The Idea That Wouldn't Die

Gary Shteyngart has written three best-selling novels and been hailed by critics as one of today's most gifted young authors. But ask Shteyngart about his life a decade ago and he sums it up in two words: "major dysfunction."

Shteyngart was just 7 when his parents transplanted themselves from Leningrad (now St. Petersburg) to New York City. Theirs was the ever-better immigrant experience. Gary's was not. Quiet, frail, frequently bedridden with asthma, Shteyngart was sent to a Hebrew school where he was incessantly teased about his wardrobe (he had two shirts), his heavy accent, and his preference for Russian food. He had few friends, frequently worried about dying, and felt neither Russian nor American.

cigar wired for analysis
Stephen Lewis

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The isolation and alienation followed him to college in the midwest and back to New York, where he worked for tiny nonprofit organizations. Although Shteyngart was spending hours a day writing, he had a paralyzing fear of sharing his work with publishers. (His wildly comic first novel, The Russian Debutante's Handbook, was published only after he sent a portion of the manuscript to a fellow immigrant, who ran an MFA program in writing in New York; Shteyngart thought he was applying to the program, but his bowled-over friend sent the manuscript to his own publisher.) A series of "disastrous relationships" with women only fed his feelings of being a "second-class citizen."

And so Shteyngart, still in his 20s, embarked on a course of psychoanalysis. Although he was often depressed, there were no specific symptoms he sought to address. "I felt that my entire personality needed to be entirely re-examined and, when necessary, changed," Shteyngart says. "Other forms of therapy do not explore and rewire the personality to the same extent."

What attracted Shteyngart to psychoanalysis is precisely what has for more than a century made it fodder for impassioned, and often ugly, debate.

It is time-intensive and prohibitively expensive. Its benefits are not easy to measure, particularly compared with those promised by more popular, contemporary methods of treatment like cognitive behavioral therapy (CBT). As a result, psychoanalysis has been dropped from the curriculum of many medical schools and is rarely covered by insurance plans. When it is taught and practiced, experts say, modern psychoanalysis, also called psychodynamic psychotherapy, often bears little resemblance to the treatment put forward by its founding father, Sigmund Freud.

But psychoanalysis is a profound exploration of human subjectivity—our inner world with all its memories and desires and impulses—and its relation to the external, objective world. And it is much more than a treatment. It's also a set of theories about the nature of human experience, its depth and complexity. "Analysis is the most elaborate and nuanced view of the mind that we have," Nobel-winning neuroscientist Eric Kandel recently told a meeting of the American Psychoana-lytic Association.

At its center is the belief that subjectivity matters, that regardless of how many millions of circuits science shows are carrying out the work of the brain without our awareness, we still experience a unified sense of self that gives our lives coherence and meaning. In this regard, experts argue, psychoanalysis, which celebrates its hundredth anniversary in America this year, is very much alive.

"Psychoanalysis reflects decades and decades of thinking about and pondering on the nature of the human mind," says Peter Fonagy, Freud chair in psychiatry at University College London and director of the London-based Anna Freud Center. "We've identified the core constructs within psychoanalysis as a theory"—the nature of consciousness, the role of early childhood in shaping understanding and behavior, the effect of unconscious processes on everyday life, to name a few—"and shown that they continue to advance our understanding of the human mind. In this sense, I think psychoanalysis is in the best shape it's ever been in."

Fonagy and other long-time psychoanalysts credit the staying power of psychoanalysis in part to a culture shift among their colleagues. For most of the 20th century, psychoanalysis became a guru science, driven by cults of personality around Freud and other dominant figures rather than by scientific investigation.

Many analysts were spinning out theories about the mind without gathering evidence to support them—say, the idea that all our thoughts and actions are driven by only two basic motives, sex and aggression—and doing little to disseminate them outside their own exclusive circles. One result was the creation of factions and intense infighting within them over details that had no currency in the wider world of psychiatry.

"There were prejudices built into psychoanalysis that really hurt it," says Mark Solms, head of neuropsychology at the University of Cape Town, South Africa, and a practicing psychoanalyst. "Many psychoanalysts felt they didn't want to reduce what they did to numbers, that their work was about the soul. So when other sciences were advancing with research, psychoanalysis didn't. They essentially shut their eyes and said 'we don't do that.' And that only reinforced the caricature" of a field that was old-fashioned, spoke largely to itself, and was obsessed with sex.

