05/30/17

Psychoanalysis Without Freud

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An article in STAT News on Freud and psychoanalysis, “Saving Sigmund,” caught my attention. It described how psychoanalysis is trying to “reinvigorate” itself. In the process, psychoanalysts are trying not to be “unduly fixated” on Freud’s stages of psychosexual development or his tripartite psyche of the id, ego and superego. One psychoanalyst said assuming she was Freudian was “like asking a modern-day nuclear physicist whether he’s Copernican.” While much of what Copernicus said was not true, it was a helpful foundation.

The analogy is a bit over the top and seems to be an attempt to distance current psychoanalysis from the rejection of many of Freud’s ideas. Writing for STAT, Carter Maness pointed to what may be the foundation of the need to reconceptualize psychoanalysis: only 15% of the members of the American Psychoanalytic Association (APA) are under 50. Traditional Freudian analysis is a dying art. “Lying on a couch, talking about your childhood, day after day for years — is widely seen as a musty relic, far too expensive and intensive to fit into modern life.”

The 1945 film Spellbound, directed by Alfred Hitchcock, captured Freudian psychoanalysis at the zenith of its popularity. The movie’s producer, David O. Selznick wanted Hitchcock to make a movie reflecting his own positive experience with psychoanalysis. Selznick even brought in his own analyst as a technical advisor for the film. The advisor clashed frequently with Hitchcock. Of course in a pro-Freudian movie like Spellbound, there was a dream sequence, which was designed by the artist Salvador Dali. In it, the Freud look-a-like character encouraged Gregory Peck to continue recalling the details of his dream—“the more cock-eyed, the better for the scientific side of it.”

Freud saw himself as a pioneering scientist and repeatedly asserted psychoanalysis was a new science. In his work, An Outline of Psycho-Analysis, Freud said conceiving mental life as a function of the psychical apparatus of id, ego and super-ego was “a scientific novelty.”

We assume that mental life is the function of an apparatus to which we ascribe the characteristics of being extended in space and being made up of several portions—which we imagine, that is, as resembling a telescope. . . . we have arrived at our knowledge of this apparatus by studying the individual development of human beings.

However, Freud’s claim that psychoanalysis was a science of the mind is the subject of continuing debate. As was pointed out in the article on Sigmund Freud in the Internet Encyclopedia of Philosophy, the scientific status of psychoanalysis is undermined since it cannot be falsified. Karl Popper’s criterion of demarcation between the scientific and the unscientific is that for something to be scientific it must be testable and therefore falsifiable.

 It is argued that nothing of the kind is possible with respect to Freud’s theory–it is not falsifiable. If the question is asked: “What does this theory imply which, if false, would show the whole theory to be false?,” the answer is “Nothing” because the theory is compatible with every possible state of affairs. Hence it is concluded that the theory is not scientific, and while this does not, as some critics claim, rob it of all value, it certainly diminishes its intellectual status as projected by its strongest advocates, including Freud himself.

Psychoanalytic thought finally lost its stranglehold on psychiatry in the 1980s with the reformulation of the Diagnostic and Statistical Manual (DSM). That was also the beginning of the rise of biological psychiatry. The heroic figures of psychoanalytic therapists in movies like Spellbound, The Snake Pit (1948), and The Three Faces of Eve (1957) changed. Psychiatric treatment began to be seen through the lens of movies like One Flew Over the Cuckoo’s Nest (1975) and Frances (1982).

Modern popular thinking on Freudian thought is satirically captured in the 1991 comedy, What About Bob? Bill Murray plays Bob Wiley, the unstable patient of an egotistical psychiatrist, Leo Marvin, played by Richard Dreyfuss. Unable to cope on his own, Bob Wiley follows and befriends Dr. Marvin’s family when the family leaves for a month-long vacation. Ultimately this pushes the good doctor over the edge and there is a role-reversal of sorts. Look for the appearance of a bust of Sigmund Freud in several scenes throughout the movie. By the way, Dr. Marvin’s son is named Sigmund. Here is a clip of the therapy session at the beginning of the film.

