Who is an addict?

Who is an addict? It depends on who you ask.  To some people it’s an ugly word with negative connotations relative to, say, substance abuser. To others it’s a term with an important meaning, and recovering addict is a badge of honor, one day at a time. Addict is just a word for something real; it’s not a specific thing like a tiger or the Pope. It has no absolute meaning, but is associated with the medical model, in that it classifies addiction as a disease – specifically a chronic, progressive, relapsing disease.  Some add “fatal” to the list of adjectives, believing that if you can’t maintain recovery, your addiction will eventually kill you. To admit you’re an addict is to admit that you’ve lost control.

I’ve attended open Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings, and believe that regular attendance of 12 Step meetings is the only path to recovery for some addicts. I’ve recommended checking out 12 Step programs to many substance abusers during my career, but I disagree with anyone who claims there’s only one way – whether 12 Step programs, or Rational Recovery, or the Bible – to stay clean and sober.

My prescription for long-term recovery from substance abuse is “whatever works for you.” If believing you have a treatable life-long disease works to keep you in recovery, or believing you have an addictive personality, or believing that you have to “get right with God” to stay clean and sober, go with it. Your path to recovery is yours, but might not be what others need. It takes most people with substance abuse problems many relapses to learn what does and doesn’t work for them, as was the case with my recovery from nicotine addiction.

Not everyone has to “hit rock bottom” before getting it right. I’ve known a few people with many years in recovery who didn’t relapse once after resolving to quit. I’ve also known people in long-term recovery who initially needed to attend 12 Step meetings, but said that at some point they internalized the principals of the program and no longer had to attend meetings. Nobody has the authority to tell you that you’ll have to go to meetings for the rest of your life, in order to stay in recovery. But if you do, that’s not  a sign of weakness. It’s just part of your personal recovery plan.

Substance abuse occurs along a spectrum, and people’s definitions of abuse may differ; but being addicted generally means not being able to control your drug use once you start using mind altering chemicals. Within the recovery community it’s generally believed that if you’re addicted to whatever “drug of choice,” you also have to abstain from all other chemical highs in order to keep from relapsing on your favorite drug. I’ve known a number of chronic substance abusers who believed that substituting alcohol and/or marijuana would help them to keep from relapsing on “hard drugs” like meth or heroin or crack. (Alcohol is a hard drug, but it’s legal.) I’ve never seen it work and have concluded that you can’t solve a chemical dependency problem with chemicals.

The concept of addiction has broadened, and now a lot of people believe that sex and gambling and other non-drug-related behaviors can be addictive. The “old school” definition of addiction was characterized by three clinical phenomena: tolerance, withdrawal and physiological cravings. Tolerance means that you have to increase your dose over time to get the high you used to get from a lower dose. Withdrawal means that when you abruptly stop using an addictive drug, your body goes through distinct physiological changes – ranging from unpleasant or painful to potentially fatal – for a period of time. Physiological cravings are like hunger. Your body is telling you it needs something, and a strung-out heroin addict craves a fix the same way a starving man craves food.

Chronic marijuana use can lead to psychological dependence, but cannabis doesn’t meet the old school definition of addictive. Similarly, sex and gambling aren’t characterized by tolerance, withdrawal and physiological cravings. However, in many respects compulsive sexual activity and compulsive gambling resemble addiction, because they involve loss of control over certain activities, and some of the same neurotransmitters are involved. Like drugs, sex and gambling can predictably stimulate the brain’s “pleasure centers.” Psychological learning theory provides a good framework for understanding such compulsive activities, and I’ll elaborate in a future post.

Denial has killed millions of addicts. If drug abuse or compulsive behavior is hurting you or others, or you’re losing control of some important aspect of your life, find someone reliable and get real with them. Explore options and work on developing your personal recovery plan. Even if your plan doesn’t include active participation in a 12 Step program, it may borrow from the 12 Steps or Rational Recovery or other models. And you can’t stay in recovery without help from supportive people who understand you and don’t judge you. You need someone to share your thoughts and feelings with in recovery. We come to know ourselves better by letting others know us better, warts and all.

