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Freud is Dead, Long Live Freud!
Arguing about Causality and Change in Psychotherapy
Though there are many useful aspects to Frank Cioffi's recent, densely and technically argued, Freud and the Question of Pseudoscience, his opening chapter, the only original essay in a collection of reprints dating back to 1969, "Why Are We Still Arguing About Freud?", asks precisely the right question and one which Cioffi himself doesn't quite answer, especially as it appears he has spent a large part of his career arguing about Freud. Though Cioffi has clearly read far more copious amounts of Freud than many of the Freud-Bashers, like many of them, Cioffi can't quite seem to let Freud go and holds him responsible not just for some sort of wrong-headed psychotherapeutic approach but for influencing, indeed, a whole climate of opinion. Rather than proposing an alternate climate of opinion, or even ways to think about and help our suffering patients, Cioffi and other Freud-Bashers want more than anything else it seems to reduce the edifice of all that appears Freudian to rubble.
Freud remains a structural necessity then as a placeholder for Cioffi, the absolute negation of whom could become the catalyst for an alternate theory of mind and psychic causality. Indeed, the appearance of Cioffi's book appears timed as a negative companion volume to the controversial and initially deferred Library of Congress Freud show, touring now into the next millennium. Yet Cioffi proposes no real alternative.
It is worth noting that several of the most vituperative critics of Freud (Frederick Crews, Adolph Grunbaum, Jeffery Masson, Richard Webster, Cioffi, Popper) are not clinicians. This relationship to psychoanalysis makes it easier to criticize a text, an author, or a set of (mis?)perceptions than it is to actually wrestle with the day-to-day clinical realities that arise when trying to sit with and be helpful to a suffering patient. Patients, therapists, Freud himself, are pulled to try to make sense of what is before them, to tell a story of that suffering and how to transcend it to write a different ending. In the quest for clinical utility, patients and therapists are drawn to create myths of origins to account for the suffering they endure or bear witness to. Though he lacks this clinical dimension, Cioffi's cautions are necessary to the degree that effective therapy entails eliciting the patient's theory of change, myth of origins, and preferred view of self rather than imposing the therapists's theory of change and universal myth of origins on all patients.
Treatment must be individualized based on the patient's theory of causality and change (whether Freudian or biochemical), but treatment must be based rigorously on what we do know to be helpful to patients in treatment (Simply put, the factors which make a difference in psychotherapy are relationship, hope, and a plan, not elaborate theoretical edifices.) and directed accountably for verifiable signs of improvement.
Although endeavoring to differentiate himself a bit from Karl Popper, Cioffi, a senior Research Fellow in Philosophy at the University of Kent at Canterbury, is clearly indebted to Popper. In fact, this text, in large part due to its technical-philosophical language will be of most interest primarily to Popperian specialists and other philosophers of science. However, in this era of increasing psychotherapeutic accountability, a return to Popper and Cioffi's interests in the empirical testability and the unfalsifiability of some of the causal claims of psychoanalysis are worth revisiting.
Cioffi provides a useful refresher course in scientific method for philosophers in his examination of Freud's theories of causality. Cioffi submits that what makes Freud pseudoscientific are not his occasionally spurious claims themselves, but the inability to investigate them. Cioffi, like Popper, contends that Freud is not scientific because his causal claims are unfalsifiable, ie, nothing can count against them. As I understand the argument, this unfalsifiability undermines any possibility for the empirical testability of the causal claims for the symptoms encountered in psychoanalytic treatment. Yet Cioffi's focus on the pseudoscientific unfalsifiability of the causal claims of Freud ultimately becomes a red herring from two widely divergent perspectives - one a rigorously scientific, biopsychiatric perspective and the other derived from a closer reading of Freud himself.
Despite the tremendous advantages made by biological psychiatry in opening the body and understanding the mechanisms of illness and the pathways of treatment, we still don't really know what causes many psychiatric illnesses or their associated set of symptoms. Just because fluoxetine hydrochloride (Prozac) appears to diminish symptoms associated with depression and some anxiety and eating disorders, it does not necessarily follow that these symptoms are caused simply by an imbalance in the serotonin system. Although it is clear that many psychiatric illnesses and symptoms are part of disease processes like the way hypertension and diabetes are seen, the genetic locations and specific neuropathologies of many psychiatric illnesses have yet to be mapped.
Some things about psychotherapy that we do know scientifically are that just as psychopharmacological interventions work essentially from the bottom up (ie, if you change the biology, you may be able to change thinking, feeling, and doing), it is quite clear from imaging studies that psychotherapy works similarly from the top down (ie, if you change thinking, doing, or feeling, you can also change your biology). Seen in this way certain distinctions collapse and it may be possible to declare grandly that psychotherapy is psychopharmacology, regardless of your theory of causality.
