Psychoanalysis has fallen on hard times. Freud’s gender theories are trashed for their sexism, and his original instinct theories are regarded skeptically. Psychiatrists don’t study it, and the only attention it gets in universities is from a handful of literature professors. Health insurers prefer the quick fix of psychoactive drugs, although they help less than their popularizers would lead us to believe.
But drugs can draw attention away from individual and social realities, supporting the exaggerated claims—of both Big Pharma and overconfident scientists—that human experience can be reduced to biology. This atmosphere lends further support to insurers’ self-interested turn to time-limited and mechanical psychotherapeutic approaches, like cognitive-behavioral therapies. While they can be helpful, they target a limited range of symptoms while ignoring the powerful emotional experiences—familial and social—that so often play a prominent role in causing those problems in the first place. Increasingly, psychotherapy is offered in impersonal formats reproducible through manuals. Presented as an effort to make treatment more efficient and reliable, this approach reflects insurers’ prioritizing their profits and the growing pressure on public sector providers to reduce the costs of already underfunded mental health services.
Psychoanalysts bear some responsibility for this turn. During the mid-twentieth century, when analysis was the dominant method for mental health treatment in the United States, its practitioners felt little obligation to carefully monitor how much difference they were really making. Although there were efforts to make psychoanalytic therapy available to groups beyond the middle and upper classes, the coin of the realm remained refined, costly, long-term intensive analytic therapies, often involving the traditional use of the couch.
Still, many who distrust some aspects of analysis seek it out when they need emotional help. And over the last decades, a new flexibility has emerged in psychoanalytic practice. Analysts increasingly recognize that a variety of formats can be applied to a wide range of emotional difficulties, without compromising the core analytic values of reflectiveness, empathy, and careful attention to feelings and meanings. A number of researchers are trying to show that empirical evidence supports psychoanalytically oriented approaches. Others have been finding new ways to adapt these methods to people who have often been marginalized by mental health systems, including such diverse groups as infants and young children, trauma victims, and recent immigrants.
Psychoanalysis is most often thought of as a clinical practice, but it is also a theory of how individuals and the social world interact, one with serious ethical implications. Long before Donald Trump became president, markets and media—both mass and social—expropriated memories, emotions, and histories and suppressed the possibilities of genuine imagination. The analytic sensibility stands for the recovery of the past and curiosity about what you don’t or can’t let yourself know. It helps people confront concealed repressions and the many distractions from what’s happening all around us. It’s no wonder that totalitarian regimes, whether of the right or the left, have routinely suppressed or abolished it.
At times, these virtues have been obscured by an authoritarian clinical style and adherence to theories that reflected the cultural prejudices of Freud’s time, especially about women and LGBTQ people. He minimized the reality of child abuse, especially of girls and women. But those misconceptions are now almost universally rejected among analysts. Instead, the realities of gender, sexuality, race, and political economy are increasingly taken into account in both theory and practice.
Not Your Father’s Psychoanalysis
In the consulting room, engagement and flexibility have replaced the imperious silence of the typical New Yorker cartoon analyst. There’s a new, more responsive atmosphere, with a shift toward tenderness and creative attention rather than the paternalistic authority that too often characterized traditional analytic approaches. This parallels a new interest in infant care and the “maternal” role (not something exclusive to women). Fantasies and the unconscious mind still matter, but in even the most formal analyses (couch and all), most practitioners feel free to engage warmly and directly with patients, rather than sitting silently and imperiously. While there is something to be said for the traditional approach, it was applied rigidly and omnipotently by analysts (usually men) who saw themselves as offering exquisite insights at just the right moment. One of my mentors told me that, in the 1950s, he and his fellow trainees at the renowned Menninger Clinic would compete in earnest to be the one who spoke to his patients the fewest times per day.
When I began practicing several decades ago, I was discouraged from answering patients’ questions and was directed instead to remain quiet and allow them to struggle with their anxieties. But now, I usually try to find some kind of useful answer. When I don’t, I often confess that my thoughts are a bit jumbled, that I don’t have something useful to say, or even that I prefer to maintain some privacy about the question at hand. I work toward a generally supportive background of confidence and trust, against which an analysand can experience and come to terms with feelings and memories s/he has not previously been able to encounter. Little good can happen without a background of safety.
One of my patients, whom I will call Harold, hardly ever says anything remotely critical because he is so concerned that I will regard him as “aggressive” and retaliate, even by ending the therapy. As a child, he was humiliated for expressing even slightly negative feelings. As he has slowly become more vocal about his frustration with me and other people, he has come to trust that not everyone will react that same way. I don’t believe that he could have differentiated the present from the past without the opportunity to find something different in the present situation with me.