Who is normal?

Nobody is normal.

I think normality is one of the most misunderstood concepts in our culture, in that so many people still nervously ask the question, “Am I normal?” It seems that “normal” has come to be equated with “desirable,” is in ten-fingers-and-ten-toes-on-the-baby normal. But it ain’t necessarily so. I, for one, am unapologetically not normal, and have no wish to be seen as normal, conventional or average. I don’t dress funny or anything outwardly apparent, and my  abnormalities are benign: I don’t follow sports. I don’t own a cell phone.  I create strange art. (Check out jeffkoob.com)

“Normal” is a relatively modern social concept, and is based on a statistical idea. It isn’t found in nature, and like “Justice,” only resides in the human brain. On the street, normal correlates to  average, and abnormal has come to have negative connotations. In statistics there are three “measures of central tendency” (mean, mode and median) that produce what we call averages. But there is no values correlation between average (normal) and good, or desirable. Cigarette smoking used to be a normal adult habit when I was growing up. Obesity is normal in our society, as is divorce. Five hours or more of screen time daily seems to be the new normal. Standards of normality change over time.

There’s no such thing as a normal dog or a normal day or a normal rock, let alone a normal human being. While the average American family may have (let’s say) 1.8 children, you won’t find a single family that actually has 1.8 children. Normality is an abstraction, not a reality.

We increasingly live in a world of manufactured situations and pastimes, with a high standard of standardness.  Fashion choices may seem to set us apart, but following fashion just makes us part of the fashion parade. The mass media promote conformity and superficiality as virtues. It’s easy to see why a person who sees herself as a misfit might  long to “just be normal.” But I agree with Frank Zappa, who said that while many people think normality is grand, “normality is not grand, it is merely okay.”

If you’re conflicted or alienated, you may have an unrealistic vision of normality as a desirable destination. But balance, harmony and serenity are better destinations than normality. You are unique, and you need not be normal to live well and happily. People  who strive to be normal may not recognize or cultivate creative potentials within themselves. Original art doesn’t come from normal thinking, and “thinking outside the box” means not thinking conventionally. Extraordinary people are, by definition, not normal.

In my last post I mentioned the “Unconventional Modes of Experience” course in my humanistic psychology graduate program. It didn’t take the same approach as traditional “Abnormal Psychology” courses, as it didn’t have the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) as a textbook. Instead, the focus was on the phenomenology of madness. I won’t attempt to explain phenomenology in this post, other than to say that its focus is on subjective experience, not objective diagnosis. Crazy behaviors are often the result of unconventional experiences, such as auditory hallucinations. Scientists dismiss such phenomena as mere symptoms. Phenomenologists, like shamans, explore them for meaning.

I later took DSM-based courses and professional development classes to develop my diagnostic skills, but I’ve always appreciated my exposure to phenomenology as an alternate lens to the medical model. A belief underlying my therapeutic practice was that the better I understood each client’s unique experience of being-in-the-world, the better equipped I’d be to help him therapeutically.

I know that gay people didn’t choose to be gay any more than I chose to be straight. Being gay isn’t statistically normal, but it’s a normal variation from the heterosexual norm in every known culture on earth. I worked in therapy with a number of gay people who expressed their longing to be normal, to meet the standards of normality they were raised with in their families and communities. Some knew they’d be shunned if they were labeled abnormal. But what is considered normal is always culture-bound. Arranged marriage is normal in some cultures. That doesn’t mean it’s good or bad, just that it’s what most people do.

As long as you live your life productively and responsibly, and don’t exploit or abuse others, being normal is optional. Being abnormal isn’t necessarily a bad thing, if it’s an authentic expression of who you are. There’s no objective and timeless standard for what’s normal, anyway; so you should feel free to be your unique self. Other people’s judgments may be their problem, and may not have to be yours.


Who is mentally ill?

