Focus Factor: Understanding What Freud Got Right

We don’t need any more debate about the theories of Sigmund Freud. Many words have already been written, and the most generous way to describe his concepts today would be “strange.” It is hard to understand why they held such sway for so many years. I will focus here purely on his practice. The norm for the psychoanalytic patient was to participate in four or five 50-minute sessions per week. Psychoanalysis was intensive.

I saw a psychoanalyst for several years. I could only afford three sessions per week between insurance coverage and self-pay. Despite this reduced time commitment (and the fact that I sat in a chair rather than reclining on a couch), I was assured by my analyst that I was participating in the real thing. I can assert that I enjoyed the process, and yet I never experienced much change in my thoughts, feelings or behaviors.

It is not uncommon for people to continue in treatment for years, scheduling either weekly or multiple sessions per week. I have no recollection of why I ended my analysis. It did not relate to a sense of success or failure. It may have been financial. This is probably one of the most common reasons for the ending of treatment.

I separate the intensity and the longevity of treatment as two distinct and unrelated issues. I would also isolate the question of whether the 50-minute session is the right duration for therapy, or in the language of pharmaceutical treatment, a “therapeutic dose.” I would argue that we have been following tradition for too many years, and it is time to embrace a norm of flexibility on all dimensions: on the duration of a session; on the intensity of sessions; on the longevity of a treatment episode.

One of the biggest changes in thinking about clinical improvement in recent decades relates to an appreciation for when change takes place – that is, within the therapy session versus outside the therapy session. Psychoanalysis created the myth of the magical interpretation. The patient was transformed by the interpretation of psychic conflict that developed over many, many sessions. All the work occurred in the sessions. Today we know that a great deal of change occurs between sessions.

The intensity of the intervention

Freud was right to think that people cannot change habits of mind and behavior without intensive focus. One might suspect a financial motive for keeping people engaged in frequent sessions each week, but my reading of Freud is more favorable. I read him as being motivated to accomplish his clinical goals in the time frames he used. It is also worth remembering that it was his followers, not Freud himself, who embraced interminable psychoanalysis.

The clinical question we must ask is that of dose-response: What amount of clinical intervention is needed for the required response? The answer for psychoanalysis or psychotherapy is the same: We have no idea. The data suggest there is no direct, linear relationship between the dose and the response. Twenty-five minutes of therapy may be as effective as 45 minutes of therapy. This seems possible, but we have no data to evaluate this. We certainly have no data suggesting that 45 or 50 minutes is necessary for a positive response.

I worked as a psychotherapist for many years, and I can say that a therapy session has an arc of focus, intensity and impact. There are probably 10 minutes that are really important in any given session in terms of moving a patient to change their thoughts, feelings or behaviors.

I would argue that we need to throw out tradition. Our traditions were never based on clinical evidence. We also do not have evidence for establishing new norms today. However, we can start with our best clinical knowledge and assumptions today, which we can later validate in rigorous clinical research.

How was Freud right? Helping people to change long-cemented thoughts, feelings and behaviors takes time. Freud believed that you need to work on your goals most every day. Does that not make sense to everyone, regardless of the context for your goals? Let’s move out of the realm of psychotherapy: Did Michael Jordan believe that he could practice once each week to achieve his best?

The modality of the intervention

Michael Jordan could afford a coach who worked with him constantly to improve his game. This is ideal, and yet not reasonable or affordable for most people struggling with their health. The good news about healthcare is that we have new and effective modalities for getting healthy. Sitting down with a professional is wonderful, and yet people can get healthier by doing other things.

We have health coaches available by phone or email, and they direct people to use health-enhancing resources, rather than getting involved in clinical discussions with a licensed professional. Cognitive behavioral therapy has been proven effective for a multitude of behavioral healthcare disorders, and we now have studies showing strong effectiveness when this therapy is delivered via web or mobile connections.

People don’t make changes that improve their mental health or their physical health without a sustained focus and commitment. Freud knew this, but unfortunately, he thought the royal road to change was finding a transformative interpretation, perhaps even a potent dream interpretation. We need to abandon these unsupported traditions, from reclining on a couch, to talking for 50 minutes, to making an office visit. The main enduring truth is that change is hard.

Let us encourage people to keep moving along the unpredictable and arduous path to change. Freud realized that the work was intensive. Unfortunately, he emphasized the myth of insight over the reality of constant effort. He encouraged us to search for timeless conflicts, drawn from ancient dramas like Oedipus, but he really should have just emphasized that people only change with persistence. It is prose over poetry. Let’s find more prosaic tools.

Ed Jones, PhD, is senior vice president of the Institute for Health and Productivity Management.