In order to reinvigorate their profession, psychoanalysts are repackaging the concepts underlying analysis and introducing them to school kids. A past president of the APA said: “We’ve started applying psychoanalytic ideas outside of our offices—in schools, in agencies, in business . . . . We’ve made social issues much more on the minds of our membership.” Project Realize, an alternative school for at-risk teenagers in Cicero Illinois, has treated more than 400 students expelled from regular school for aggressive and dysfunctional behavior. Now in its 12th year, it is said to have lowered rates of violence and improved graduation.

Training requirements have been altered somewhat. In the past, would-be analysts had to first earn an MD, a PhD, or an LCSW (a license to practice social work). Then they had to complete four years of coursework in psychoanalysis AND 200 hours of clinical training. In addition, they had to undergo analysis (four sessions per week) for at least two years.

One psychoanalyst in private practice remarked those requirements fit the 1950s, when every psychologist wanted to be an analyst. “If you’re doing a MD or a PhD or an LCSW, the conditions of starting a private practice and having a job don’t fit with analytic training anymore. Candidates find their analytic voice at 50. That’s nuts.” When Mark Smaller became the president-elect of the APA at 62, he said he could have been considered “a Young Turk.”

Freud has been dethroned as the king of psychotherapy and classic psychoanalysis is increasingly seen as a dying art. Now there is a two-year training for “psychoanalytic psychotherapy” offered by some training centers. It incorporates Freudian ideas about motivation and the unconscious and offers an easier and cheaper way to train as an analyst. And recent studies of Freud have suggested new, and intriguing perspectives into the man and the development of his theories.

In The Freudian Fallacy, E.M. Thornton said Freud’s personal use of cocaine was not just limited to his late twenties and early thirties, between 1884 and 1887.  She presented evidence that Freud resumed using cocaine in the latter half of 1892, “the year coinciding with the emergence of his revolutionary new theories, and asserts that these theories were the direct outcome of this usage [of cocaine].”

The false prophet of the drug world can propagate his message with as much conviction and authority as the true and his manner will have the same burning fervor and sincerity. In common with other victims of brain pathology, Freud would still have been able to reason skillfully from his false premises and so hide his psychotic traits from his followers. And yet, over the years, one by one, most of Freud’s inner circle of early disciples left him.

Paul Vitz developed a fascinating thesis that Freud had a strong, life-long positive identification and attraction to Christianity in Sigmund Freud’s Christian Unconscious. Vitz said there was also a concurrent secondary influence of unconscious hostility to Christianity seen in his preoccupation with the Devil, Hell, and the Anti-Christ.

All of this very substantial Christian (and anti-Christian) part of Freud should provide an understanding of his ambivalence about religion. It should also furnish a new framework for understanding major aspects of Freud’s personality, and allow us … to re-evaluate Freud’s psychology of religion.

As a young child, Sigmund had a Catholic nanny from around the age of one until he was two years and eight months old, maybe longer. It is likely that given that his mother had two pregnancies and births, and took care of a sick child who died during this time, that the nanny was also his wet nurse. Freud himself admitted that his nanny told him a great deal about God and hell. In a letter to his friend Wilhelm Fiess, he said:

I asked my mother whether she remembered my nurse. “Of course,” she said, “an elderly woman [Freud’s mother was 21 at the time of his birth], very shrewd indeed. She was always taking you to church. When you came home you used to preach, and tell us all about how God conducted His affairs.

In “Reassessing Freud’s Case Histories,” science historian Frank Sulloway said the intellectual quicksand upon which Freud built his theories and assembled his “empirical” observations was extensive. “His controversial clinical methods only served to magnify the conceptual problems already inherent in his dubious theoretical assumptions.” The training methods he supported were “highly influential” in removing psychoanalysis from academic science and medicine. “As a result, the discipline of psychoanalysis, which has always tapped considerable religious fervor among its adherents, has increasingly come to resemble a religion in its social organization.”

In “Why Freud Still Isn’t Dead,” John Horgan pointed out how there has been a recent trend in trying to find common ground between neuroscience and psychoanalysis. From one perspective, this fits as Freud originally trained as a neurologist and tried to base his theory of the psyche on an evolutionary sense of brain development. Here he followed the thought of Ernst Haeckel, who theorized the soul/psyche evolved biologically. In his classic 1892 work, Monism as Connecting Religion and Science, Haeckel said:

What we briefly designate as the “human soul,” is only the sum of our feeling, willing, and thinking—the sum of those physiological functions whose elementary organs are constituted by the microscopic ganglion-cells of our brain. Comparative anatomy and ontogeny show us how the wonderful structure of this last, the organ of our human soul, has in the course of millions of years been gradually built up from the brains of higher and lower vertebrates.