Sometimes as the group leader in my psychoeducational groups, I’d start my standard rap on psychopathology by writing two words on the board: sad and depressed. Then I’d ask, “Do these two words mean the same thing?” After listening to responses from group members, I’d proceed in this manner: Yes and no. On the street they’re synonymous, but to a psycho-diagnostician they can be very different things. Sadness is a universal human experience. Sometimes we can identify the reason or reasons for our sadness, other times not. When a person says, “I’m depressed because my friend is moving away,” they’re likely describing “normal” sadness that will probably diminish over time.

Sadness is a mood, and moods come and go. If a sad mood becomes persistent and affects your functioning, depression may be a better description for the experience. This persistent mood may also be due to an identifiable cause, such as a romantic breakup, or it may be unrelated to life circumstances. The former is referred to by some  clinicians as “functional” (caused by some external circumstance), the latter as “endogenous” (caused by internal, biologic factors). This isn’t an absolute distinction in all cases, but it has its utility.

There’s a deeper level of depression that isn’t a universal experience. Even at the lowest points of my life, I’ve never been as sad as the clinically depressed people I’ve known personally and professionally. People living with this kind of depression may experience hopelessness, despair, and suicidal ruminations. I’ve never been there, and I have great compassion for those who have.

One way of classifying psychopathology is assigning people to distinct diagnostic categories. You either do or don’t meet the diagnostic criteria for depression, or schizophrenia, or bipolar disorder, or antisocial personality disorder. If you don’t have the disorder, you may have traits associated with it. Another way of classifying pathological traits is to view them along continuua: straight lines with opposite poles. Everybody can be placed somewhere on a continuum between happy to be alive and suicidal, gentle and violent, honest and dishonest, paranoid and trusting, and other traits and tendencies.

If I’m extremely unconventional but functional, some people may refer to me as “crazy,”  but to others I’m merely eccentric. If I’m unconventional to the point I can’t function in society and may endanger myself or others, I could be mentally ill. In my graduate program in humanistic psychology, we didn’t even have a course titled “Abnormal Psychology”; that was considered too pejorative. Our course was titled “Unconventional Modes of Experience,” lest we apply unnecessary or judgmental labels to people.

Psychopathology is characterized by impairment or disability. I have obsessive-compulsive traits, but I don’t think of them as pathological, because I’ve been able to recognize, control and channel them. I’ve had doctors and lawyers tell me that they never could have made it through medical school or law school if not for obsessive-compulsive traits. You too may have traits of a mental disorder, but not meet the diagnostic criteria, because you’re not impaired by them. For instance, you might have some symptoms of depression, but not be pathologically depressed. Or you might have paranoid traits,  but not be diagnosable as having a paranoid disorder. The hyper- vigilance characteristic of a truly paranoid person might even be desirable, if you’re a spy.

Even if you have a diagnosed mental illness or engage in crazy behavior, you can’t be involuntarily committed to a treatment facility without a Probate Court hearing. (I only refer to behaviors as “crazy,” not people.) In most states you must be interviewed before the hearing by two Designated Examiners (DEs), one of them an MD, and have court-appointed legal counsel to represent you at the hearing. In order for you to be involuntarily committed, both DEs must agree – and convince the court – that you are of danger to yourself or others, due to a diagnosable mental illness. I’ve had the privilege and responsibility of being a DE for most of my career, and in my experience the system works most of the time to prevent people from being “railroaded” onto locked wards against their will.

Mentally ill people are often shunned, and even blamed for their symptoms. With good treatment most mentally ill people can function in society, although some are too disabled to hold a steady job. All people with mental and emotional illnesses deserve good treatment, regardless of income. But unfortunately, state mental health systems all over the country are terribly under-funded, and many folks don’t get the treatment they need to remain functional. A significant portion of homeless people have mental illnesses. Hospital ERs, jails, and prisons have become major mental health service providers. I’ll describe how we got to this sorry state of affairs in a later post.

Is insight necessary?

