WHAT WENT WRONG WITH PSYCHOANALYSIS AND HOW TO SET IT RIGHT

Although Freudian psychoanalysis dominated the practice and training of psychiatrists in the first part of the 20th century, it gradually fell from grace and became marginalized by the beginning of the 21st.

In retrospect, the reasons were obvious. Many Freudians were rigid, narrow, arrogant and blind. They undertreated some patients, over-treated many and mistreated a few. Psychoanalytic papers tended to be commentaries on the commentaries of Sigmund Freud and the neo-Freudians. Many of Freud's techniques were followed slavishly and shamelessly. Analysts were too often ghostly silent blank screens and bland personalities. Many analysands had no choice but to accept minimally guided self-analyses at steep fees.

Many analyses took decades and cost fortunes. Analysts priced themselves out of the medical market and mostly treated the wealthy. For a long time medications were eschewed and pertinent facts provided by friends and relatives were avoided. In many cases, serious brain disorders were given the talking-cure, while they got progressively worse.

This is not to say that many patients did not get excellent treatment and did very well. That was when the diagnosis was correct and analysis or dynamic psychotherapy was indeed the treatment of choice. Now we know that psychoanalysis or psychoanalytic psychotherapy was NOT the treatment of choice for most schizophrenics, bipolars and those with obsessive-compulsive disorder. Still, there were a few analytic psychiatrists who were comfortable and particularly effective prescribing drugs and continuing psychotherapy in cases where combined treatment was indicated. Unfortunately, this became the exception, rather than the rule.

Psychiatric training centers gradually marginalized the teaching of dynamic psychotherapy and concentrated more and more on brain disease and pharmacologic theory and therapy. That's where the money was. At least in the short term, quicker results led to a false confidence, based on so-called controlled studies of newer psychotropics promoted by the powerful pharmaceutical industry.

The pendulum must swing the other way now that the need for dynamic psychotherapy is again becoming clear. The few dynamic psychiatrists and psychoanalysts who remain need to become more numerous and active in departments of psychiatry, if young psychiatrists are to be taught right; that is, to become more balanced and effective.

Studies continue to show the benefit to patients of a combination of medications and dynamic psychotherapy, especially in ongoing relationships with trusted therapists. As in the rest of medicine, accurate diagnosis and ongoing aftercare are the twin keys to effective treatment. When the pendulum swings back to the center what remains will be a more balanced and effective treatment for psychiatric patients and psychiatry can resume its place as a respected member of the medical profession.

Victor Bloom, M.D.

1007 Three Mile Drive

Grosse Pointe MI 48230

313-882-8640

Clinical Associate Professor

Department of Psychiatry

Wayne State University

School of Medicine