Horgan observed that science has failed to produce “a theory/therapy potent enough to render psychoanalysis obsolete once and for all.” Neither Freudians nor proponents of “more modern treatments” can point to any unambiguous evidence that psychoanalysis works or doesn’t work. “Until science yields an indisputably superior theory/therapy for the mind, psychoanalysis–and Freud–will endure.” Here’s the rub. When psychoanalysis asks “fundamental questions” like, “Why do people do the things they do,” it goes beyond the limits of what can legitimately be investigated by science. So science will never be able to develop unambiguous evidence for ANY theory/therapy for the mind.

Psychoanalysis may not be dead as a therapy, but it is not the science Freud thought it was. In a world dominated by the DSM, neurotransmitter dysregulation, and the search for the biomarkers of mental disorders, there is increasingly less room for Freudian constructs like psychosexual development and the id, ego and super ego. We might even say that Freudian thought is in danger of being overcome by its own death instinct.

04/7/17

Souless Psychiatry

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A psychiatric resident at Stanford University School of Medicine wrote an essay on the crisis with psychiatry that appeared in a Scientific American blog. The author said the field was in decline as fewer medical students sought to specialize in psychiatry. He stated psychiatry was looked down upon by nearly every segment of society; and patients avoided treatment because of the stigma related to the field. His solution was to change the name of the field—call it something else.

The crisis, in his view, stems largely from a misunderstanding of what psychiatry is. He said it was “the medical field where doctors incorporate neuroscience and medical research to treat patients with diagnosable mental disorders.” But his friends seem to think he interprets dreams and administers Rorschach tests. Administering Rorschach tests and interpreting dreams are activities associated with psychoanalytic practice that dominated psychiatry up until the 1970s. While “mental health” has made great strides raising awareness (i.e., May is now National Mental Health Awareness Month), “psychiatry has been left behind as its anachronistic forebear.” So he asked, “Would renaming the field help?”

The word psychiatry evokes thoughts of dated medical practices, like Freudian analysis and ice-pick lobotomies. Its sordid history turns away patients, providers, and the public from the progress of mental health care today.

He acknowledged where relabeling could be seen as a Band-Aid. A mere name change ignores the root causes of the problem, which from his perspective is the stigma attached to psychiatry and mental illness. However, citing studies of name changes within the U.S. and other countries, he suggested these language shifts helped psychiatry sound more reputable. He imagined most people would rather have a mental health disorder than a psychiatric disorder, “even if it were the same thing.”

“Mental Health Care” would be a simpler name for the field instead of psychiatry. Psychiatrists would then become “mental health physicians.” Medical centers could create departments of mental health, combining specialties such as internal medicine, psychiatry, psychology and social work. “By uniting these fractured disciplines under one roof, clinicians could provide more comprehensive care to patients without the stigma associated with aging terminology.” Mental health units were said by the author to be far less frightening than psychiatric wards.

In conclusion, he noted how the term psychiatry meant: “healing of the psyche,” drawn from the Greek goddess of the soul—Psyche. “It’s a romantic notion, but we don’t treat patients’ souls. We treat diagnosable diseases of the brain. Perhaps it’s time to rename the field.”

In reading this essay, I was reminded of what psychiatrist Jeffrey Lieberman wrote in his book, Shrinks about psychiatry. He commented that in the 1970s, “the majority of psychiatric institutions were clouded by ideology and dubious science,” mired in a pseudomedical Freudian landscape. But now in the twenty-first century, psychiatry offered scientific, humane and effective treatments. “Psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” You can read about the fallacies of “Freudian analysis and ice pick lobotomies” in Shrinks, but you won’t hear the complete and unvarnished truth about psychiatry.

Robert Whitaker astutely commented that Shrinks is more of a story of how psychiatry sees itself as an institution, than it is an accurate history of psychiatry. And I see the same approach here. I wonder if the Stanford psychiatric resident who wrote “Maybe We Should Call Psychiatry Something Else” is simply rehashing the received view of psychiatric history.