A major influence of psychoanalytic theory on contemporary psychotherapy is the notion that insights can be breakthrough experiences, opening the door to liberation from undesirable behaviors.  Freud posited that repressed memories and emotions could block our progress, and that insight into the blockage in psychoanalysis could “resolve ” it. He also identified resistance as a phenomenon in treatment. The patient might want to change his dysfunctional behavior, but unconsciously resists the change, not knowing what’s on the other side of the door.

Epiphanies can happen in or outside of the therapy session, but is insight necessary for a client in treatment to choose to change her behavior in a positive way? I’ve witnessed “Aha!” moments in therapy sessions that led to chosen changes in behavior in short order. In therapy, as in standup comedy, timing is crucial. You may, as a therapist, know something about your client that he isn’t ready to face or accept yet. If you’re a strategic therapist, you try to help build a framework that will facilitate eventual insight. A poem about psychotherapy put it this way: “I do not open that rusty door/I show you how you’ve locked it, nothing more.” When epiphanies have occurred in session, it’s almost like the cliché of seeing the lightbulb light up.

Such an epiphany in therapy can be a watershed in treatment. As Carl Rogers put it, once you accept yourself as you are, you can begin to change. Susan’s sudden realization that she harbors a lot of justified anger toward her father might allow her either to forgive him, or to place the blame where it belongs without feeling guilty for doing so. Tom’s breakthrough understanding, that accepting he’s gay isn’t the end of the world, opens up a new world of possibilities. So insight has its place in therapy, but is it necessary?

Not necessarily. I’ve had alcoholic clients who declared that they couldn’t stop drinking until they understood why they turned out to be alcoholics in the first place – why they couldn’t control their drinking once they got started, unlike their friends who could. Because I often used sly humor in therapy, I’d earnestly ask clients with this rationalization, “Were you breast-fed or bottle-fed?” Regardless of their response, I’d frame it as the answer to their question. “Now that we’ve established why you can’t control your drinking, let’s discuss what you’re going to do about it.” The what is often more important to focus on than the why.

Sometimes people who aren’t in treatment choose to change their behavior in positive ways, then have insights into their past problem behaviors. Avoidance reinforces avoidance, because it relieves you of anxiety for the moment. People in therapy can be given behavioral prescriptions (as in cognitive behavioral therapy) to do things they typically avoid. It’s called exposure, and it can not only extinguish the fears underlying the avoidance, but result in insight into the origins of those fears. There is value in studying the ways that positive change occurs spontaneously in people’s lives, and adapting the findings for use in psychotherapy. Ericksonian therapists work in this manner.

In conclusion, insight isn’t necessary for a person to change dysfunctional behavior patterns, in or outside of therapy, although it can be helpful sometimes. Waiting for insight to kick in can be a means of avoidance. We’re more likely to learn from the consequences of our changed behavior than by insights we don’t act on. Insight can be a motivating factor in changing your behavior, but not necessarily. I think there’s something to Freud’s notion of resistance. Some  clients in therapy are deeply ambivalent about changing their behavior, and insight might not serve to resolve that ambivalence. I used to say to clients, “Insight and a dollar will get you a cup of coffee.” Now it’s more like two bucks, minimum.

Identity and diagnosis

I’ve  written two prior posts on the paradox of identity, and now I want to return to the topic. I’ve run into different versions of the  following affirmation/mantra and I don’t know who to attribute it to, but it’s a good starting point for this brief examination of what identity is and isn’t: “I have a body. I am not my body. I am more than my body. I have emotions. I am not my emotions. I am more than my emotions. I have thoughts. I am not my thoughts. I am more than my thoughts. ” For people with identified mental illnesses I’d add: “I have a diagnosis. I am not my diagnosis. I am more than my diagnosis.”

Folks grappling with mental illnesses often find themselves stigmatized, treated as the modern equivalent of lepers, although they’re not contagious. Even within the mental health community individual patients are sometimes referred to by clinicians as “a schizophrenic” or “a borderline.” Mentally ill people often sense that others stereotype and define them by their mental illness. One of my great revelations early in my career (I already knew it intellectually, but not experientially) was that people with mental illnesses are, first, unique individuals – like the rest of us. Their mental illness is a feature of who they are, not a defining characteristic.

