Theoretical Work

Lay Analysis

In Austria in Freud's day to treat patients without having earned a medical degree constituted quackery and warranted punishment by law. Theodor Reik, a lawyer by training, had studied with Freud and was a practicing member of the Vienna Psycho-Analytical Society in 1926 when, at the instigation of a former analysand, he was prosecuted under this charge. Reik was exonerated eventually, but not until a number of expert witnesses had testified on his behalf, and Freud himself, having discussed the case with a high official, "had, at his request, written a confidential opinion on the subject."

Later that year, in The Question of Lay Analysis, Freud made public this opinion in the rhetorical form of "Conversations within an Impartial Person." There he summarized the prevailing argument against lay analysis as follows: "Neurotics are patients, laymen are non-doctors, psychoanalysis is a procedure for curing or improving nervous disorders, and all such treatments are reserved to doctors. It follows that laymen are not allowed to practice analysis on neurotics and are punishable if they nevertheless do so." Freud did not oppose this reasoning, but disagreed with its major premises, arguing "that in this instance the patients are not like other patients, that the laymen are not really laymen, and that . . . doctors have not exactly the qualities which one has a right to expect of doctors and on which their claims should be based."

Freud began his discussion by noting that neurotic patients present medical-like complaints for which medical doctors can find no organic cause. He reviewed for his "Impartial Person" the psychoanalytic model of the mind and the psychodynamic theory of neurosis, concluding that neurotics are not like other patients because they suffer disturbances, not in the medical province of the body, but in the separate and sovereign domain of the psyche. They differ, too, he said, because they act as if driven by a (most un-patient-like) desire to remain ill (see Repetition Compulsion). Freud went on to show that, for these patients, the lay analyst is not really a layman because analytic training, by way of didactics, personal analysis, and clinical supervision, brings the analyst to proficiency in this form of therapy. Medical training, by contrast, not only omits such instruction, but entirely overlooks "the mental side of vital phenomena." Worst of all, said Freud, orthodox medicine with its one-sided emphasis on objective science inculcates "a false and detrimental attitude" toward neurotic patients: the notion that, because their suffering is merely psychic, for medical purposes it is not real. He continues: "Only psychiatry is supposed to deal with the disturbances of mental functions; but we know in what manner and with what aims it does so. It looks for-the somatic determinants of mental disorders and treats them like other causes of illness."

Thus without addressing it directly, Freud pointed to the split in our thinking about ourselves that divides the mind from the body and seems to necessitate separate approaches to the sufferings of the body and of the soul. While human suffering in fact defies this split, human attitudes reify it again and again. Psychoanalysis, which arose in part as an effort to redress the problems of this dualism, itself often divides along mind/body lines. Thus the field finds itself perennially plagued by controversies over the primacy of either the subjective or the objective domain of clinical theory and procedure-- for example, whether it is "fantasy" or "what really happened" that ultimately explains the genesis of psychological symptoms, or whether "transference" or "the real relationship" offers the solider foundation for therapeutic change.

Acknowledging the limits of the medical science of his day, Freud ended his essay on an optimistic note. Someday, he wrote, "the paths of knowledge and, let us hope, of influence will be opened up leading from organic biology and chemistry to the field of neurotic phenomena. That day still seems a distant one, and for the present these illnesses are inaccessible to us from the direction of medicine." Until that time, he argued, the diagnosis and treatment of neurotic suffering would remain a province far enough removed from mainstream medicine to call for its own specialized and non-medical treatment profession. Toward that end, he proposed that neurotic patients should be screened by physicians for recognizable signs of organic illness, then referred for treatment in the hands of "secular pastoral workers" trained in psychoanalysis. "A new kind of Salvation Army!", his Impartial Person quipped. "Why not?" was Freud's reply.

The question of lay practice divides psychoanalysis to this day. The arguments for and against it remain essentially unchanged. Despite Freud's optimism, it seems, psychoanalysis has become no more scientific, nor science more psychoanalytic, through the passage of these seventy-and-more years.

References

Eissler, K.R. (1965). Medical Orthodoxy and the Future of Psychoanalysis. N.Y.: International Universities Press.

Freud, S. (1926). The Question at Lay Analysis. S.E. 20: 179-258.

Mann, D.W. (1988). The question of medical psychotherapy. American Journal of Psychotherapy, 43: 405-413. [Various Authors].

(1927). International Journal of Psychoanalysis 8, Part 2 : 174-283.

David Mann