Book Review

Therapy's Delusions: The myth of the unconscious and the exploitation of today's walking worried

N Engl J Med 1999; 341:133July 8, 1999

Article

Therapy's Delusions: The myth of the unconscious and the exploitation of today's walking worried
By Ethan Watters and Richard Ofshe. 288 pp. New York, Scribner, 1999. $25. ISBN: 0-684-83584-3

The concept of an unconscious mind is an old one, going back to speculations in the 12th century and articulated clearly by a Professor W.B. Carpenter of London in his lectures 25 years before Freud ever wrote his papers on the topic. Without reading a scientific article on the subject, anyone who has made an embarrassing slip of the tongue is well aware that our minds function outside our awareness.

Freud's contribution was to use the knowledge of these forces in the treatment of psychological difficulties. His explorations did for our understanding of the mind what Spallanzani did for biology in the 18th century and what Pasteur did a century later. They showed that there was no spontaneous generation but that things arose from causes. In other words, our mental functions do not result from random neuronal discharges from the cerebral cortex; instead, they have meanings of which we may not always be aware. This concept may be among Freud's most lasting contributions, and it has given rise to what is called psychodynamics — the understanding of the meaning of mental life.

Written by a journalist and a sociologist, Therapy's Delusions attempts to prove that the concept of an unconscious is a delusion and that psychodynamic therapy is therefore a fraud. The authors cite stories of incompetent treatment, wild interpretations made years ago by analysts, recent forms of spiritual treatment, and even alien-abduction therapy — all of which, for some reason, they include under the rubric of psychodynamic therapy. They constantly repeat the phrase “the myth of the unconscious,” as though the repetition itself served as a proof.

The authors insist that because we have learned so much about the brain, the psyche is irrelevant in the treatment of psychological difficulties. However, although it is obvious that the brain mediates all mental functioning, in our present state of knowledge we cannot explain how it does so. Even major psychoses have not yet been explained in terms of brain function. For example, when schizophrenia develops in a monozygotic twin, in only 50 percent of cases will the same condition develop in the remaining twin, even though the twins have identical genes. This finding has been cited by geneticists as evidence that environmental, nongenetic factors play a part in the disease. We have a long way to go before we can be certain of the causes of psychological difficulties.

Although Freud founded psychoanalysis, many of his ideas have been enlarged, changed, and discarded by analysts, just as in any medical discipline. However, the importance of unconscious mental functioning is universally recognized, both within and outside the field.

In the field of psychiatry, the past 100 years have been marked by a conflict between psychiatrists who view all mental illness as caused by brain pathology and psychiatrists who focus on psychological issues. This either–or dichotomy is arbitrary and restricting — it has been called “mindless versus brainless psychiatry.” Clearly, both neuroscience and psychology contribute to our understanding of how the mind works and are certainly not contradictory. There is evidence that not only can brain difficulties affect psychological functioning, but also psychological events can alter brain structures and bodily functions.

Recent advances in neuroscience have shed much light on mental functioning, and some psychoanalytic training institutes have started to give courses in neuroscience and its relation to the mind. The authors complain that those in the field of psychodynamics do no research into their subject, but a great deal of sophisticated research is being carried out, much of which is sponsored by the major psychoanalytic associations.

Many books have been published recently that are critical of psychodynamic psychiatry, and some have been written by thoughtful investigators. I am afraid that Therapy's Delusions is not one of them. It is more a polemic than a serious study and is selective and slanted in its presentation. For the knowledgeable reader, it adds nothing new on the subject.

Richard S. Blacher, M.D.
Tufts University School of Medicine, Boston, MA 02111