When I worked in a Dialectical Behavior Therapy (DBT) program, designed to help “borderlines,”  one of my individual therapy clients was a highly intelligent and assertive  woman. She let me know up front in our first therapy session that she wouldn’t abide being referred to as ” a borderline” by me or my colleagues. “I’m a person who meets the diagnostic criteria  for  Borderline Personality Disorder.” And that describes her better than any diagnostic label. (Years later she saw me at a mental health event and gave me one of the finest and most honest compliments I’ve ever gotten from a former client. She said that I was the second-best therapist she’d ever had.) She refused to let others define her by her diagnosis, and was her unique self. I’ve worked with a number of people diagnosed with Borderline Personality Disorder, and no two of them were alike. I’ve worked with many more who carried the diagnosis of schizophrenia, and no two were alike.

It’s easy to stereotype people we don’t understand, and whose behavior might confuse or threaten us. As with homophobia, fear of crazy people – the most common stereotype –  is rooted in the unconscious or conscious fear, “what if I were that way.” The idea of “losing your mind” is frightening to anyone who thinks about it. Les aliens is a French term for the insane. Many people with chronic mental illnesses feel internally alienated because of their symptoms, whether depression or hallucinations. But on top of that, mentally ill people are frequently treated as aliens by people who don’t understand, and therefore fear, them.

People struggling to cope with the symptoms of mental illness often find themselves judged or blamed for their symptoms. A person in a manic state may be told, “Just pull yourself together and stop acting crazy!” A person suffering from clinical depression or PTSD might hear, “What’s wrong with you, anyway? You should have gotten over that by now.”, as if they had a choice.

Psychodiagnosis is a necessary part of the medical model but, as discussed in a previous post, it’s based on decisions made by committees and applied to unique individuals. It’s not rocket science. Psychiatry puts the people it treats in the patient role, or sick role. There are both advantages and disadvantages to being conferred the sick role. It absolves you of responsibility for certain things you’d normally be held responsible for; but it prescribes what you must do as a patient, and often keeps you dependent on ongoing treatment. This makes sense for a kidney dialysis patient, but not necessarily for everyone with a psychiatric diagnosis.

In some circumstances, for mentally ill persons there’s no substitute for good psychiatric treatment. But all too often patients are told that medication is the only option, and that they’ll have to depend on medications with awful side effects for the rest of their lives. The recovery model is person-centered, not patient-centered. Centers run on the recovery model work with their clients to come up with a unique recovery plan that serves to empower them, encouraging autonomy and hope. The plan may include referrals for psychiatric treatment when it’s needed, but other options are explored. More about the recovery model soon.

Anger management

I’ve taught anger management to groups of police officers, incarcerated felons, Marine drill instructors, and school teachers, as well as to many individuals – some of them referred by the Family Court. A lot of people with anger problems are highly resistant to attending anger management classes or counseling sessions, so I’ve had to learn how to get past people’s defenses if I was going to help them.

My definition of anger management took a lot of people by surprise. “Anger management,” I’d say, “doesn’t mean that you don’t get angry anymore, or that you can control when you get angry. Everybody gets angry, and sometimes anger can be a good thing. Anger management simply means that no matter how angry you feel, you can still make good decisions and you don’t do things you’ll have reasons to regret later. It means that you don’t let your anger control you.”

Nobody has absolute control over their emotions. Sometimes we feel carried away by them; it’s part of the human condition. People aren’t accountable for what they think  and feel, but for what they do. In certain situations, like combat, anger may help you to survive. But if your anger creates problems in your life, you can learn to stay in control of your behavior when angry. In order to do this you first need to understand some things about how your anger affects you: your personal triggers and cues, and your choices.