We also know that the treatment relationship context in which psychiatric medications are prescribed (essentially the placebo effect) can affect their effectiveness. Patient X may well respond better to the same dose of Prozac prescribed by Dr. Smith than by Dr. Jones which suggests that there is more involved than simply the active ingredients of fluoxetine hydrochloride. So though we are wise to be empirical, and certainly the practice of psychotherapy could use more scientific rigor, we must also be alert to instances where empirical claims are not causal claims and where empirical claims are confounded with less empirically testable influences such as relationship and placebo.
We know from decades of outcome research that psychotherapy is exceedingly effective - as effective as pharmacological treatments in many cases. We also know that all models of therapy are equally as effective - again supporting the claim that it's not the particular theory of therapy that ultimately makes a difference, but simpler, common factors to all treatments, like relationship, hope and a plan.
Yet not all therapists are equally as effective!
This is one of the most shocking conclusions from some of the recent psychotherapy outcome research and one which should require us to recalibrate our attention from arguing about theories of causality and change, and from trying to create empirically validated treatments, to promoting empirically validated treaters.
There are effective therapists who ascribe to a wide variety of treatment models and theories, and no one psychotherapy model is necessarily more effective with one kind of diagnosis than another. Despite the claims of cognitive-behavioral therapists with anxiety disorders and EMDR practitioners with trauma survivors, it is quite clear that it is not the specific techniques as much as it is the common underlying features which contribute to positive outcome. So though Freud may offer many useful proposals to guide psychotherapy, we must not become completely enamored of the "romanticist tendency in psychotherapy...to rely upon feelings for evidence, on metaphors for reality, on inspiration and myth for guidance...(which) has been a recurrent temptation for therapists confronted by patients with perplexing problems" (McHugh PR. Psychotherapy awry. American Scholar. 63(1), 1994, p. 17).
As therapists we must look for and pay attention to the "drab facts" (ibid) which we do have available to us, facts emerging from scientific and empirical approaches, and facts which emerge as to whether our patients are getting better or not. So although causal claims may be difficult to test empirically for both Freudians and psychopharmacologists, if psychotherapy is to survive its challenges from managed care, therapists must be willing to be held accountable, demonstrate their effectiveness, and not just settle for the slide into the infinite regress of theory to explain why a particular patient is not getting better. Patient-anchored outcome measures are one way toensure that treament is proceeding in a useful direction.
We must attend to our patients' theories of change and consider that there are four central perspectives from which to view mental distress, create causal hypotheses, and direct treatment. The "Four Perspectives" as developed at the Johns Hopkins University School of Medicine include the perspectives of disease (e.g., delirium and dementia; less clearly schizophrenia and bipolar illness since there is as of now no known neuropathology), dimensions (intelligence, temperament), behaviors (addictions, anorexia), and the life story perspective (demoralization, grief). Sometimes the perspectives overlap and sometimes they don't, but they begin to allow us to appreciate aspects of resilience even in a Freudian theory.
While Cioffi identifies some useful caveats for Freudian-influenced therapists, the second major component of his straw-man argument pertains to his misreading of the entirety of Freud's theories. One of the most common and dramatic misapprehensions of Freud's thought, which Cioffi also makes, is to see Freud operating exclusively within the confines of an archaeological metaphor of causality.
Part of the overall difficulty in grappling with Freud is the sheer volume of his writing. There are 23 volumes in the Standard Edition of the Complete Psychological Works of Sigmund Freud and within these 23 volumes many central concepts are revised and reworked repeatedly. Some critics call it incoherent for Freud's work to be so unstable, others attempt to periodize it, while others see it, frankly as an effort by Freud to remain "scientific" and open to reconsideration of his theories and "discoveries." Toward the end of his career in around 1937, Freud wrote two key essays, "Analysis Terminable and Interminable" (SE23) and "Constructions in Analysis" (SE23).
In the latter essay in particular, Freud makes quite clear that a simple archaeological metaphor of causality, ie, digging around in the past to unearth a kernel of trauma which would somehow explain it all, is untenable. Although some excavation is required, psychoanalysis also requires a constructive and prospective capacity to situate the discoveries from the past in the present, and to bring them into the future with the patient in language in treatment. Essentially, a story must be constructed about the archaeological discovery, both aspects of which can be verifiable.
