Shrinks (6 page)

In the pages of this book we will encounter many psychiatric luminaries (like Nobel laureate Eric Kandel) and psychiatric frauds (like orgonomist Wilhelm Reich). But Sigmund Schlomo Freud stands in a class of his own, simultaneously psychiatry’s greatest hero and its most calamitous rogue. To my mind, this apparent contradiction perfectly captures the paradoxes inherent in any effort at developing a medicine of mental illness.

I doubt I would have become a psychiatrist if it weren’t for Freud. I encountered the Austrian physician for the first time as a teenager when I read his most celebrated work,
The Interpretation of Dreams
, in a freshman psychology course. There was something about Freud’s theory and the manner in which he communicated it that seemed to unlock the great mysteries of human nature—and resonated with my own efforts to understand myself. I thrilled to such sentences as: “The conscious mind may be compared to a fountain playing in the sun and falling back into the great subterranean pool of subconscious from which it rises.”

There’s a common phenomenon among medical students known as “intern’s syndrome”: studying the list of symptoms for some new ailment, the student realizes—lo and behold—she herself must be afflicted with diphtheria, or scabies, or multiple sclerosis. I experienced a similar reaction with my initial exposure to Freud. I began to reinterpret my behavior through Freud’s theories with a sudden rush of apparent insight. Did I argue so often with my male professors because of a repressed Oedipal conflict with my father over winning my mother’s attention? Was my room messy because I was stuck in the anal stage of psychosexual development as a consequence of my mother making me wear a diaper to nursery school?

While I may have indulged in overly elaborate interpretation of trivial behaviors, Freud did teach me the invaluable lesson that mental phenomena were not random events; they were determined by processes that could be studied, analyzed, and, ultimately, illuminated. Much about Freud and his influence on psychiatry and our society is paradoxical—revealing insights into the human mind while leading psychiatrists down a garden path of unsubstantiated theory. Most people forget that Freud was originally trained as a hard-nosed neurologist who advocated the most exacting standards of inquiry. His 1895 work
Project for a Scientific Psychology
was intended to educate physicians about how to approach psychiatric issues from a rigorous scientific perspective. He trained under the greatest neurologist of the age, Jean-Martin Charcot, and—like his mentor—Freud presumed that future scientific discoveries would clarify the underlying biological mechanisms responsible for thought and feeling. Freud even presciently diagrammed what may be one of the earliest examples of a neural network, depicting how systems of individual neurons might communicate with one another to learn and perform computations, foreshadowing the modern fields of machine learning and computational neuroscience.

While Wilhelm Reich frequently made public claims that Albert Einstein endorsed his ideas about orgonomy, in actuality, Einstein considered Reich’s ideas ludicrous and demanded that he stop using his name to market his products. But the great physicist had a very different attitude toward Freud. Einstein respected Freud’s psychological acumen enough to ask him, shortly before World War II, to explain man’s capacity for warfare, requesting that Freud “might bring the light of [his] far-reaching knowledge of man’s instinctive life to bear upon the problem.” After Freud responded with a dissertation upon the subject, Einstein publicly endorsed Freud’s views and wrote back to Freud, “I greatly admire your passion to ascertain the truth.”

Freud’s pioneering ideas on mental illness were initially sparked by his interest in hypnosis, a popular nineteenth-century treatment that originated with Franz Mesmer. Freud was captivated by the uncanny effects of hypnosis, especially the mysterious phenomenon whereby patients accessed memories that they could not recall during their normal state of awareness. This observation eventually led him to his most celebrated hypothesis: that our minds contain a hidden form of awareness that is inaccessible to our waking consciousness. According to Freud, this
unconscious
part of the mind was the mental equivalent of a hypnotist who could make you stand up or lie down without your ever realizing why you had done so.

These days we take the existence of the unconscious for granted; it strikes us as so obvious a phenomenon that it almost seems ridiculous to credit a single person with “discovering” it. We casually use terms like “unconscious intention,” “unconscious desire,” and “unconscious resistance” and tip our hat to Sigmund by referring to “Freudian slips.” Modern brain and behavioral scientists also take the unconscious as a given; they embrace the unconscious in such concepts as implicit memory, priming, subliminal perception, and blindsight. Freud called his counterintuitive theory of an unconscious mind
psychoanalytic theory
.

Freud dissected the mind into various components of consciousness. The primal
id
was the voracious source of instincts and desires; the virtuous
superego
was the voice of conscience, a psychological Jiminy Cricket proclaiming, “You can’t do that!”; the pragmatic
ego
was our everyday consciousness, called upon to mediate between the demands of the id, the admonitions of the superego, and the reality of the world outside. According to Freud, humans are only partially privy to the workings of their own minds.

Freud drew upon this novel conception of the mind to propose a new psychodynamic definition of mental illness that would shift the course of European psychiatry, then come to reign over American psychiatry. According to psychoanalytic theory, every form of mental illness could be traced to the same root cause: conflicts between different mental systems.

For example, Freud would say that if you unconsciously wished to have sex with your married boss, but consciously knew that doing so would lead to all kinds of trouble, this would produce a psychic conflict. Your conscious mind would first try to deal with the conflict through straightforward emotional control (“yes, I think my boss is attractive, but I’m mature enough to not give in to those feelings”). If that failed, your conscious mind would try to resolve the conflict using psychological sleights of hand that Freud called
defense mechanisms
, such as
sublimation
(“I think I will read some erotic stories about forbidden affairs”) or
denial
(“I don’t think my boss is attractive, what are you talking about?!”). But if this psychic clash was too intense for your defense mechanisms to manage, it might trigger hysteria, anxiety, obsessions, sexual problems, or—in extreme cases—psychosis.

