By LEV GROSSMAN
Published on January 20, 2003

 
How many Freudians does it take to change a light bulb? Two. One to change the bulb, and one to hold the penis ... I mean ladder! Although Sigmund Freud isn't exactly famous for his sense of humor, he actually liked jokes — in fact, he wrote a book about them, Jokes and Their Relation to the Unconscious. But he probably wouldn't have liked that one. Freudian psychoanalysis was one of the great innovations of the 20th century, and only 50 years ago, it was a mainstay of mental-health care. But since then it has gone from a medical and cultural institution to the punch line of a mildly dirty joke told by psychiatry residents. The members of the American Psychoanalytic Association today treat fewer than 5,000 patients in the U.S. How did the treatment Freud called the "talking cure" fall from grace? And now that it has fallen, can it get up again?

For almost a century, Freud's followers have treated his techniques like Holy Scripture. Now they are being forced to update his theories to compete with new drugs and new therapies, even if it means using methods that would have been unthinkable to their patriarch. At the same time, post-Freudian psychotherapists are figuring out that the old master still has something to offer the science of mental health: an understanding of the human mind and its many malfunctions that's richer, fuller and more exciting than anything invented since.

In their time — the early decades of the 20th century — Freud's ideas radically and irrevocably changed the way we think about who we are. He both explained the human mind and made it more mysterious. One of Freud's key insights was to divide the mind into the conscious and the unconscious: he showed us that beneath the surface banality of everyday thoughts and gestures lurk subterranean caverns of forbidden longings that reach all the way back to our earliest childhood memories. Freud's therapeutic technique, psychoanalysis, was an intellectual exploration of those depths, where patients could confront their deepest, darkest desires. If they recognized and overcame those repressed desires, the theory went, they could return to the surface with a calmer, healthier mind.

By the 1920s, psychoanalysis had become wildly popular in America (a country Freud visited only once and hated). Jazz age sophisticates held "Freuding" parties at which they told one another their dreams. Samuel Goldwyn, the movie-studio magnate, offered Freud $100,000 to write a love story that Goldwyn could turn into a motion picture. (He was rebuffed.) But Freud died in 1939, and the golden age of psychoanalysis lasted only until the 1950s. By then competing psychotherapeutic theories and approaches had begun to spring up, among them ego psychology, self-psychology, the object-relations school, interpersonal therapy and existential therapy. All revised Freud, and some rejected him outright.

Cognitive therapy is one of the most virulently anti-Freudian strains of post-Freudian therapy, and it has become one of the dominant approaches to therapy today. It was pioneered in the early 1960s by the psychiatrist Aaron Beck, who was trained as a Freudian but — in classic Oedipal fashion — rebelled against his master. Beck dismissed Freud's ideas about the subconscious as so much scientifically unverifiable cigar smoke. In their place he crafted a quick, pragmatic therapeutic approach that dispensed with abstract theories and focused on results. Cognitive therapy attacks such symptoms as anxiety and depression by "coaching" patients on how to think about their lives more clearly.

Not only did Beck reject Freud's idea of the unconscious self, but he also abandoned the formal reserve of the classic Freudian analyst. Freud believed the analyst should be as neutral and silent as possible. That way, Freud theorized, the patient can project personalities from his or her past onto the analyst and relive past conflicts right there on the couch. Freud called this process "transference." Beck and his followers aren't interested in transference. Instead cognitive therapists talk back to their patients, pointing out their misconceptions and advising them on how to see their lives more clearly.

Cognitive therapy is everything psychoanalysis isn't: simple, quick, practical, goal oriented. "There's this mystique about psychoanalysis," says Judith Beck, daughter of Aaron and herself a leading cognitive therapist. "Psychoanalysis is esoteric and creative and interesting, and the psychoanalyst holds himself up as the expert who interprets what the patient is saying and has all the answers. It's kind of the opposite in cognitive therapy." Cognitive therapists tend to follow the same basic script for each session, so the treatment is remarkably standardized. It's also remarkably effective; research shows that when it comes to treating depression, cognitive therapy works as well as drugs like Prozac. And though it's not quite as quick as antidepressants, the results last longer after treatment stops. One study published in the New England Journal of Medicine found that, used together, cognitive therapy and antidepressants can help 85% of patients suffering from chronic major depression.

— With reporting by Janice Horowitz and Andrea Sachs/New York
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