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November 12, 1998


To the editor:

In the University Times issue of Oct. 29, 1998, Adolf Grunbaum was interviewed about psychoanalysis. He is a professor of philosophy who has specialized in the philosophy of science, and had written on a variety of scientific subjects. In 1977 he wrote his first article dealing with whether Freud's original psychoanalysis was scientific. Since then his papers have repeatedly focused on criticisms of psychoanalytic theory and technique so that the subject has become the focus of his career for the last two decades, and the core of his academic reputation. Zeroing in on the scientific aspects of psychoanalysis is like picking on the smallest, skinniest kid on the block. Many, psychoanalysts and non-psychoanalysts, have long acknowledged that the scientific aspects of psychoanalysis are weak, and not salient with regard to the contributions of psychoanalysis.

Grunbaum, who dismisses psychoanalytic theory, except for Freud's theory of religious belief — which he accepts without validation because it seems plausible to him — is at a loss to explain the enormous cultural impact in the Western world that Freud has had in this century on literature, art, theater, music, anthropology, sociology, linguistics and neurophysiology, to name a few. These applications of psychoanalysis are so widely known that no elaboration seems necessary. Rather, I will turn to his criticisms of psychoanalytic treatment.

His criticisms are based on his reading of psychoanalytic papers, with special focus on Freud's writings and early concepts such as repression. Freud died more than one-half century ago, so Grunbaum is criticizing a largely defunct one-person model of psychoanalysis which conceived that the patient's free associations are interpreted by an objective, anonymous analyst and the patient's insight produces therapeutic gain. When he scans recent psychoanalytic papers, I am not sure he recognizes and accounts for the considerable discrepancy that often exists between what an analyst writes in his/her paper (on which Grunbaum bases his criticism) and how he/she actually behaves with his/her patient. He shows little interest or knowledge of current, clinical psychoanalysis; nor does he does come to the Pittsburgh Psychoanalytic Institute or Society to hear case presentations or to learn what is taught to candidates. In other words, he shows little awareness of the substantial changes in psychoanalysis in the last 15 years to a two-person model in which the interactions between patient and analyst are in the foreground of the psychoanalytic work. He shows little understanding of the intense human, emotional aspects of psychoanalytic treatment. I do agree with Grunbaum that the causation of neuroses and psychoses cannot be established from the data of psychoanalytic treatment. However, Grunbaum does acknowledge that it is not necessary to know the etiology of a disorder to develop an effective treatment for it. In fact, many if not most medical treatments — such as those for hypertension — have been developed in the absence of knowledge of etiology. Interpretation of dreams, which plays a significant role in psychoanalytic treatment, is dismissed by Grunbaum who denies the role of unconscious wishes in dream production and sees no value in exploring the meaning of dreams. Let me report, as an example, a fragment of a dream of a male patient in psychoanalytic treatment. This man, who had not expressed any sexual concerns when he came for treatment, after approximately four months of analysis, in a session started to talk about his sexual relationship with his wife, noting they had been having sex more frequently recently. He had always had some difficulty with intercourse. He was reluctant to mention he had noticed a diminished compulsion to masturbate. He had dreamed the preceding night that he was attempting to enter a stadium by driving a car through a tunnel they called "the hole." There were cave formations on the sides of the tunnel and he drove very carefully so he would not scratch the sides of the car. In the context of his sexual discussion in the session it seems plausible to hypothesize that the car represents his phallus and that he had an unconscious fantasy that his penis could be damaged during intercourse. Interestingly, the increased sexual frequency suggests he had undergone some diminution in this sexual fear that his penis would be damaged before he came to understand this underlying fantasy. Psychoanalytic treatment, Grunbaum writes, is not more effective than rival therapies, is not cost effective and is too expensive for most people. Neither he nor anyone else knows whether psychoanalytic treatment is more effective than rival therapies because it has never been tested, and for that psychoanalysis must be faulted. Having said that, it must be understood how extremely difficult conducting such a test would be. Selecting "matched" patients, randomly assigning them to different treatments, and measuring subjective variables like self-esteem and inner strength would be problematic. Psychoanalytic treatment unfortunately is expensive, but in every city like Pittsburgh where there is a psychoanalytic institute a limited number of low cost treatments are available. Cost effectiveness is extremely difficult to assess if the therapeutic outcome is not just a short-term diminution in specific symptoms but a generalized improvement in the person's confidence, self-esteem and satisfaction with relationships and with life. How much is that worth? Parenthetically, a commonly observed benefit of psychoanalytic treatment is an increased earning capacity. Among rival therapies medication often can be very helpful with symptoms such as depression and anxiety, but if the patient is struggling with unconscious feelings and conflicts that are damaging relationships and disrupting his/her life, Prozac won't do much alone, though psychoanalysts do use appropriate ancillary medications. A psychoanalyst is uniquely equipped to help the patient understand and deal more effectively with those unconscious forces because he/she has been psychoanalyzed and is better able to prevent his/her own personal conflicts from interfering with the patient's treatment during the development of the intense, intimate relationship between patient and analyst. Psychoanalytic practice persists because it is helpful to many patients, including some who no other treatment has been able to help.

Joseph Schachter

Training and Supervising Psychoanalyst

Pittsburgh Psychoanalytic Institute

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