of, “basic psychoanalytic concepts.”

In an article discussing the importance of psychotherapeutic integration – that is,

combining psychotherapeutic models to extract what is most effective and leave the rest (more on that later) – my colleagues and I [11] discuss the way that Cognitive Therapy borrows from and elaborates on psychoanalytic ideas. In particular, we note that what Beck refers to as “automatic thoughts” – those thoughts that arise, often without our awareness, that can influence our moods – are really generated by those unconscious schemas learned in childhood. As we write:

To a remarkable degree, Beck’s notion of schema comes close to Bowlby’s notion of “working model” and object relations theory’s notion of “internalized object,” and provides a bridge from cognitive to psychodynamic thinking. Just as classical psychoanalysis involves the analyst interpreting symbols and images that emerge in the course of free association in order to get at unconscious meanings, the cognitive therapist uses the content of spontaneous conscious thoughts and images to identify the cognitive distortions in the relevant schemas, which are not necessarily conscious. ([11])

Isn’t Cognitive Behavioral Therapy (CBT) the Best Anyway?

Cognitive Behavioral Therapy (CBT), born out of Beck’s Cognitive therapy and Skinner’s Behavioral therapy, has enjoyed decades of prominence as the premier psychotherapeutic model. Whereas psychoanalytic models relied for years on the force and coherence of their arguments, Cognitive Behavioral therapists got to work in the lab to turn their arguments into evidence. As a result, CBT is considered by some to be the “gold standard” psychotherapy and is a recognized and recommended treatment by both the American Psychological Association [12] and The National Institute for Health and Care Excellence. [13]

Although many psychoanalysts take their fight to be with CBT, there is no doubt that Cognitive Behavioral Therapy is an effective treatment for many conditions (I, myself, am a certified Cognitive Behavioral Therapist and trained in psychoanalytically based treatments). However, there is a reason for the disproportionate acclaim that CBT gets compared to its psychoanalytic counterparts that has nothing to do with effectiveness.

CBT is a highly structured, highly operationalized psychotherapy meaning that it can be broken down into discrete techniques [14] and employed by whomever to whomever. As well, CBT is designed to be a brief and directed treatment approach to an identified problem. Taken together, these features make it much easier to design a randomized control trial to examine its effectiveness than psychoanalytic therapies which vary in length (but often are longer in duration than their CBT counterparts) and which are less easily broken into discrete, operational, components.

Once researchers figured out how to operationalize psychodynamic therapies, it was shown to be clinically effective [15-17] at rates similar to CBT.[18-21] In one three-year follow-up study,[22] psychoanalytically based psychotherapies had a more lasting posting effect on interpersonal relationships than CBT. Indeed, a landmark study by the U.K.’s National Health Service (NHS) found that long term psychoanalysis not only performed as well as CBT and antidepressents in the short-term, but outperformed CBT on long-term measures for severe depression.[18]

That does not mean that CBT is ineffective, or less effective in all cases, than psychoanalytically informed treatments. Many people are seriously helped by CBT and that is a wonderful thing - it is why a number of our therapists are trained in CBT. The point is only that no single psychotherapeutic modality is the key to all conditions for all people all of the time.

Babies. Bathwater.

Philosophically and psychotherapeutically, I am an integrationist, meaning that I employ cognitive behavioral therapy, psychodynamic psychotherapy, somatic psychotherapy, and schema therapy into my practice. Despite the sweeping claims made by the progenitors of these systems, no single psychotherapy works for all people, in all circumstances, at all periods of life. And there is good reason for this. If you have a headache and prefer Tylenol over Advil (or vice versa) it is because they work along different pathways in the body. Similarly, the human mind is a complex system that includes more than just its physical substrate. The mental component – that part that thinks, values, and feels – has multiple meaning systems: cultural, familial, conscious, unconscious, and perhaps many others. It is possible that cognitive based therapies family systems therapies, and therapies focused on unconscious processes, all address different aspects of the same issue.