The shift of mainstream psychiatry to psychotropic medication and the development of short-term therapies—beginning in the late 1950s and accelerating through the 1990s—eventually jolted psychoanalysts into the realization that they had to subject their grand theories to rigorous testing. Today, scientists are working to build a body of empirical research to support the efficacy of psychoanalysis, a tough task for a treatment that often takes years and hundreds of sessions.

Unlike its therapeutic rival CBT, psychoanalysis does not lend itself to easy-to-measure evidence like the speedy elimination of symptoms. But a growing body of research—including neuroscientific interest in the nature of consciousness—has helped bring psychoanalysis to a new place at the psychiatric table.

Jonathan Shedler, an associate professor of psychiatry at the University of Colorado School of Science, has examined the efficacy of psychodynamic therapy—a term describing treatment based on psychoanalytic theory and methods but briefer and less intensive—for everything from depression and anxiety to panic disorders, personality disorders, and substance abuse. He has found that the benefits of psychodynamic therapy extend well beyond symptom relief.

"The benefits of newer therapies often start to decay after treatment ends," Shedler contends. "Studies of psycho-dynamic therapies show that people not only look much better in terms of symptom relief, personality functioning, and social functioning after treatment, but they stay better. What's more, they display continued improvement."

Insights gained in analysis appear to beget psychological skills that grow stronger with use; patients are able to think and reflect more productively, says Shedler. Among patients with borderline personality disorder—a condition notoriously resistant to treatment—only 13 percent still met the diagnostic criteria for the disorder five years after completing psycho-dynamic therapy compared with 87 percent who underwent other forms of treatment.

To those familiar with traditional psychoanalysis, there's no small irony in the idea that it has lacked the science to support it. Before he invented psychoanalysis, Freud was a neuroscientist, and while he didn't have available to him the technology to explore the brain, he believed his theories about the mind had to be rooted in biology. "Freud recognized that you need to bring the subjective side of nature into science," says Solms, a pioneer in the field of neuropsychology.

Today, however, science provides technology to explore some of the most fundamental questions posed by psychoanalysis, such as the very structure of the psyche. And while there is still a large gap between what brain scans reveal and what happens in treatment, the research is proving the validity of many tenets of psychoanalysis, both theory and treatment.

Through the use of functional magnetic resonance imaging, for example, neuroscientists have found that many operations of the psyche take place in widely disbursed neural circuits. Specifically, such mental functions as passion, reason, and conscience are activated in different areas of the brain. The finding supports Freud's contention that the psyche can be differentiated into id, ego, and superego.

"We've confirmed one of the central premises of psychoanalysis," says Shedler. "That is, we have different brain structures that operate at the same time but respond in very different ways to information. One result is that the mind is often in conflict, and we experience contradictory motives."

Shedler points to the basal ganglia, situated at the base of the forebrain and driven by rapid emotions, and the prefrontal cortex, which houses our capacity for logic and reasoning. When both are active, we might experience a deep visceral fear, even though we're not aware of any imminent danger. Or we might feel the desire for an intimate relationship while at the same time fearing intimacy.

Neuroscience has also confirmed another fundamental tenet of psychoanalytic theory—the idea that our motivations are largely unconscious, and that our brains have active repressive mechanisms that protect us from disturbing thoughts and impulses. "Neuroscience tells us unambiguously that consciousness really is just the tip of the iceberg," says Shedler.

Ask a psychoanalyst which theories have proven most enduring over a century of research, science, and clinical practice, and you're likely to hear it's the theory of the unconscious. Freud put forth the idea that there are three levels of consciousness: the conscious part of the mind of which we are aware and about which we can verbalize; the preconscious, consisting of all the memories and thoughts that, with effort, can be brought into conscious awareness; and the unconscious, the part of the mind that is not accessible to us and which houses some of the most intense urges, feelings, and desires that drive us.

"We now know that most of the mind is unconscious, and that it's complex," says Robert Michels, a university professor of medicine and psychiatry at Cornell University, formerly dean of its medical school, and supervising psychoanalyst at Columbia University. "That's the basic stance of psychoanalysis, and it's absolutely spot-on."

Psychoanalysis has special relevance in today's wired world, contends Todd Essig, a training and supervising psychoanalyst at the William Alanson White Institute in New York. We're not humanly equipped to shut out the technologies of connection offering us a steady stream of distraction and providing constant feedback and reinforcement.

Technology is not going away, says Essig, but it can leave us feeling distracted, overstimulated, hollowed out, and alienated. "Psychoanalysis is one way to recapture the important piece of life that is being leached out of our experience. While technology compels us to live in a constant present, psychoanalysis connects us with memory, the past, and desire, what we want next. It stretches the existential muscles that are atrophying when we spend too much time with our Blackberries." For Essig, the corrective to passing our days in the ever-connected moment is not less technology but more life, including more inner life.

