Once they were the last word in chic, their concepts -- translated into popular phrases like "Freudian slip," "phallic symbol" and "guilt complex" -- dropping casually from the lips of the au courant sophisticate. Until World War II, these psychoanalysts were, for the mentally ill, the only game in town.
But in the 47 years since founder Sigmund Freud's death, discoveries about the brain have changed the approach to treating some mental illness. Diseases such as schizophrenia and manic depression have been shown to be mostly biological, often genetic, and more usefully treated by a combination of drugs along with less intense psychotherapy. As a result they have been removed from the purview of analysis alone.
Today there are about 3,000 American psychoanalysts, who rely on classic Freudian methods, compared with about 35,000 psychiatrists, who use a broader range of therapeutic approaches.
Despite the evolution of the science of the mind, the basic goal of the modern psychoanalyst remains the same: To unravel the secrets of what makes a human being a human being and, in doing so, to ease psychic pain, especially the kind that evolves from glitches along the developmental path.
And if some of Freud's thoughts and principles do not hold up in the light of modern knowledge, or have been superseded by cultural changes in, say, the role of women, well then, the analysts will remind you, Freud himself modified his own theories again and again during his remarkable life.
Moreover, in recent years, even his own most orthodox followers have clarified, enhanced, amended and, in some cases, discarded elements of his revolutionary series of discoveries and hypotheses about how the human mind develops, how it is structured and what can be done to lift the repressed agony that blocks so many men and women from fulfilling the potential of their lives.
This month marks the 75th anniversary of the American Psychoanalytical Association, an organization that has had an immeasurable impact on the treatment of the mentally ill, on the training of psychiatrists and psychologists, on, in fact, virtually every field of mental health that has developed in the past three quarters of a century.
Before Freud and the psychoanalysts, the mentally ill were sent to snake pits. So-called "psychiatrists" in those days were little more than keepers of inmates at mental hospitals. There were no treatments, therapies, knowledge about causes. There was little hope.
At their anniversary meeting here earlier this month -- and at the concurrent 30th anniversary of one of its spinoffs, the American Academy of Psychoanalysis -- the analysts looked back over the years. And they looked across the city at a meeting of some 15,000 psychiatrists at the annual meeting of the American Psychiatric Association. Many of the analysts are also practicing psychiatrists and belong to both groups. Many of the psychiatrists were trained in analytic techniques. Although most psychoanalysts train as psychiatrists first, there is a burgeoning population of non-medically trained analysts from related mental health fields such as psychology and social work.
To understand the field in 1986, "You must distinguish psychoanalysis as a treatment from psychoanalysis as a body of knowledge," says Dr. Gertrude Ticho, a practicing analyst who also teaches a course in psychiatric diagnosis at the George Washington University Medical Center.
"In the early days, psychoanalysis as a treatment method was a little bit oversold," Ticho says. "We have studied and learned over the past 40 years that psychoanalysis is -- for a certain group of psychological problems, not to say mental disorders -- the best and most proficient treatment. But for a host of other patients, it is not.
"And that we have learned the hard way, because in the beginning there was nothing else."
Psychoanalysis as a body of knowledge -- the insights into the mind first formulated by Freud -- "is going to be developed further," said her husband, psychoanalyst Ernst Ticho. "But the basics will probably, certainly in one form or another, stay forever."
Gertrude and Ernst Ticho are Viennese-trained analysts who met first in Vienna about 40 years ago, and again in the 1950s at the Menninger Clinic in Topeka, Kan., where they married and spent 20 years studying, practicing and watching their chosen field change. Both now help guide analysts-in-training at the Washington Institute of Psychoanalysis.
Said Ernst Ticho: "I still remember the time 40 years ago in Vienna when a manic depressive patient was introduced into a course on 'Introduction to Psychiatry.' It was a large group of hundreds and hundreds of people -- all laughing wildly at the patient . This is something we don't understand anymore, the indignity versus the way the patient is regarded now."
Sitting in the spacious consultation room in their Northwest Washington home/office, at a small table, across the dimly lit room from their spare Swedish-modern leather couch, the Tichos appear to enjoy both their work and each other. They laugh easily and often. As they speak enthusiastically about their profession, each one frequently picks up the other's thoughts -- one sometimes finishing the other's sentence or adding to a concept.
"To a high degree, psychoanalysis accomplished something that people in our field today take more or less for granted -- respect for the mentally disturbed patient," said Gertrude Ticho. "When I began my training, the patient wasn't listened to. He wasn't taken seriously. He wasn't dealt with. He was locked up or shocked and that was it.
"Finally we had psychoanalysis, something with which we could approach these patients like human beings."
"Then, when drugs were introduced," said Ernst Ticho, "it was quite clear that for some very disturbed patients, for schizophrenic patients, the drugs worked better." In many major mental disorders, the Tichos believe, a combination of drugs and psychotherapy is the best treatment. Yet "at the present time, psychoanalysis is still by far not only the best, but really the only way to really understand the psyche and the mind."