Freud’s broad term for all mental disturbances caused by unresolved psychic conflicts that affected people’s emotions and behavior but did not cause them to lose touch with the reality of the external world was
neurosis
. Neurosis would become the foundational concept within psychoanalytic theory for understanding and treating mental illness—and the most influential clinical concept in American psychiatry throughout most of the twentieth century, until 1979, when the seminal revision of psychiatry’s system of diagnosis was completed and neurosis would become the subject of a climactic battle over American psychiatry’s soul.

But in the early 1900s, Freud had no tangible evidence whatsoever of the existence of the unconscious or neurosis or any of his psychoanalytical ideas; he formulated his theory entirely from inferences derived from his patients’ behaviors. This may seem unscientific, though such methods are really no different from those used by astrophysicists positing the existence of dark matter, a hypothetical form of invisible matter scattered throughout the universe. As I write this, nobody has ever observed or even detected dark matter, but cosmologists realize that they can’t make sense of the movements and structure of the observable universe without invoking some mysterious, indiscernible
stuff
quietly influencing everything we can see.

Freud also provided far more detailed and thoughtful reasoning about mental illness than had been offered as the basis for any prior psychiatric theories. In particular, he considered neurosis a neurobiological consequence of Darwinian processes of natural selection. Human mental systems evolved to support our survival as social animals living in communities where we needed to both cooperate and compete with other members of our species, Freud argued. Therefore, our mind evolved to repress certain selfish urges in order to facilitate essential cooperation. But sometimes our cooperative and competitive urges conflict with one another (if we become sexually attracted to our boss, for example). This conflict is what produces psychic discord, and if the discord is not resolved, Freud postulated, it could unbalance the natural operation of the mind and create mental illness.

Critics of Freud often wonder why sex figures so prominently in his theories, and though I agree that his overemphasis on sexual conflict was one of his most glaring mistakes, he had a rational explanation for it. Since sexual urges are essential for reproduction and contribute so heavily to an individual’s evolutionary success, Freud reasoned that they were the most potent and selfish Darwinian urges of all. So when we try to repress our sexual desires, we are going against millions of years of natural selection—thereby generating the most intense psychic conflict of all.

Freud’s observation that sexual desires can often lead to inner conflicts certainly resonates with most people’s experiences. Where he went astray, to my mind, was in presuming that because our sexual urges are so strong they must make their way into every single one of our decisions. Neuroscience, as well as casual introspection, tells us otherwise: that our desire for wealth, acceptance, friendship, recognition, competition, and ice cream are all independent and equally real impulses, not merely lust in costume. Although we may be creatures of instinct, our instincts are not solely, or even mostly, sexual.

Freud described several examples of neuroses in his celebrated case studies, including that of Dora, the pseudonym for a teenage girl who lived in Vienna. Dora was prone to “fits of coughing accompanied by a loss of voice,” particularly when talking about her father’s friend Herr K. Freud interpreted Dora’s loss of speech as a kind of neurosis he termed a “conversion reaction.” Herr K. had apparently made a sexual advance to the underage Dora, pressing himself against her. When Dora told her father about his friend’s behavior, he did not believe her. At the same time, Dora’s father was having a furtive affair with Herr K.’s wife, and Dora, who knew of their romantic liaison, thought that her father was actually encouraging her to spend more time with Herr K. as a way of giving himself greater opportunities with Herr K.’s wife.

Freud interpreted Dora’s conversion disorder as resulting from the unconscious conflict between wanting to maintain harmonious relations with her father and wanting him to believe her about his friend’s repulsive behavior. Dora’s mind, according to Freud, “converted” the desire to tell her father about his friend’s sexual aggressiveness into muteness in order to preserve her relationship with him.

Conversion disorders had been recognized for a long time before Freud gave them a name, but he was the first to offer a plausible explanation of the phenomenon—in Dora’s case, explaining her inability to talk as an attempt by her conscious mind to repress a truth about something that might make her father angry at her. While Freud’s analysis of Dora’s case becomes increasingly far-fetched and insensitive—he eventually suggests that Dora was sexually attracted to both her father and Herr K., and we can’t help but sympathize with Dora when she abruptly terminated her therapy with Freud—his core insight that certain kinds of abnormal behaviors can be traced to inner conflicts remains relevant to this day. In fact, I’ve encountered patients who seem to have stepped straight out of Freud’s casebook.

Some years ago I was asked to examine a forty-one-year-old man named Moses who worked at a neighboring community hospital. All in all, Moses’s life was fairly stable—except for the situation with his boss. Moses liked his boss, the chief of cardiology; after all, the man had promoted Moses into the comfortable position of chief division administrator. Moses felt he owed the man his loyalty since, as Moses saw it, his boss had single-handedly enabled his professional success. But at the time I started seeing him as a patient, Moses was beginning to understand the cost of this loyalty.

Moses’s boss was embroiled in an intense battle with the hospital president over financial issues. During their angry skirmishes, Moses was often called upon by his boss to review financial data and compile reports. Gradually, Moses began to piece together a troubling picture: His boss was intentionally misrepresenting the division’s finances to the president. Worse, it was becoming increasingly clear that his boss was covering up a string of deceptive and possibly illegal financial transactions.

Moses was horrified. He knew that the hospital administration would eventually discover his boss’s secret—and Moses himself would share the blame, since everyone would presume he had known about his boss’s transgression and was therefore complicit in it. He was torn between his loyalty to the man who gave him his job and the desire to behave honestly. As the confrontation between his boss and the president escalated, Moses’s anguish increased until he reached his breaking point.