Essig points to one of his patients, a music industry hipster, who begins and ends each session by making a show of checking his iPhone for messages and offering up a report on his latest Twitter followers. At first, Essig thought that the patient's ritual of checking was a show of importance. But by exploring the patient's need to be constantly connected, he understood the man was letting him know he was releasing himself from being trapped in the present tense of stimulation to enter a more reflective state.

Dreams are another domain in which ongoing research supports many ideas that originated in psychoanalytic theory. For sure, modern scientific studies of the brain have led to some contradictory theories about dreaming—that dreams mean little, that dreams mean something (if only we could figure out what), that they represent strategies of rehearsal for events that matter, and much more.

In the 1960s and '70s, scientists learned that dreams occur involuntarily but regularly—about five or six times, of increasing duration, throughout the night—while the brain is aroused physiologically but the body is immobilized physically. The discovery of dream sleep, distinguished by the presence of rapid eye movements, contributed to the discrediting of psychoanalysis. Dreams, it seemed clear, were the product of a revved-up brain—not, as Freud believed, a reflection of hidden or frustrated desires, especially those of a sexual or aggressive nature.

But studies conducted in the 1990s, using imaging technology to examine neural activity in the dreaming brain, corroborate some ideas Freud laid out in The Interpretation of Dreams. During dream states, certain circuits of the brain—notably those based in rational thought and reality—are inactive. The neural circuits that remain active while we dream, however, are those governing emotions, sensations, and memories. While much remains to be discovered about the dreaming brain, the neuroscientific evidence suggests that there's a close link between the content of our dreams and our deepest instinctual drives.

"Dreams are not froth," says Solms. "They're a valid mental construction under which lies the core of what we really want out of life." What Freud observed makes sense, he adds: "If you take it as fact that we have this desire system in our brains that drives our dreams, then there's every reason to believe that if you explore your dreams you can learn something valuable about yourself."

While contemporary psychoanalysts interpret the desires underlying dreams much more broadly and far less rigidly than earlier generations did, they still borrow early techniques in analyzing dreams. They ask patients to recall their dreams in detail and say whatever comes to mind as they do. Solms notes that by taking the time to recall the content of a dream, it's the patient—not the analyst—who almost always discovers the desire that underlies it.

"We don't say 'Mr. or Mrs. Jones, your dream means this,'" Solms says. "Instead, patients figure it out themselves. When you take the time to deconstruct a dream, it just makes sense."

Why bother to make sense of dreams—particularly those that seem too fantastical or bizarre to have any obvious value? Precisely because dreams are vivid, uncensored representations of our desires and fears, they can be a window into what we really want out of life, Solms insists.

Another theory that vies for a spot among the most enduring legacies of psychoanalysis concerns the importance of experiences in early childhood. The understanding that our past influences who we are today, and especially that the first few years of childhood have a profound influence on all our development, informs almost all types of contemporary therapy.

It might sound obvious, but the view that early development creates an enduring template that stamps behavior and feelings throughout life can be credited to classic psychoanalysis. Researchers now know that early experiences of care literally shape the developing nervous system and play out in the nature and quality of emotional attachments we form decades later. Neuroscience has shown that personal experience is so powerful it even influences whether or not specific genes get expressed, including those determining responsiveness of nerve cells to various neurohormones.

Encouraging adults to talk about their early life and relationships, particularly with caregivers, can provide tremendous insight into current psychological problems, says Peter Fonagy. "This, to me, is the great triumph of the last century of psychoanalysis," he adds. "It can completely alter people's experience of culture and childhood."

Exploring our personal narrative—the modus operandi of psychoanalysis, the therapy—helps us to understand why we do what we do. Finding meaning in certain behaviors (which help or harm us) is a valuable step in summoning the wherewithal to change them.

Of course, no conversation about psychoanalysis is complete without discussion of transference. Freud defined it as an unconscious phenomenon that influences the relationship between patient and therapist, occurring when a patient shifts onto a therapist feelings about family or friends experienced earlier in life.

But the idea has since grown into a more general theory of behavior. Without being aware of doing so, we all constantly transfer feelings about significant figures in our lives onto those with whom we currently interact. It seems to be one of the mind's prevailing heuristics.

"Transference can cause a tremendous amount of suffering," says Glen Gabbard, professor of psychiatry and psychoanalysis at Baylor College of Medicine and director of the Baylor Psychiatry Clinic. "It's like having a movie projector in your head that plays out the relationship you had with someone in your past onto the face of someone else. This can lead you to assume someone is thinking something they are not or to expect them to act in specific ways."

