Having addressed psychoanalytic theory, I turn now to the even more vexing predicament of psychoanalytic treatment and psychoanalytic therapy. Here I shall discuss what happens to psychoanalysis if one loses confidence in its supposedly scientific account of human development.

The master in Massachusetts: Freud (left front), Carl Jung (right front), Ernest Jones (center rear), and others at Clark University in 1909. Photograph courtesy Austrian Press and Information Service, New York City

In some sense, what all schools of psychoanalytic therapy have in common is a developmental, historical account of the individual. We may disagree about which events are critical, but we agree that the individual's history is important in understanding and treating the individual's psychopathology. "The history of desire in the person" seemed to me a good way to think about psychosexual development and to begin to think about all object relations. I was prepared to believe those who claimed that psychoanalysis was more like history than like science, and that the task of psychoanalytic therapy was to reconstruct that history. Out of that enterprise of understanding the individual's history would come an important therapeutic element-a believable self-description. The appeal of Freud to the twentieth century is that his theories of individual development gave men and, to a lesser extent, women, revealing and believable self-descriptions that helped them make sense of their personal histories. A more dramatic example of what I mean-because it comes from an unexpected quarter-is to be found in Jean-Paul Sartre, who made elaborate and brilliant arguments against Freud. But when it came to giving a self-description of his own life, he reported that a psychoanalyst had told him that he did not have a superego because his father had died when he was an infant. This wild interpretation delighted Sartre; he wrote that other men went through life weighted down by their fathers "like Aeneas carrying Anchises from the walls of Troy," but he, the philosopher of radical freedom, had no such burden.

The construction of narratives as self-descriptions, though usually in much more subtle and convoluted ways, is what much of psychoanalysis is about. Freud generated self-descriptions based on developmental events and psychosexual stages like those he described in Three Essays and The Ego and the Id. That is how we in the twentieth century came to understand our sexual preferences, our foibles, and our character. Now the important challenges for psychoanalytic therapy, as posed by our critics, are first, that these developmental events have no important causative relationship to the phenomena of psychopathology, and second, that the self-descriptions generated by our explanatory theories are both irrelevant and unverifiable.

Early in my career as a psychiatrist and a psychoanalyst I believed that every form of mental illness-be it psychosis, neurosis, or personality disorder-could be understood in terms of psychoanalytic developmental stages. If one wanted to understand psychopathology better, one had to learn more about infant and child development. This idea was basic and it was unquestioned.

Our problem is that, in light of the scientific evidence now available to us, these basic premises may all be incorrect. Our critics may be right. Developmental experience may have very little to do with most forms of psychopathology, and we have no reason to assume that a careful historical reconstruction of those developmental events will have a therapeutic effect. I know that it is difficult to assimilate this idea; it certainly is for me. Recently, in reviewing a new psychoanalytic textbook on affect, I read, "There is growing consensus that adult psychopathology can be understood with reference to normal child development." I nodded inwardly in agreement, but then I stopped in my tracks and thought about those words more carefully. There is certainly no longer any consensus that schizophrenia, bipolar disorder, depressive disorders, or substance abuse can be understood with reference to normal child development. In fact, most research psychopathologists would say that child development explains very little about most so-called Axis 1 disorders. (There is, of course, one very important exception-post-traumatic stress disorder; but the trauma is not crucially related to childhood development.) Psychoanalysts can no longer assert that what they learn about their patient's childhood will help them to explain the etiology of the patient's psychopathology, or even of the patient's sexual orientation.

The task of constructing self-descriptions in psychoanalytic therapy also encounters the problem of memory. Everything we have learned in recent years about memory has emphasized its plasticity, the ease with which it can be distorted, and the difficulties of reaching a hypothetical veridical memory. Much of what psychoanalysis considered infantile amnesia may be a function of the reorganizing brain rather than of the repressing mind. All of this makes the task of constructing meaningful histories of desire in the individual more daunting.

If there is no important connection between childhood events and adult psychopathology, then Freudian theories lose much of their explanatory power. If memory cannot be trusted to construct a self-description, what does one do in therapy?

I no longer ask my patients to lie on a couch and free associate, but I certainly have not given up on face-to-face psychotherapy. My focus is almost entirely on the here and now, on problem-solving, and on helping patients find new strategies and new ways of interacting with the important people in their lives. I still believe that a traditional psychoanalytic experience on the couch is the best way to explore the mysterious otherness of one's self. But I do not think psychoanalysis is an adequate form of treatment. There is certainly no reason for psychoanalysts to withhold medication from their patients. If I can call on Freud, I would suggest that he would have welcomed Prozac, Ativan, and all the rest. Despite his disclaimer, he himself tried to find substances that would relieve human suffering.

Freud's famous conclusion was that, when our patients' neuroses are cured by psychoanalysis, they have to deal with ordinary human suffering on their own. Perhaps it will be no further offense to Freud for me to suggest quite the opposite. When a patient's symptoms are treated, he may then need a psychoanalyst to help him deal with his ordinary human suffering. That is the therapeutic domain in which the art of psychoanalysis will survive.

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