Why Psychoanalysis? (Book Review)

To paraphrase Nietzsche; I think I have never read a book to whose every conclusion I responded with such a resounding “no”. Elisabeth Roudinesco aims, in her book “Why Psychoanalysis?”, to make a case that psychotherapy, and especially psychoanalysis, is something incredibly valuable not only for the “neurotic”, but also for society overall. I think that for a critical reader, this case is — likely because of Roudinesco’s ignorance or absentmindedness — presented very poorly, amounting to no more than an anti-advertisement for psychoanalysis. Let’s start at the beginning.

Psychoanalysis is the sign of a triumph of civilization over barbarism. It brings back the idea that man is free in his words and that his fate isn’t held down by his biological being.¹

Quite the opposite, in fact. Freud wasn’t a believer in the freedom of the psyche. In a series of introductory courses to psychoanalysis in Vienna, he oftentimes remarks to his students that such a belief is a mistake. The necessary precondition for so-called Freudian slips, or the way dreams are created by the psychic apparatus, is the lack of mental freedom.

And I think while psychoanalysis might be a triumph of civilization over barbarism, one has to keep in mind that Freud diagnosed civilization, or culture, as being the cause of neurosis, the internalization of prohibitions leading to conflicts within the psyche, etc. He didn’t exactly see civilization in a great light, unlike Roudinesco here (which she does by contrasting it with “barbarism”, like Rosa Luxembourg does with socialism).

It is known that the discovery of a new kind of psyche by Freud has made possible the existence of a subject who is able to interiorize prohibitions. (…) This kind of subjectivity, so characteristic for the existence of democratic societies (…) is being phased out from the modern way of thinking in lieu of the psychological idea of the depressive personality.²

I think Roudinesco is giving Freud much more credit than he deserves. This kind of subjectivity was in fact born during the Enlightenment, more specifically in the German idealist circles. Democracy is the fruit of the Enlightenment, I would say, and everything we have today — the law or our conception of subjectivity — is grounded in that era’s thinkers. Freud discovered, or perhaps constructed, a certain kind of an unconscious part of the psyche. The Id, the primal unconscious forces, are subdued by the Ego and Superego, the conscious and the cultural aspect of the psyche, respectively.

In democratic countries everything happens so that no revolt is possible, as if the idea of a revolt, even an intellectual one, became illusory, as if conformism and hygienism, specific for a new kind of barbarism of biopower, have won this battle. This is where the sadness of the soul and sexual inability come from, this is the root of the depression paradigm.³

This is the first part where Roudinesco namedrops biopower, a Foucauldian term (long before this, she namedrops Derrida’s différence). Isn’t it quite ironic that this book, longing for the Freudian subject, longing for autonomy and freedom, is using a term by a philosopher who, all throughout his life, was at constant war with the “I”?

For Foucault, the subject is always a result of subjection. And his diagnosis is completely opposite to the one Roudinesco proposes. The subject, or the soul, or the “I”, is the prison of the body (reversing the Platonic phrase). In other words, what Roudinesco calls “a new kind of psyche” is not emancipatory, but subjugating. What psychoanalysis puts forward is a deeper, more profound type of subjection, created not only to control body movements, actions, interactions, but to control the sexual and interpersonal sphere of life, mostly unscathed by the disciplinary mode of power. Kind of strange that she quotes an author who completely disagrees with her, no? To add to this, he was a strong critic of what Roudinesco praises, “interiorizing prohibitions”, what Foucault calls “panoptism”.