"There is so much we do not know about how the mind functions," said Washington psychoanalyist Dr. Stefan Pasternack, who illustrates the problem with a metaphor he learned from one of his professors at the University of Cincinnati. The teacher, Pasternack recalled, was "an old erudite neurologist. He would say: 'Imagine a society that has never seen a book, and book washes up on the shore. Now the biologists show you how it fits together. The biochemists tell you that it's made of a cellulose impregnated with carbon particles. And the physiologists tell you something else. But but no one can read the damn thing.'
"That," said Pasternack, "is our state of knowledge about the mind."
Pasternack has a private psychiatric and psychoanalytic practice, is a clinical professor of psychiatry at Georgetown University Medical Center and teaches budding analysts at the Baltimore-District of Columbia Institute for Psychoanalysis. He has made a personal campaign of refurbishing the public image of psychoanalysis. This image, he said, has been tarnished by decades of misinterpretation by a public titillated with its sexual underpinnings and by biologically oriented psychiatrists and psychopharmacologists who came more and more to believe that all mental ills are biologically or genetically rooted. Freud himself is often perceived as sexist, with his concept of "penis envy" cited as the proof.
Then, the development of a myriad of so-called "talk" therapies -- a recent Science 86 article put their number at more than 250 -- has given rise to a certain public disdain for the long and intensive commitment required for psychoanalysis. Total therapy time is estimated in the neighborhood of 1,000 hours -- in hour-long sessions (actually 50 minutes, or now even 45) four days a week for five, six or seven years, or more. The total cost could range from as little as $5,000 to more than $100,000.
Finally, and not least, most psychoanalysts, and many psychoanalytically trained psychiatrists, are reluctant to speak publicly about their actual practice for fear of damaging the fragile, all-important relationship with their patients, which is marked by the vital concept of transference.
"Transference is the distortion of the relationship with the therapist by unconscious forces usually from early development," said psychiatrist Samuel Shem. He is referring to the need of people to fall in love with or learn to hate or somehow become emotionally engaged with their analyst -- as a stand-in for an authority figure out of the past.
"And what you have to admire Freud and the analysts for," says Shem, "is that they don't turn away from it. They face into it. When the therapist remains clear enough and present enough in a way, the distortions become obvious. And when they become obvious, healing can occur."
"Transference is probably Freud's most important contribution," says Shem, author of "The House of God" and "Fine," a fictional satire on psychoanalytic training. To protect his relationship with patients, he writes under the name Shem and does not disclose his real name.
"People," said psychoanalyst Pasternack, "have the image of the uncaring, silent, judgmental analyst sitting silent, stern and aloof. One of the things people have not understood about analysis is that there never was a group of people who cared more about their patients, but the caring gets shown in a very unusual way."
The goal of the analyst is "to recreate the psychological moments in a person's life when they suffered hurts, and then enable them, with an adult's perspective, to see how they experienced this with the less mature mind of themselves as a child. When they do this, they are better able to come to grips with it, strip away the infantile distortions, realize what their fantasies were about, what was happpening and how that colored their attitude about life and love."
When the proper transference has been achieved, "someone in the height of a moment might feel great anger toward the analyst who has said or done nothing to provoke it and only in the moment of that anger would they realize that they've always been angry at authority figures, that for some reason they have felt a simmering rage and only through this recapitulation can they get at it."
Analysis -- virtually all psychoanalysts and most psychiatrists would agree -- is doing it the hard way. Because, the analysts say, for certain things there is no easy way.
"The theory of psychoanalysis," says Pasternack, "will tell you that when you're in pain you often run away from it. We get better at making ourselves face and grapple with painful situations, but the mind tends to run away from it and use various mental defenses against it. Analysis was invented to help a person recognize their defensive patterns and to change them to healthier ones."
According to Freud's theory, the mind is composed of three abstract entities that are constantly vying for superiority: The "id," the infantile self-centered part of us that is constantly demanding instant gratification. It is the respository of instinctual drives, including the sex drive. The "ego," the more realistic and rational self, which manages the personality and controls the id and the superego. The "superego," the moralistic, judgmental and guilt-trip inducing part of us.
Freud often focuses on material repressed in the infantile "id," hidden from the conscious, rational ego. For this reason Freud dealt with our secret selves -- things most people have been taught are shameful or dirty or fearful. There is the Oedipus complex, for example, the infant or young boy's sexual desires for his mother, or the little girl's similar feelings for her father.
As his interpretations underwent reshaping, largely through the work of his daughter, Anna Freud, and others, there developed a more ego-oriented psychology, somewhat easier for people to accept, instead of, as Pasternack put it, Freud's "in- terpretations that were aimed at the pump, the primary unconscious juices."
Post-Freudian analysts then began to debate at what age the Oedipal development occured. This continues to be a an issue of ongoing research, such as that conducted by Dr. Stanley Greenspan in his own practice and with the National Institute of Mental Health. And there appears to be unanimous agreement that abuse or neglect of infants can have long-lasting effects.
(However, as psychoanalyst Dr. Charles Brenner told conferees at the recent 75th anniversary meeting of the American Analytical Association, it can get out of hand, as in the theory that there is an "organic substrate of sadomasochism in the penetration of the ovum by the spermatozoa in the act of fertilization.")
