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Vladimir Nabokov notoriously dismissed the “vulgar, shabby, and fundamentally medieval world” of the ideas of Sigmund Freud, whom he called “the Viennese witch doctor”. His negative judgment has been shared by many in the near 90 years since Freud’s death. A reputational high-water mark in the postwar period was followed by a collapse, at least in scientific circles, but there are signs of newfound respectability for his ideas, including among those who once rejected him outright. Mark Solms’s latest book, a wide-ranging and engrossing defence of Freud as a scientist and a healer, is a striking contribution to the re-evaluation of a thinker whom WH Auden described as “no more a person now but a whole climate of opinion”.
It would be difficult to improve on Solms’s credentials for the task he sets himself. He is a neuroscientist, expert in the neuropsychology of dreams, the author of several books on the relationship between brain and consciousness, a practising psychoanalyst and the editor of the 24-volume revised standard edition of Freud’s complete works. He is also a wonderfully witty and lucid writer.
I read The Only Cure through the lens of its bold – perhaps too bold – title. It contains two claims. First, that psychoanalysis is a cure in the sense that its benefits are lasting and may continue after treatment has been completed. Second, it is the only cure since rival treatments – notably drugs – may lose their effect when they are discontinued because they do not address underlying causes. Solms cites overviews of clinical trials that he believes support these claims. The story he tells seems extremely encouraging – unless, like me, you are obsessional enough to read the papers to which he refers.
Solms opens his defence by citing a review that lumps together psychological, educational and behavioural treatments. It is not clear how this makes the case for the specific benefits of psychoanalysis. Moreover, a response to this review from an equally impressive source deems the various therapies no more effective than a placebo.
When Solms homes in on the evidence for what he calls “good old-fashioned psychoanalysis”, he cites the positive findings of an authoritative systematic overview, but omits reference to the final lines of the paper, which warns against drawing hasty conclusions and calls for “larger studies of higher quality”. A more recent systematic review published in the Lancet Psychiatry was similarly cautious. Admittedly, the treatment schedule was brief. More relevant, perhaps, is an examination of the effectiveness of long-term psychoanalytic therapy (at least 50 sessions over a year). This seems to show clear benefit, but again the authors counsel caution “given the low quality of available evidence”.
In fairness, researchers in this area face daunting problems. Gold-standard clinical trials are double-blind (meaning neither the patient nor the doctor knows what treatment the patient is receiving until the end of the study); incorporate an appropriate alternative against which to measure the effect of the treatment being tested; require a well-defined, even homogeneous, patient population; have objective, quantifiable measures of outcome, and control for other relevant variables. These criteria cannot be met for psychotherapies.
The jury is still out, therefore, as to whether psychoanalysis is a cure, never mind the only cure. At best one can conclude it is as effective as other psychological treatments such as cognitive behavioural therapy, which are, however, less labour intensive.
Near the end of his life, Freud reflected that better therapies than psychoanalysis might be discovered when we understood more about how the brain worked. Has this hope been fulfilled? Here we might look to drugs such as antidepressants, anxiolytics, and anti-psychotics. Solms accepts that these can complement or supplement psychotherapies, but argues that, since they do not address the fundamental causes of mental health conditions, they are palliative, not curative. He compares prescribing drugs to employing painkillers rather than surgery to treat angina due to a blocked coronary artery.
That said, Solms does not dismiss neuroscientific understanding of mental illnesses. This would anyway conflict with his fascinating and laudatory account of the early Freud as a serious contributor to neuroscience, and Freud’s belief that there would ultimately be a convergence between functional models of the mind and physiological ones. In highlighting Freud-the-neuroscientist, Solms distances him from the image of a quack whose theoretical claims were unscientific, not least because, as Karl Popper argued, they were unfalsifiable. This charge underlies the much-quoted joke about the patient who protested to Freud that his dreams were often horrible, disproving the psychoanalytic dogma that dreams are wish fulfilment. To this, Freud responded that horrible dreams fulfil a patient’s wish to upset his therapist.
Solms rejects much Freudian orthodoxy, loosening some of the connections between the more notorious and vulnerable theoretical underpinnings of psychoanalysis and its clinical application. “We don’t need to rehabilitate every thought Freud had,” he writes. Articles of faith such as the sexual basis of all pleasures, the death drive, penis envy and the id are discarded. He also deals sceptically with the carnival of characters – among them shrink from hell Jacques Lacan – who developed their own eccentric versions of psychoanalysis.
Nevertheless, Freud’s central insight is retained: the longstanding and profound effects of early-life experiences. These are more powerful for being buried. In modern society, an individual’s emotional needs may go unmet for long periods of time, meaning “we can spend our lives under the intoxicating influence of contextually inappropriate emotions”. Solms illustrates this with deeply moving case histories of patients who have been prisoners of unresolved issues from their past, as well as an account of his own psychoanalysis. These cases show that at the heart of psychoanalytic practice is an empathy that enables patients to detoxify their experiences by being allowed to speak about them to a sympathetic and intelligent listener. His description of psychoanalysis as “a re-parenting process” captures its humanity.
One particularly compelling story opens and closes the book. Teddy P is a doctor whose professional and personal life disintegrate after his mother’s sudden death. Overwhelming depression, memory loss, sleep disturbance, episodic unconsciousness, headaches, muscle pains and so on attract various diagnoses, which prompt a range of ineffective treatments whose side effects add to his woes. Over four years of therapy, Solms helps Teddy P to exhume his loveless early life and the subsequent inward deflection of aggressive impulses originally felt towards his emotionally unavailable mother. We learn of his ultimate recovery, leading to a happy marriage and work life.
The extrapolation from successful cases to a defence of the psychoanalytic approach reminded me of the aphorism “data is not the plural of anecdote”. And Solms’s claim to be able to synthesise “the best of modern neuroscience” with “the core insights of psychoanalysis” remains a promissory note.
Notwithstanding lingering doubts about the evidence for the unique clinical efficacy of his cure, Solms has nudged the attitude of this sceptic towards Freudian (or Freudian-inspired) psychoanalysis from scorn to agnosticism. I am prepared to recognise its clinical role, though further research would be welcome. What it delivers in practice will, of course, depend on the personal qualities – above all the acumen and integrity – of the therapist.
Professor Raymond Tallis is a clinical neuroscientist and philosopher.
