Robert Winer, M.D.

Main | January 2007 »

Freud and the Provision of Care

Pop culture has given Freud and his followers a bad rap, either declaring them passé or just dead wrong. The movement in clinical practice has been toward medication, short term treatment, cognitive-behavioral therapy, goal-focused work, and the like. Health insurance companies, facing spiraling overall medical costs, have seen psychiatric treatment as a place they can save money (even though psychiatric costs are at best a couple percent of the total national health bill). They can do this because psychiatric patients, valuing their privacy, are less likely to complain. So quick fixes fit their bill, and they implicitly blame patients for failing to recover.

The problem is that when wounds have been decades in the making, they can’t be patched up overnight, and these bandages don’t cure anything.

The real heart of Freud’s psychology isn’t his ideas about infantile sexuality, penis envy, the analyst as a blank screen, his thoughts about gender, and the like. The core Freudian ideas, which are at the heart of most modern psychotherapeutic work, are these:

- We do things for a reason, our actions aren’t random.

- The reasons that especially get us in trouble are the ones we’re not aware of.

- Our unawareness isn’t a matter of being oblivious – it comes from our need to keep our motives hidden from ourselves because they’re unacceptable or shameful.

- “The past isn’t dead,” as William Faulkner famously said, “It isn’t even past.” We are powerfully shaped by our early experiences, and those ways of coping control our lives, even as they’ve outlived their relevance or usefulness.

- We are at war within ourselves, pulled in opposing directions. We want to make contact, for example, but we also want to protect ourselves from being hurt again.

- However we are leading our lives, however ineffective that might seem to be from an objective perspective, is the way that we truly believe is safest for us. (The abusive marriage, for example, feels less terrifying than being alone. The consequences of drinking are more tolerable than the pain the drinking covers. And so on.)

This is what’s at the center of a Freudian approach: discovering the compelling reasons for acting the ways we do, and thus creating the possibility of choice. And this takes time. Psychoanalysis is not really about the couch or the analyst’s caricatured vow of silence. I’ve thought that the single greatest value of a sustained treatment is not the confessions made, the feeling of having been understood, the experience of having been loved, the life events reconstructed, the enactments deconstructed, the interpretations made – although all of these can be useful. The greatest value, I now think, is the experience of an intense unforgiving struggle with another person toward meaning. That seems far more important to me than the particular theoretical framework that the analyst favors. It’s what Roger Angell said in The New Yorker about baseball – that baseball is all about dailyness, picking up your glove and bat yet again and going out to give it your all, on days when you feel great and on days when you’re hung over, knowing that the difference between the guy hitting .330 and the guy batting .230 is just one more hit out of every ten at-bats, and going out and doing your best anyway. Doing analysis is dailyness for two.