It is not difficult to see why some people balk at psychoanalysis and psychoanalytic concepts: some of Freud's ideas were asinine, some terrible therapists were terrible using psychoanalysis as a cover, some people simply want to agree with others who seem to know what they are talking about, others no doubt want to be contrarian and enjoy the iconoclasty. The truth is somewhere between all of these: Freud forever altered psychology, transforming the subject matter of the discipline from consciousness to mind and yet his belief in sexual theories of the neuroses was extraordinarily wrong and did lasting damage to the field. However, what is right with psychoanalysis (the unconscious) has persisted and is a tent-pole of modern cognitive science and psychotherapy. It would be a mistake to throw out so much that is right because the other part is so obviously wrong. Especially when this has been corrected for, a century ago.

---

[1] Burakoff, M. (2022). Stone Age skeleton missing foot may show oldest amputation. Associated Press. Retrieved from: https://apnews.com/article/science-health-606cbfe3040b8fed2b9435fb1fbc2d29

[2] Cosmacini G. (1997) The long art: the history of medicine from antiquity to the present. Oxford: Oxford University Press

[3] Freud, S. (1955b). Two encyclopedia articles. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 18, pp. 233-260). London, UK: Hogarth Press. (Original work published 1923).

[4] Jackson, J. H. (1887). Remarks on evolution and dissolution of the nervous system.

Journal of Mental Science, 23, 25–48. p. 39

[5] James, W. (1950). Principles of psychology (Vol. 1). New York, NY: Dover (Original work published 1890). p. 170

[6] Brentano, F. (1995). Psychology from an empirical standpoint. London: Routledge (Original work published 1874). p. 106

[7] Wakefield, J. C. (2018). Freud and Philosophy of Mind. New York: Routledge.

[8] Wakefield, J. C. (2023). Freud's Argument for the Oedipus Complex: A Philosophy of Science Analysis of the Case of Little Hans. New York: Routledge.

[9] Wakefield, J. (2024). Foucault versus Freud: Oedipal theory and the deployment of sexuality. New York: Taylor & Francis

[10] Rosner, R. I. (2012). Aaron T. Beck’s drawings and the psychoanalytic origin story of cognitive therapy. History of Psychology, 15(1), 1–18.

[11] Wakefield, J. C., Baer, J. C., & Conrad, J. A. (2020). Levels of meaning, and the need for psychotherapy integration. Clinical Social Work Journal, 48, 236-256. doi: 10.1007/s10615-020-00769-6

[12] Society of Clinical Psychology (2022). Psychological treatments. Division 12: American Psychological Association. Retrieved from https://div12.org/treatments/

[13] The National Institute for Health and Care Excellence (2011). Common mental health problems: Identification and pathways to care. Retrieved from: https://www.nice.org.uk/guidance/cg123/chapter/Recommendations

[14] Ewbank, M. P., Cummins, R., Tablan, V., Bateup, S., Catarino, A., Martin, A. J., & Blackwell, A. D. (2020). Quantifying the Association Between Psychotherapy Content and Clinical Outcomes Using Deep Learning. JAMA psychiatry, 77(1), 35–43. https://doi.org/10.1001/jamapsychiatry.2019.2664

[15] Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA, 300(13):1551-65. doi: 10.1001/jama.300.13.1551.

[16] Leichsenring, F., Rabung, S., & Leibing, E. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Archives of general psychiatry, 61(12), 1208–1216. https://doi.org/10.1001/archpsyc.61.12.1208

[17] Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. The American psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378

[18] Leichsenring F. (2001). Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: a meta-analytic approach. Clinical psychology review, 21(3), 401–419. https://doi.org/10.1016/s0272-7358(99)00057-4

[19] Fonagy, P. (2015) The effectiveness of psychodynamic psychotherapies: An update. World Psychiatry. 14(2),137-50.

[20] Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174, 943-953.

[21] Leuzinger-Bohleber, M., Hautzinger, M, Fiedler G, et al. (2019). Outcome of Psychoanalytic and Cognitive-Behavioural Long-Term Therapy with Chronically Depressed Patients: A Controlled Trial with Preferential and Randomized Allocation. The Canadian Journal of Psychiatry, 64(1), 47-58. doi:10.1177/0706743718780340

[22] Huber, D., Zimmermann, J., Henrich, G., & Klug, G. (2012). Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients–a three-year follow-up study. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 58(3), 299-316.