But is the usage of the word “biopower” itself wrong? Not quite, but it definitely contrasts with the subject-affirming tone of the book. Biopower is the management of bodies at a larger scale than that of disciplinary power. It’s the power of epidemiology, trends, immigration, emigration, statistics, predictions and plans. The forces guiding us to “stay the fuck home” during COVID, but also the dispersed, more subtle forces; washing our hands or pooping in toilets instead of behind our homes. The problem with this is, for someone to conform and for someone to be hygienic, he first must be disciplined, taught how to be hygienic, where to go, how to act, what to do. That is, he must be subjected and thus made into a subject. In discipline, not in biopower, lie the roots of “the depression paradigm”. Perhaps simply because the “sadness of the soul” has no right to exist if there is no “soul”, and no sadness of it defined. Speaking in Foucauldian metaphors, one might think of it this way: to reach down into the well of the subject and pull up a bucket of sadness, one first needs to dig a deep well.

All of the above could be differences of opinion. But what really caught my suspicion was the next chapter, where Roudinesco talks about the science behind the effectiveness of psychotherapy and psychoanalysis:

From 1952 in the United States several studies were conducted to estimate the effectiveness of psychotherapy and psychoanalysis. (…) In short, all of those studies showed an incredible efficacy of the entirety of psychotherapy. However, none of the studies could statistically prove whether psychoanalysis is better or worse than other methods of healing.⁴

For this, she quotes 5 works: 4 psychoanalytical books about theory and clinical practice, thus not studies; and one empirical study: “The Effects of Psychotherapy: An Evaluation” by Hans J. Eysneck. Lets see what conclusion Eysneck⁵ reaches:

A survey was made of reports on the improvement of neurotic patients after psychotherapy, and the results compared with the best available estimates of recovery without benefit of such therapy. The figures fail to support the hypothesis that psychotherapy facilitates recovery from neurotic disorder. In view of the many difficulties attending such actuarial comparisons, no further conclusions could be derived from the data whose shortcomings highlight the necessity of properly planned and executed experimental studies into this important field.⁶

I think it would be a far reach to assume, given the context of this book and, well, the phrasing itself, that “incredible” in Roudinesco’s case means “disappointing”. Eysneck, the most cited psychological researcher before his death, has reached the conclusion that in fact psychotherapies are not “incredible”, but useless.

This book was published in 1999. Eysneck’s study is from 1952; why not, instead, opt for much newer, methodologically sound meta-analyses of psychotherapy efficacy? Why does Roudinesco instead choose one of the oldest studies on the effects of psychotherapy? I reach one conclusion: she hasn’t read it, but she’s seen it cited before. Speaking of modern, I have found a study by Ebert et al. rediscovering Eysneck. Here’s what it tells us:

In the 1950s, Eysenck suggested that psychotherapies may not be effective at all. Twenty-five years later, the first meta-analysis of randomised controlled trials showed that the effects of psychotherapies were considerable and that Eysenck was wrong. However, since that time methods have become available to assess biases in meta-analyses.⁷

So at least with a 1977 study, according to this paper, Elisabeth Roudinesco would have had the ability to show that psychotherapy had considerable effects. She wouldn’t have had the ability to read this particular study from 2018, of course; but let’s see what interesting conclusion it reaches:

These results suggest that the effects of psychotherapy for depression are small, above the threshold that has been suggested as the minimal important difference in the treatment of depression, and Eysenck was probably wrong. However, this is still not certain because we could not adjust for all types of bias. Unadjusted meta-analyses of psychotherapies overestimate the effects considerably, and for several types of psychotherapy for adult depression, insufficient evidence is available that they are effective because too few low-risk studies were available, including problem-solving therapy, interpersonal psychotherapy and behavioural activation.⁷

There are a lot of uncertainties, but Eysneck was “probably wrong” (the authors indeed claim that he wasn’t completely wrong, and there could be other types of biases in the studies). However, the “small” effects still do not quite reach up to Roudinesco’s “incredible efficacy” claim.

The effect sizes we found for the four therapies with sufficient studies after adjustment ranged from g = 0.20 to g = 0.35. Problem-solving therapy and psychodynamic therapy did not cross the threshold for clinical relevance, and the effect sizes for CBT and supportive therapy were close to this threshold.⁷

Psychodynamic therapy, for those not in the know, is pretty much Freudian psychoanalysis modernised. So at least this study revisiting Eysneck shows that in fact psychoanalysis is worse than other therapies. Surprised?