In psychoanalysis, exploring the emotions at play between patient and therapist remains central to successful treatment, Gabbard points out. Identifying patterns within the therapeutic relationship helps patients identify the dynamics of self-defeating relationships outside of treatment and gives them the skills to change such patterns.

Despite the enduring value of some key psychoanalytic concepts, psychoanalysis has no shortage of hurdles to overcome if it is to remain a viable therapeutic option. Chief among them is health insurance. The vast majority of insurance companies do not cover the cost of psychoanalysis—practitioners often recommend a course of three or more sessions a week to keep the process intense and deep and to maintain access to core problems—relegating it to those who can afford upwards of $150 an hour or who are able to negotiate a lower fee with their analyst.

Then there's time; most working professionals don't have several hours a week to devote to therapy. Finally, there's the tantalizing promise of relief that other, shorter forms of the therapy offer, to say nothing of the ease of pharmaceutical bliss, for the speedy elimination of distressing symptoms.

But those who remain at the forefront of psychoanalysis are not sounding any alarm bells just yet. They contend that the complexity of the mind assures that no single perspective can capture the whole truth of the human experience. And there will always be a place for psychoanalysis. It might remain beleaguered as a treatment, but it will always offer value in making sense of the messy reality of mental life.

"Maybe we will lose psychoanalysis as a traditional institution," Fonagy says. "If that happens, I'd say good-bye and good riddance. As long as the core tenets of psychoanalysis remain, that's all that matters. And I am confident they will."

Not Your Parents' Psychoanalysis

If there's one fact about psychoanalysis that practitioners wish could permeate the national conscious, it's this: The methods of most modern day psychoanalysts have evolved significantly since the time of Sigmund Freud.

Despite the prevailing caricatures, psychoanalysis today is not all about sex. And you can be quite certain you don't have an Oedipal complex or penis envy. Nor is your shrink likely to light up a cigar and wait expectantly as you lie on a stiff couch and struggle for something to say.

Psychodynamic psychotherapy, as it's known today, takes a much less doctrinaire approach to treatment than it once did. "Psychoanalytic therapists are warm, interested, and curious to find out about the causes of a person's suffering," says Nancy McWilliams, a visiting professor at Rutgers University's Graduate School of Applied and Professional Psychology. "People come to therapists for very complex emotional experiences that do not usually translate into categories, and I think the best language we have for addressing them is still that of psychoanalysis."

McWilliams adds: "At its core, psychoanalysis is an openness to another human's experience. It can suit almost anybody."

Take the case of David Weiss. A New York-based writer who covers the music industry, Weiss says his interest in psychoanalysis grew out of a "classic combination of issues" including sex, substances, and his mother. Weiss, 38, says he was fortunate to find an analyst who made analysis affordable for him.

Including travel time, Weiss dedicates approximately 16 hours a month to psychoanalysis, an experience he chronicles in his PT blog, Mr. Analysand. Weiss considers his analyst contemporary in many ways. She does not consign him to a couch (although he once decided to try it out and found reclining to be too isolating and that he much preferred looking his analyst in the eye). She is not silent or dispassionate, and sometimes talks for an entire session. What's more, Weiss says his analyst is young, friendly, and listens to him in "a highly-trained, special way."

"There are aspects of psychoanalysis that are immovable," says Peter Fonagy, Freud chair in psychiatry at University College London and director of the London-based Anna Freud Center. "But there are also many aspects that can be played with. We are not all rigid in the way we treat people; we work with people to find a method that works for them."

Some contemporary analysts sit directly facing their patients, instead of perching outside the patient's line of vision. Today's psychoanalysts do not use silence to encourage patients to freely associate, and they do make suggestions to patients, ones that are neutral, but potentially helpful—such as pointing out when a patient is actively avoiding a topic that might be distressing. And while many psychoanalysts prefer to see patients several times a week to maintain the intensity that is a hallmark of their approach, there are no rules as to what schedule constitutes successful treatment.

"If you've been stuck in the same place in life for a while and can't get out, then treatment might require more time and deeper scrutiny," Fonagy suggests. "But if a psychoanalyst tried to persuade you that you need five-times-a-week analysis for five years, you should run a mile."

And whether or not they are willing to admit it, many contemporary psychoanalysts borrow from an array of therapies, including cognitive behavioral therapy, and vice versa.

"Psychoanalysts are coming around to the idea that you don't always have to get to the navel of the problem to solve it," says Fonagy. "Some people can be helped without having to dig up the entire root."

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