Sheila Hafter Gray, MD
The opinions or assertions contained in this presentation are the private views of the author and are not to be construed as official or as reflecting the views or policies of the United States Department of Defence or any of its associated institutions.
Thank you Madam Ambassador.
Ladies and Gentlemen.
I hope that at the conclusion of my presentation you will able to discern the influence of Freud’s experience and education on his approach to the care of patients and to clinical research, and to decide for yourselves if Freud is, or ought to be, a model for contemporary clinical scientists.
In the 21st century we hold te value of diversity, and I want to remind us that Freud was inherently an outsider. He was a Jew among Catholics in the Holy Roman Empire, for that is what Austria was at that time. He had his place there because the Habsburg protected minorities and this, to some important extent, mitigated against the effects of Anti-Semitism. So, he had some place in the university. He was able to have a good education; and he was in – though not quite in – that environment.
He had fellowship education in France which was outside the Viennese university establishment. That taught him a different approach to the practise of medicine. In France, clinical observation was always privileged over theory or laboratory findings, whereas the German model ,which we know here from the work at the Johns Hopkins University, prefers scientific over clinical truth. So Freud returned from France knowing how to focus on patients; and, to quote one of my own professors, “Listen to the patient. She, or he, will tell you the diagnosis.”
And that is precisely, what Freud did. Because he had different points of view he could have empathy for the other. That allowed him to listen attentively to what was then considered the irrational ravings of hysterical housewives. He could feel his way into their emotional life and, therefore, he could create innovations in the clinical care of these individuals. Also, he was able to integrate a variety of perspectives from art, archaeology, medicine/ surgery, and literature, with all of which he was familiar from his background and to integrate them into a comprehensive theory, actually the first complete bio-psycho-social model that we know, a model that explains in one theory the body and the mind, the individual and society, about one person.
Now, where would we locate Freud in today’s healthcare practise?
Some of you know about evidence-based medicine. Very briefly David Sackett who invented it, calls it the “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” It is research based, but the evidence from clinical research takes precedence over theoretical concepts and basic research which may use animal models rather than individuals.
If you look back at Freud’s work, he practised evidence-based medicine as we understand it correctly today. He used the research techniques of his generation, which were case studies and clinical-pathological correlations. If you look at his papers, they are in form the same as surgical papers or medical papers of that time. This is the way people wrote about their patients. He applied the relevant scientific findings from a variety of disciplines to improve clinical practise. I will mention only one: The personal equation was something that has bothered astronomers for generations. They knew that no two people had the same reaction time. If one tries to observe a star and press a button when a phenomenon is first seen, there is always a variation among individuals, a variation that cannot be eliminated by training. Astronomers finally decided that each person would get his own personal equation which could be used to correct his observations. And that is, if you think about it, very similar to the origin of our training analysis. When we learn what we contribute to the process, we can approach the patient and discern what is the patient’s and what is our own contribution to the interaction.
Again, Freud was a person who privileged the clinical over the laboratory, and particularly in his case, his neurohistology.
He also practised something about which you may know less, narrative-based medicine. This is more a feature of primary care medicine than of psychiatry. There they believe that medicine is best taught and remembered as stories about patients. Also, intuition is an essential skill for clinical practise and to generate scientific hypothesis. But, they point out, this requires systematic critical reflection about one’s intuitive judgements via creative writing, dialogue with colleagues, etc. In Britain they have Balint groups which are essentially a kind of a support group, helping physicians dealing with their feelings about patients, using those feelings to generate understanding what is going on in the patient, etc. And here again you can see the role of personal analysis and self analysis in the practise of day to day ordinary medicine.
What Freud would not have practised is evidence-based treatment. That, I think, is the focus of Professor Zaretsky’s critique. Evidence-based – or empirically supported – treatment involves randomized control trials, manual-driven uniform interventions, and measured outcomes. It focuses on group statistics, and discounts the individual case. It is true that psychoanalysis cannot be studied in this way; but some of our colleagues have cheerfully made manuals of psychotherapy that are now in clinical trials. For the past 15 years this has been a great force; but now people are returning to what these investigators call TAU (treatment as usual), in which one forges a specific treatment for each patient. This is essentially a craft. It is not science; it is something one and the patient co-construct to meet that individual’s needs. It was used as the control or active placebo for trials of manual-based therapy; and they found out that it works much better. Clinicians are actual able now to study these treatments, including psychoanalysis, using new investigative techniques. I shall mention just the psychotherapy process Q-sort and new statistical tool that analyse changes in individuals rather than in groups. Those are patient-centred researches that are clinically relevant.
I shall mention one further thing that I wish were still true, but that I fear is not. I wish we could write in a way that facilitates people understanding what we say. I will remind you that Freud was awarded the Goethe Prize. He was honoured for the literary quality of his scientific writings, because that supported a deep understanding of patients and of his theory. In Germany today they award a Freud Prize for the best written scientific paper in German language. The winner can come from any science: it is the language that counts. This is a contemporary recognition that beautiful prose helps the reader grasp and remember the subject matter of any discipline.
I will stop here, and thank you for your attention.