To defend psychoanalysis, Roudinesco goes on to say that, in short, controlled trials and experimental trials should not apply to psychoanalysis, all that matters is clinical practice and case studies:

A big flaw of such judgments is that they are always based on experimental trials. (…) the judgement of so-called experimental therapy has no value in psychoanalysis — it always makes an object out of the soul.

When asked about this in 1934 by psychologist Saul Rosenzweig, Freud (…) Didn’t fight back the idea of an experiment, though underlining that their results were surface-level and not bringing anything new to the table of already preexisting clinical experiences conducted by psychoanalysis and known thanks to several publications of case studies.⁸

One of the most famous case studies of Freud, Anna O., though her case was published, did not even get cured of her hysteria. Psychoanalysis has failed her, and she remained a hysterical woman for the rest of her life. Such is the questionable healing power of psychoanalysis; but Roudinesco knows this. Later on she thinks this is intentional and she shows that what happened to Anna O. is therapeutical because she lived on to become a feminist. Not quite a scientifically rigorous conclusion; what comes to mind is that correlation is not causation. Who’s to say that she became a feminist because of Freud’s analysis, and what does it matter in terms of the telos of psychotherapy? What is it, anyway?

When the subject [in regards an unspecified study on psychotherapy — E.K.] of psychotherapy was asked, he oftentimes answered that thanks to this experience he became indeed “changed”, he could not however claim that he got “cured”.

(…)

In the case of the psyche, symptoms do not fall into just one disease, and it doesn’t, truth be told, constitute a disease (in the somatic sense), but signifies a state. Thus being cured is nothing more than the existential change of a subject.

This is how many hoops you have to go through to somehow claim that psychoanalysis is good for something. First, back it up by contradictory empirical science. Then, say this particular kind of science is good for nothing and in fact, Freud was right in that case studies are the only viable science for researching psychoanalysis. And lastly, exclaim that the point of psychotherapy is not to get “cured” of disease (and there’s not really such a thing as disease of the mind) but to be changed as a subject. Why would I go to therapy — from the Greek therăpeíā, medical treatment — if not to get cured, or at least get better? And why this redefinition? Perhaps it is to prove to the reader that what these studies (she doesn’t say which ones she’s referring to) claim is in fact that psychotherapy cures people, because changing is curing. Question remains, what if I change into a mass murderer? What sort of change constitutes being cured, and what change doesn’t?

This shifting of goalposts is incredibly confusing when you look at the position of psychoanalysis and psychotherapy both historically and in contemporary times. Freud was a doctor and neurologist; psychoanalysis has always oscillated near the medical fields, and was practiced on “patients”. Psychotherapy in modern times is practiced at psychiatric hospitals (not the total institution kind) and in medical establishments — this includes descendants of Freudian psychoanalysis, such as psychodynamic therapy. This means therapy is indeed a kind of medical treatment, and not an existential change like a trip to the Himalayas, or travelling the world to discover yourself, acvitites which are not offered at medical establishments. Thus it is completely credible to dismiss it on empirical, experimental, and philosophical grounds.

From the previous point in the book, Roudinesco goes on a crusade to own the liberals and denounce any enemies of psychoanalysis. However, I think her retorts are void of facts and logic, and based solely on eristics.

What is the conclusion of this book then? I’m not really sure. It straddles along trying to win some sort of legitimacy for the, as beautifully put by the scientism crowd, “system of literary interpretation of affects and desires”¹⁴ called psychoanalysis, and fails to do so on every account. It tries to win the reader over with eristics, false citations, and rhetorical devices. I don’t think there is a single logical argument for psychoanalysis, or against anti-Freudists in the entirety of this text. In short, to answer the titural question: why psychoanalysis? Or, as it’s phrased in Polish: “Po co psychoanaliza?”, “For what is psychoanalysis?” I would answer: for the 19th century graveyard.