Paying attention to the analyst-patient relationship has thus added flexibility and clarity to psychoanalytic practice. New movements, like “relational analysis,” put forth a “two-person perspective” that includes the contribution of each therapist’s particular character—including her neuroses and vulnerabilities. I do believe Harold’s apprehension about speaking out has its roots in his punitive family. But it is also true that I can be a probing, critical interlocutor. At times, Harold’s caution (through which a kind of quiet contempt may leak) has gotten under my skin, which comes through in my tone and the timing of what I say. Contemporary analysts thus see ourselves as participants in a highly personal and shifting two-way relationship that depends on the mutual influence between the therapist and patient. The myth of the idealized analyst is losing its appeal.
Relationships and the Social World
There is a similar movement outside the consulting room. Analysts are collaborating with theorists and researchers in other disciplines, changing how they conceptualize their work. Relationships, rather than drives, are now seen as the primary motivators and organizers of psychic life. In tandem with this, feminist and queer critiques have had a substantial influence. The patriarchal theory that the Oedipus complex is the most important moment in civilizing the child’s “primitive instincts” and organizing conscience and gender in the personality has been superseded. The earlier Freudian misogyny and homophobia has been largely discredited, with a new generation learning from critical theories about gender, power, ethnicity, and more. Theoretical cross-fertilization is common: analysis is influential in some of the more visible contemporary social critiques, including those of Slavoj Žižek and Judith Butler. Butler applies new conceptions of sexuality to illuminate how power is internalized in the current psychopolitical setting. Žižek “unmasks” the ideological functions of ordinary social forms, like films, as ways of unconsciously organizing everyday desires that might otherwise be expressed in more turbulent and subversive ways.
Similarly, analysts are no longer claiming that their form of therapy is the be-all and end-all of mental health care. They work in community settings and often collaborate with other professionals, including teachers, psychopharmacologists, and cognitive and body-oriented therapists. In my own practice, I’m currently working with a behaviorist who is helping a child patient with her phobias while the youngster and I look for underlying causes. I’m also collaborating with a speech and language therapist who is helping an adult with auditory processing problems, while the patient and I explore his childhood shame and anxiety at being unable to follow instructions in class, along with his current trouble keeping up with his wife’s banter.
More recently, analysts in the United States and Europe have spawned what is now a worldwide infant mental health movement aimed at helping babies and their caregivers, especially those in severe distress due to abuse, custody disputes, foster care, or traumatic separations, among other causes. In the United Kingdom, many NHS pediatric offices have child therapist consultants on site who are available to support stressed families and their healthcare providers, whether they face the ordinary strains of parenting or the emotional pain evoked by caring for sick children. Every family gets regular, developmentally oriented home visits from professionals trained for this task. Even Princess Diana had a home visitor.
The most persuasive accounts of the effects of the recent separation of children from parents at the U.S.-Mexican border have emerged from analytic theory and research, as do the best strategies for helping them. Child psychoanalysts and developmental researchers led the way in describing the devastating effects of disrupting children’s ties to their caregivers. These include anger, despair, and the even more crippling detachment that looks like “playing dead” in the face of overwhelming distress. Therapists have documented the enduring effects of such disruptions into adulthood, including problems regulating emotions, poor judgment, and chronic mistrust of oneself and one’s relationships. They have long argued for rapid attention to these crises, including timely reunions with caregivers whenever possible and appropriate, and the provision of sensitive care in the interval.
For the first few decades of my career, I worked at one of the first “infant-parent psychotherapy” programs, serving babies from mostly black and Latinx families who had suffered from abuse or neglect, homelessness, and an array of other acute and chronic traumas. The “patient” was the relationship between the infant and parents. We tried to meet families on their own terms through home visits and other forms of direct social support. At the same time, we maintained an interest in how parents who had been traumatized as children would inflict similar abuse on their own children, often despite their best intentions. Typically, such programs involve cooperation among a wide array of community agencies, including hospitals, child-care providers, child protective systems, family courts, homeless services, and even police.
I made weekly visits for almost two years to the home of an African-American couple (Karen and James) who lived in a rough housing project in San Francisco. Their two young daughters (ages two and five) had been removed from their care after one of them suffered severe burns from scalding bath water. The girls had recently been returned to their family home after it was discovered that a neighbor had been responsible for this abuse.