This poses a perennial problem for clinicians. Even if we are able to sell our theories to our patients, or if they develop their own theories regarding their past, insight alone is never enough to move a treatment forward accountably. Psychotherapy often deals with questions like this: "Well that's all well and good, and this historical truth may be more verifiable, and this other biological theory more testable than that spurious unfalsifiable narrative truth, but what do I do about it? How can I begin to use this knowledge, these theories, theses archaeological finds, to tell a different story about myself today and tomorrow and to do things differently to help alleviate my symptoms and suffering?"
Freud's attention to "Constructions in Analysis," and his concern about "Interminable" analyses unless a patient's theory of causality and change is somehow affirmed, suggest that he was worried about the infinite regress of unfalsifiability that could be elicited in psychoanalysis and who got to decide the truth - the analysand or the omniscient analysts.
Another dynamic of causality that Freud really only makes clear in his later writings is the notion of deferred action or retroactive causality. Cioffi essentially argues that Freud maintained consistently a model of causality of prospective inevitability in which a traumatic childhood, castration anxiety, Oedipal crisis etc. etc. will result in symptomatic distress. However, Freud's views were more complex and considered that not everyone who had a traumatic childhood becomes damaged goods as a result. Indeed, Freud was interested in finding the adult within at the same time he sought the inner child.
Most people who are traumatized do not become symptomatic, and most people who are symptomatic have not been traumatized. Psychotherapy must become a science of verification again and not remain simply a pseudoscience of assertion. Certainly Cioffi is right to argue against the wild psychoanalytic "genitalisation of the cultural landscape" and of many hermeneutical pleasures. In the seductive case of psychobiography, we must resist the urge to explain every adult behavior by childhood events, and certainly this was not Freud's intent. He warned against such pathographies and sought to learn from the arts and history rather than using psychoanalysis to attempt to interpret the past.
As we have seen in the clinical necessity of myths of origins, in Freud's "causal" mechanism of deferred action, a suffering patient will retroactively rediscover or create a traumatic memory or other explanation to structure their present suffering. Therefore, for Freud, a trauma isn't necessarily a trauma until later, when more contemporaneous events or sufferings require the reawakening of the earlier event, again, to act as point of origin.
Such a theory is by no means to endorse child abuse, as Jeffery Masson implies, but rather to suggest that noxious childhood events or fantasies of psychic structures do not, for Freud, always proceed in a linear, causal trajectory to create symptoms later. Freudian symptoms are "overdetermined," caused by many things in a two-stage temporal process of awakening, and they show themselves in many ways as well.
In two chapters in his book on Jeffrey Masson and Adolph Grunbaum, two other prominent critics of Freud, Cioffi nicely reveals that not all Freud-Bashers are alike. Cioffi actually offers material useful to supporters of Freud in his own distancing from the sexual politics of Masson's accusations about Freud's allegedly collusive suppression of the seduction hypothesis and Cioffi closely examines the philosophical methodology in Grunbaum's critiques
We have seen, in conclusion, that despite Cioffi's attacks on Freud's theories of causality as being not only spurious, but also pseudoscientifically unfalsifiable, causality is also a problem for even the most rigorous science, and that Freud's theories of causality are a bit more complicated than represented by Cioffi. Insofar as Freud was committed to a theory of causality it was an evolving one which was concerned as much with prospective utility in "Constructions in Analysis," and with retroactive reconstruction of cause in the mechanism of deferred action.
Ultimately, however, Freud and the Question of Pseudoscience is a collection for specialists. An interested lay reader, or someone new to the Freud wars, may be better served by reading Cioffi's essay, "The Freud Controversy: What is at Issue," in Michael Roth's excellent companion volume to the controversial but epochal Library of Congress show, Freud - Conflict and Culture: Essays on his Life, Work, and Legacy (NY: Knopf, 1998). Cioffi's essay in Roth's collection is more accessible and nicely contextualized with other critics and supporters of Freud.
Cioffi concludes that psychoanalysis is a testimonial science which rests on the credibility of Freud and his followers and not on the cogency of their arguments, especially regarding causality. For Cioffi, the question for Freud and psychoanalysis becomes, "Would you buy a used car from his man?" I suppose many still would, but in this era of accountability, most would want some sort of extended warranty regarding the utility of the treatment, and Freud himself might even be willing to consider it nowadays.
Daniel Buccino is student coordinator in the Community Psychiatry Program at the Johns Hopkins Bayview Medical Center and he maintains a private practice in Baltimore. He is Co-Founder and Co-Director of the Baltimore-Washington Brief Therapy Institute and he is on the faculties of the Johns Hopkins University School of Medicine and the Smith College and University of Maryland Schools for Social Work.