Another important psychoanalytic tool is "object relations theory," which examines the effect a kind or hostile parent has on the developing personality of the child. Or, as Pasternack put it, "it holds that you internalize scenarios in your mind, based upon your relationships, so that if you have a witch for a mother, you will eventually have to contend in yourself with what it's like to be a victim of a witch as well as what it is like to be a witch."
Psychoanalysts typically are omnivorous readers of literature, of criticism, of history, anthropology, biography. They are aficianados of concerts, theater, dance and film, and to each activity they apply the same psychoanalytic techniques they have learned in their years of training, ever seeking insights into the myriad ways the mind's unconscious expresses itself, manifests itself symbolically -- in art, in literature and music, in all aspects of life, including, as Freud noted, in jokes, slips of the tongue, fantasy and dreams.
"Analysts are concerned with the cultural life of the nation," said Pasternack, "because art often expresses material that is sublimated. Our sublimations are very important. Works of art, books we write offer new metaphors, new opportunities to illustrate human experience, give it successful outlets."
Also, he noted, a significant amount of psychoanalytic study has to do with how people love. This is an area most modern medicine and treatments ignore.
"It is hard to justify to an insurance company that someone is in analysis because they are chronically asthmatic and also because they have never had a successful love relationship.
"How do you show how love is stamped on a neuron?"
There is a tremendous amount of resistance to Freud," said Washington psychoanalyst Dr. Gene Gordon, "because of very simple and very Freudian reasons. Namely, people are not in touch with their early development. They have forgotten it. They have repressed it. Most of us remember only very small fragments from the first six years of life, and a surprising proportion of people don't remember much of anything before puberty."
Gordon, who is a senior attending physician at Children's Hospital National Medical Center and a clinical professor of psychiatry at George Washington University Medical Center, said he does not find it at all remarkable that people are "amnesic about their early years.
"These are horrifying years for many of us, even those of us who had 'good' childhoods . . . There are biological determinants of shame and guilt. For example, all kids of 10 have dirty minds. You can't bring up a kid of 10, no matter what you do, who doesn't think sex is a dirty, wicked thing to do. So what does he struggle with in adolescence? He struggles with that guilty conscience against the pressure of his hormones which say, 'Do it! Go to it!' "
Gordon is amusing, articulate and outspoken in his views, which tend to be strong, sometimes dogmatic, firmly on one side or another of some of the controversies that simmer within the psychoanalytic community.
For example, Gordon takes the rigid Freudian view that homosexuality "is a compulsion, not a preference. Even more," he says, "it is a profound inhibition . . . I'm not saying they should be read out of the human race, but . . . it doesn't mean that you don't say it is a sickness."
Gordon strongly disagrees with the American Psychiatric Association's decision a few years ago to eliminate homosexuality as an illness category in the Diagnostic and Statistical Manual. "They were really pushed by political winds," he said. "I understand that it is political, but politics has never made good medicine, and medicine has not always been popular in politics."
This is one of the issues that precipitated a split 30 years ago when a group left the American Psychoanalytic Association and formed the rival American Academy of Psychoanalysis. The two groups now agree more than they disagree, some psychoanalysts say, although arguments between them and within them continue to erupt periodically.
Dr. Cecile Bassen, one of a group of relatively young analysts in the field, agrees that the APA decision to drop homosexuality from the DSM-III was politically motivated. But, she says, "The question of what goes into homosexuality, whether there is a biological component and what are the psychological components, I think we're only just beginning to find out. And it may be that there are so many different kinds of homosexuals and homosexuality that it is a mistake to say there is one reason or one answer.
"It seems to me that if you have a patient or you're dealing with someone who wants treatment and who is homosexual, you have to try to understand the individuality of that, just as you try to understand the individuality of anything else.
"I think there are a lot of analysts, certainly not all, who are comfortable analyzing a homosexual where the goal is not trying to change the homosexuality. The goal might be to understand it, just as a woman might come to understand why it is that she is always attracted to foreign men, for example.
"You also have to differentiate. There are homosexuals who are clearly capable of very meaningful long-term commitments, and there are homosexuals -- and heterosexuals, for that matter -- who are promiscuous in a self-destructive way and aren't capable of love."
Debate is intrinsic to analysis, some analysts say.
"In the first place, analysts work with words, so they are exceptionally verbal," says psychoanalyst Ernst Ticho. "They tend to have strong convictions, and when one makes a particular breakthrough with a patient, they have a tendency to become so convinced that if it works for a few, it will work for everyone. Quite often it will have a kernel of truth, but sometimes only a kernel. Also, you could say there are certain personality types who are drawn to the profession. You do not get psychologically minded unless you have difficulties, become aware of them and try to work them out."
"Another problem," says Gertrude Ticho, "is that since you deal with total personality, the field is enormously complex and scientific controls are limited, because each person is a unique entity. Even identical twins will have enormous personality differences, so we cannot always come up with hard truths, and there is always room for a personal bias."
Or as psychoanalyst Pasternack puts it, "When we stop arguing, we're dead."