The roots of anger in childhood. You’re less likely to have anger problems if you grew up in an environment where your primary role models practiced anger management. Some parents know the right words to say to their kids: “Just because you’re angry at your brother, that doesn’t give you permission to hit him.” But role modeling works better than lecturing, and if adults can’t practice what they preach, their children learn more from what they do than from what they say. If you grew up with physical or emotional or sexual abuse, you’re not necessarily destined to have anger problems, but it’s more likely that you will. Bad tempers aren’t an inherited trait; but if you have one, you probably came by it honestly. If we were taught by our social environment that violence is a solution to interpersonal conflicts, we need to learn that there are better solutions.

Abraham Maslow said that if the only tool you have is a hammer, you’re likely to treat every problem as a nail. Some people learn to rely on anger and physically- or verbally-aggressive behavior, using intimidation tactics and threats to get their way, and resorting to violence when they don’t. Sometimes people take out their anger, not on the person who triggered it, but on those weaker than themselves. Dad yells at Mom, then Mom smacks Junior, who kicks the dog. It’s called displacement.

Triggers. The first step in learning anger management is to be aware when you’re angry. This may sound elementary, but often people who are angry are focused on externals, not on their here-and-now feelings. “I’m not ANGRY, you messed up!” People have different triggers for anger, and awareness of your triggers can help you to own what you’re feeling right now, and take those feelings into account when you choose how to respond to the situation. Sometimes the best thing to say is something like, “Look, I’m just too angry to continue this now. Give me time to chill and we can take up where we left off.” Personal insults, taunts, or sarcasm may or may not be triggers for you. Tone and loudness of voice, and body language, may be triggers if they remind you of someone with similar features. Situations (i.e. traffic jams) can be triggers. We all have identifiable triggers, and it helps to know what they are.

Cues are physical sensations we predictably experience when we’re in a specific emotional state, although a focus on the triggering experience might eclipse our awareness of our subjective state. Common cues for anger are a rapid heartbeat, heavy or rapid breathing, tensed muscles, a flushed face, and an adrenaline rush. Awareness of your cues in the here-and-now can help you to recognize and own your anger, and make good decisions despite it.

Owning your anger means not blaming others, or external circumstance like traffic jams, for what you feel. As a therapist I’ve encountered many people who typically, reflexively blamed others for their feelings, rather than owning them. “You make me so angry when you talk to me that way” is a cop-out, a manipulation. If others are responsible for your anger, then they need to change their behavior to stop “making you mad.” The idea that others will always have the power to make you mad puts you at a disadvantage in relationships. It’s much more rational to think of it as, “When you talk to me that way, I get angry.” If you don’t own your anger, you give away your personal power. If you own your anger, you can learn how to make decisions you can live with, no matter how angry you are at the time.

Physical anger management.  Here are some suggestions for physical things you can do to deal with angry feelings. (1) Vote with your feet. Walk away from the triggering situation, if that’s an option. Stay away until you calm down. (2) Slow your breathing. You don’t have an on/off switch for your anger, but breathing slowly has a physiological calming effect. (3) Physicalize your anger. Once you have the opportunity, release your anger by exerting yourself in harmless ways: do pushups, run, shadowbox, work out on a punching bag, or whale away at your bed with a pillow.

Mental anger management. In teaching anger management, I’ve compared anger to building a campfire. You can’t start one without an initial flame or spark, and once it’s started you need to keep adding fuel, or it will go out. First you ignite twigs from the spark, then you throw branches on the blaze, then logs. Anger is like that. It starts with a spark (trigger) and needs fuel to grow. The fuel that’s required for momentary anger to grow into a rage is angry thoughts. All people engage in self-talk. Some of it helps us to feel compassion for others and to make rational decisions, some of it can lead us to do irrational things that we’ll regret later. Rational self-talk (“She didn’t mean to hurt my feelings.”) can extinguish a blaze of anger, while irrational self-talk (“He needs to get his butt kicked!”) can turn a spark into a bonfire. Rational thinking will be a continuing topic here. It’s a cornerstone of cognitive therapy.