Before we could consider whether I could help them deal with their daughters’ (and their own) feelings about the twin traumas of the burns and separations, it was essential to talk about their anger. They were not just angry about what had happened. They were incensed that Child Protective Services had required them to meet with me, a white professional, in their own home, to administer this reunion. We spoke extensively about whether I could be trusted as I was coming from a bureaucracy dominated by people of my ethnic and class background. Only later, as Karen followed her younger daughter’s lead in a crayon scribbling game, could we talk, amid her tears, about how no one had ever played with her when she was little. This is not to say that the matters of race and power just fell away. But discussing them in the open gave us room to have a more honest and beneficial conversation than ignoring that power dynamic would have allowed.
The Sociohistorical Perspective
The current political moment, especially the Trump presidency, has increased interest in socially oriented psychoanalysis. Practitioners feel a sense of crisis, and patients often bring their worries about the country and the wider world into the consulting room. With this in mind, the analytic journal I co-edit, Psychoanalytic Dialogues, ran several therapists’ accounts of their work on the days following the 2016 election. One described how a patient who had never cried in eight years of treatment now sobbed regularly. Another patient was described by her analyst, Orna Guralnik, as “in the process of trying to get her family to understand the aftermath of having been raped in high school. Anguishing about her mother’s vote for Trump, she said, ‘He boasts about being a sexual predator, does she deep down think that is okay?!’”
More broadly, there is a growing interest in situating clinical practice in its cultural, economic, and historical contexts. Discussions of racism and ethnicity, gender and LGBTQ identity, trauma in families and cultures, immigration, economic disadvantage, and privilege are increasingly common. Some writers, for example, are pursuing the idea of “radioactive identifications”—unprocessed fragments of historical trauma that make their way across generations. After several years of therapy with an Israeli-born analyst, a German immigrant returned to her homeland to tell her family about her pregnancy. Learning that her grandfather had been a Gestapo agent, she became suicidally depressed when she returned to the United States. She and her analyst now talked, for the first time, about her analyst being Jewish, and an array of feelings emerged that helped her find a way out of that depression. Similarly, a number of analytic writers have implored their colleagues to examine their own whiteness and that of their profession.
These efforts and experiences draw on a long historical tradition. Since the early days of the psychoanalytic movement, therapists and theorists have worked to uncover and disclose compromises and repressions that are concealed or disguised through fear, distraction, complacency, custom, or compliance. Wilhelm Reich wrote a study called The Mass Psychology of Fascism in 1933. Frankfurt School leaders like Theodor Adorno, Walter Benjamin, Erich Fromm, Max Horkheimer, and Herbert Marcuse developed critical theories melding psychoanalysis with Marxism to analyze new forms of social control that Marx had not foreseen. In the 1960s and 1970s, Frantz Fanon and R. D. Laing (both formally trained psychoanalysts) unmasked the hidden cruelties of race, colonialism, psychiatric diagnosis, and family life. Psychoanalytic feminists like Juliet Mitchell, Nancy Chodorow, Jessica Benjamin, and Dorothy Dinnerstein contributed core ideas to the Second Wave.
Efforts to extend such theoretical developments into everyday clinical practice are also taking hold. At a recent symposium of the American Psychoanalytic Association, I heard how, on the day after Trump’s election, a light-skinned black analyst struggled with his complex reactions to hearing his darker-skinned patients deride the distress of white Democrats who were just catching up to what African Americans had felt all along. Another symposium considered how an Australian-American analyst with an aristocratic background and her socialist patient managed to overlook their own class differences and shared privilege as white women, even as they were talking about how the very same issues played out beyond the consulting room.
Psychoanalysis as Resistance
Psychoanalysis offers a resource for subversive thinking, even if it has sometimes fallen into complacency and been too quick to align with prevailing cultural biases. Whether in the broader social arena or the mental health system, it remains a bulwark against the evacuation of our personal, emotional worlds into the world of pseudo-objects and media unrealities. Recently, the carton in which an online purchase came to my house was sealed with a sticker that said, “The Internet sent me to make you happy.” Emotion is depersonalized and commoditized, and interpersonal contact has been destabilized and mechanized, even for those who don’t feel alienated by online communication.
Psychoanalysis has always prized authenticity, introspection, and deep contact. It insists that emotional cruelty and trauma are as real as physical pain, that the truth matters, and that the deeper truths matter the most. It offers a serious but imaginative method that values curiosity and a historical sensibility, pushing against the forces that keep us from seeing what is hidden in plain sight. In a retrograde moment like ours, the analytic ethic provides a strong source of resistance.
Stephen Seligman is the author of Relationships in Development: Infancy, Intersubjectivity, and Attachment (Routledge, 2017). He is a psychoanalyst, Clinical Professor of Psychiatry at the University of California, San Francisco, and Joint Editor-in-Chief of Psychoanalytic Dialogues: International Journal of Relational Perspectives