Drugs Treat the Symptom, Talking Treats the Cause: Freud Wasn't All Wrong
Neuropsychologist Mark Solms mounts a defense of Freud: talk therapy still outperforms medication on outcomes, because psychic suffering originates in unmet emotional needs rather than in chemical imbalance.
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Freud still won't go away because he got there first
Solms argues that the first reason Freud's influence persists is simply that he got there first. He was the first person to try systematically to describe and understand the subjective mind — not behavior, not language, not perception, not cognition. As the one who originally mapped that territory, the basic cartography belongs to him, and everything that came afterward only fills in detail. Freud himself was convinced he was doing science, but science almost by definition excludes subjectivity, and that made his enterprise difficult from the very start.
— Mark SolmsCognitive neuroscience is retracing the path Freud already walked
Around 1900, when Freud claimed that most mental activity is unconscious, the claim was treated as a contradiction in terms — as absurd as saying "a non-mental mental process." Today cognitive neuroscience not only accepts unconscious mental processes but holds that they make up the bulk of mental functioning, with consciousness a very small and limited resource. Solms points out that modern scientists arrived at the same conclusion independently, from scratch, by different methods — usually without knowing they were retracing Freud's path.
— Mark SolmsThe mind can only be studied from within, never observed as an object
What made Freud's method distinctive is that he studied the mind from inside the mind, treating it as a person's very being rather than as an object available to outside observation. Twentieth-century behaviorism denied the existence of subjective states both methodologically and ontologically: the psyche was effectively expelled from the discipline that bears its name. Freud, by contrast, worked in the naturalistic setting of the analytic consulting room, recording directly what patients reported with as little reservation as they could manage, accumulating thousands of hours of the most immediate observation of mind available, and then analyzing the organizing principles underneath it.
— Mark SolmsIn the 21st century the most effective psychiatric treatment is still talking
Solms claims that, taking the various disorders together, the most effective psychiatric treatment in the 21st century remains talk therapy — and that this comes from meta-analyses of randomized controlled trials, not from personal opinion. Every modern talk therapy descends from Freud: Aaron Beck, who invented CBT, was himself a psychoanalyst. Compared with psychopharmacology, the gains from talk therapy are sustained at long-term follow-up, whereas symptoms commonly return once medication stops — evidence, he argues, that it reaches the cause rather than suppressing the symptom.
— Mark SolmsPatients keep getting better for years after treatment has ended
Psychodynamic psychotherapy shows a distinctive phenomenon: after treatment ends, patients not only hold on to their symptomatic improvement but keep improving through long-term follow-up at 6 months, 1 year, 2 years and 3 years. Solms calls this the sleeper effect and takes it as evidence that the treatment has reached the causal mechanism. Medication is symptomatic treatment, and symptoms come back when it is withdrawn; talk therapy alters the causal mechanism generating the psychopathology, which is why the change continues.
— Mark SolmsSuppressing an emotion is like prescribing only painkillers for angina
Solms uses chest pain as his analogy: chest pain signals that heart muscle is starved of blood, and a doctor does not simply hand over opiates for the pain — the narrowed vessel has to be dealt with. In the same way, fear arises from a need for safety, anger from a need being blocked, separation distress from the need for attachment. Emotions are pointers to needs that have gone unmet; they are about something. Psychopathology arises when a person has failed, in the course of development, to learn how to meet some emotional need, and the goal of psychotherapy is to help the patient find a better way of meeting it. That is treating the cause.
— Mark SolmsYou can see it and still not change, because change happens subcortically
Gaining insight without being able to change your behavior happens because the deep unconscious rests on subcortical memory systems — the basal ganglia, the cerebellum, the amygdala and others. Cognitive neuroscience has a saying that non-declarative memory is hard to learn and hard to forget: these structures have low plasticity and change slowly. That is why treatment is slow work and hard labor, and why people are forever looking for a way around it. Psychoanalytic therapy was designed precisely for the class of problem where change cannot be decided directly.
— Mark SolmsThe cure works through love, but not the romantic kind
"Cure through love" is Freud's own formulation. Solms explains that this is not romantic love but parental care: a devotion that places another person's needs ahead of your own. When someone failed early in life to learn how to meet a particular emotional need, the therapist has to provide, inside the therapeutic relationship, the opportunity to learn it again. This kind of love means an enormous investment of time and energy — which runs in exactly the opposite direction from where healthcare funding and policy are currently heading.
— Mark SolmsThe most effective therapy can't gain ground because it is slow and expensive
Even though talk therapy is the most effective option, the American healthcare system rarely adopts it. Solms puts this down to three things: the treatment takes time and money; the pharmaceutical industry has vast commercial interests and a lobbying machine pushing drugs; and people in general like solutions that are fast and cheap. In Germany, Austria and the Scandinavian countries, psychoanalysis is provided at state expense. Medication, as symptomatic treatment, is sometimes lifesaving and sometimes necessary — but "to want to change your life with a pill, that is just not possible."
— Mark SolmsIn their own words · checked verbatim
you, your joys and your sorrows, your sense of personal identity and free will are, in fact, nothing more than a vast assembly of nerve cells and their associated molecules.
Mark Solms24:41
It's absurd to say, well, which one is real.Which one is causing the other... they're just... two manifestations of the same thing.
Mark Solms28:05
On the whole.The most effective treatment that we have in psychiatry, still is talk.Therapy.
Mark Solms33:43
the patient continues to improve. In other words, if you'll excuse the bad grammar.They get more better.
Mark Solms36:00
It's devotion. It's, it's care.
Mark Solms47:08
...to cure a lifetime to become who you are. How can a pill change it. It just can't.
Mark Solms58:55
Figures
| Year Freud advanced the idea of the unconscious | around 1900 | 10:15 |
| Freud's cumulative hours observing the mind | thousands of hours | 17:43 |
| Time span of long-term follow-up in psychotherapy | 6 months to 3 years | 36:00 |
Glossary
- dual-aspect monism
- The view that mind and brain are two perspectives on one and the same entity, observed from within and from without; it derives from Spinoza.
- sleeper effect
- The phenomenon in psychoanalytic treatment whereby patients continue to improve after therapy has ended, suggesting the treatment reached the cause.
- non-declarative memory
- Memory that cannot be put into words and is hard both to learn and to forget, depending on subcortical structures such as the basal ganglia, cerebellum and amygdala.
- psychical reality
- Freud's term for the portion of reality made up of human subjective experience, as distinct from the objectively observable external world.
How to listen
Psychotherapists, psychology enthusiasts, and anyone who wants to understand why medication does not cure psychic suffering.