Freud’s legacy

Freudian psychoanalytic theory was the basis of the whole notion of  “the talking cure” – what we now know as psychotherapy. But many of Freud’s ideas have been discredited and none (to my knowledge) have stood up under the lens of scientific scrutiny. This doesn’t necessarily mean that they have no utility, just that they can’t be proven. I’m not suggesting that nobody has benefitted from psychoanalytic therapy, but its techniques and benefits haven’t been empirically validated.

The first two editions of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) were largely written by psychoanalysts, and analyzed mental illnesses through Freud’s theoretical lens. (Both editions labeled homosexuality as a mental disorder, a grave error corrected in the third edition.) Subsequent DSM editorial committees saw fit to question the utility of Freudian concepts such as neurosis and hysteria, and to focus instead on identified symptoms in establishing diagnostic criteria. Most of Freud’s psychoanalytic concepts have proven superfluous to our understanding of the pathologies, or unfounded.

Freud attributed most psychopathy to unconscious and unresolved infantile or early childhood issues and conflicts, especially those conditions he characterized as “hysterical” or “neurotic.” He posited that the Oedipus Complex was a universal experience for little boys: the unconscious wish to kill Dad and have sex with Mom. The Electra Complex was the female analogue of this Freudian notion, which no longer seems to have any utility. The concept of female “penis envy” also appears to tell us more about Freud’s psyche than about the human condition.

While there may be some metaphoric validity to the idea that some people are “accident prone” or have a “death wish” due to unresolved unconscious conflicts, there’s no real evidence for these propositions. Conversion disorders – the loss of some physical or sensory capability for psychogenic reasons – are still in the DSM, but calling them “hysterical” in origin contributes nothing to our understanding of the condition.

There’s been a steady decline over the years in people who undergo the rigorous training required to become a psychoanalyst, and its theory and techniques haven’t been validated by research. The technique of “free association” (saying the first thing that comes to mind, in response to serial stimulus words) can reveal interesting mental associations, but there’s no scientific evidence of its effectiveness as a therapeutic technique. Dream analysis can be fascinating, but it’s not a magical key to insight.

I’ve already written a post in which I presented Freud’s concept of defense mechanisms as a useful tool in psychotherapy. But what other Freudian notions have stood the test of time? In my opinion, his popularization of the concept of unconscious motivations has contributed significantly to our understanding of human behavior. Sometimes people do things for reasons they don’t consciously understand. This idea has taken root in modern life.

The personality structure of superego, ego and id still has some metaphoric validity, and was revived in Transactional Analysis as parent, adult and child. The way I used the metaphor in therapy went something like this: “It’s as if we had three aspects to our personalities, the parent, the adult and the child. Children operate on the pleasure principle – I want what I want right now! One of the tasks a child needs to master on the journey to adulthood is learning to delay gratification, to be willing to do needful things now, in anticipation of future reward.”

Another Freudian concept that still makes sense to me is that of transference and countertransference. It describes emotional dynamics within a therapeutic relationship. Freud said that patients tend to unconsciously transfer feelings for significant others (like Dad , or a lover) onto their therapist. A therapist who is aware of this dynamic in the therapeutic relationship, and who isn’t unconsciously affected by countertransference (her feelings for the patient), can use transference to the patient’s benefit in therapy. A client falling in love with his therapist or a therapist falling in love with her  client (it happens) can also be understood through this Freudian lens.

But it seems to me that Freud’s most enduring legacy (influenced by his mentor, Joseph Breuer) was his concept of “the talking cure,” the idea that talking about your problems with an attentive and caring therapist can be healing. This may seem obvious to many of us today, but without Freud’s contribution, contemporary psychotherapy as we know it wouldn’t exist.

Bonus recommendation: If you want to read an excellent novel about the genesis of “the talking cure,” I highly recommend Irvin Yalom’s When Nietzche Wept. Freud isn’t the main character, but the novel imagines a friendship between Joseph Breuer and Friederich Nietzche, and how it affects the lives of both men. Don’t waste your time on the movie adaptation.