If you want a truly unvarnished look at psychiatry, read Whitaker: Mad in America, Anatomy of an Epidemic, and Psychiatry Under the Influence. You can read more about Lieberman and Shrinks on this website. Do a search for “Lieberman.”

The term “psychiatry” was originally coined by Johann Reil—a German physician—in 1808. And it does literally mean the medical treatment of the soul. Another German physician, Johann Heinroth was the first person to hold a chair of psychiatry. He also staked out working with the mentally ill as medical territory. Since there was little or no knowledge within the medical tradition to equip doctors to deal with mental disturbances, he proposed the creation of a new branch of medicine—psychiatry.

In his 1818 Textbook of Mental Disturbances, Heinroth said: “Since we are speaking of medical art and science, we should think that nobody but a doctor should have a right to make mental disturbance the object of his studies and treatment.” In The Myth of Psychotherapy, Thomas Szasz said of this time:

The birth of psychiatry occurs when the study of the human soul is transferred from religion to medicine, when the “cure of souls” becomes the “treatment of mental diseases,” and, most importantly, when the repression of the heretic-madman ceases to be within the jurisdiction of the priest and becomes the province of the psychiatrist.

There have been some radical shifts in how psychiatrists function since the early 1800s. Initially they were administrators of large institutions for the insane. Under Freud’s influence, psychiatrists began to consult with individuals living in society rather than working solely with those within institutions. Then in 1909, Freud was invited to give a series of lectures on psychoanalysis by Stanley Hall, the president of Clark University.

The cover photo for “Maybe We Should Call Psychiatry Something Else” shows seven men from the time of that conference, but only identified Sigmund Freud and Carl Jung. At the time, Jung was still friendly with Freud. The photo credit said the others were “pioneers in psychiatry,” but that is not entirely accurate. The photo shows Sigmund Freud and Carl Jung on either side of Stanley Hall in the front row. In the back row from left to right are Abraham Brill, Ernest Jones and Sandor Ferenczi.

Stanley Hall was a well-known American psychologist in addition to the then president of Clark University. He had an interest in Freud’s psychoanalytic theories and invited him to be part of a “galaxy of intellectual talent” to celebrate the twentieth anniversary of the founding of Clark University. Jung and Ferenczi were invited as the leading European disciples of Freud. Ernest Jones, another protégé of Freud, was then in Toronto Canada, building a private psychoanalytic practice and teaching at the University of Toronto. Jones would later become a biographer of Freud. Brill was the first psychoanalyst to practice in the U.S. and the first translator of Freud into English. In 1911 he founded the New York Psychoanalytic Society.

So these individuals are better seen as pioneers of Freudian psychoanalytic practice —the approach dismissed by the author of  “Maybe We Should Call Psychiatry Something Else” as a dated medical practice, which he placed alongside ice pick lobotomies.

By the 1940s, psychoanalytic theory had not only taken over American psychiatry, it had become part of our cultural psyche. Alfred Hitchcock’s 1945 film, Spellbound is an example of how influential psychoanalytic thinking was. The opening credits of the film announce that it wanted to highlight the virtues of psychoanalysis in banishing mental illness and restoring reason. Look for the Freud look-a-like character as Ingrid Bergman’s psychoanalyst and mentor.

Psychoanalytic thought dominated the field until the 1970s when the birth of biological psychiatry was ushered in by Robert Spitzer and his reformulation of psychiatric diagnosis. After Spitzer was appointed to do the revisions for the 3rd edition of the DSM in 1974, he was able to appoint whomever he wanted to the committees. He made himself the chair of all 25 committees and appointed individuals who he referred to as the “young mavericks” psychiatry. In other words, they weren’t interested in Freudian analysis. Spitzer said: “The feeling was that the same techniques that were useful in medicine, which is you describe something, you do laboratory studies; that those same kind of studies were appropriate for psychiatry.” Except it didn’t happen because in the 1970s, there just wasn’t a lot of psychiatric research. So the decisions of the committees were based on the expertise of the committee members.

David Chaffer was part of the process back then. He said committee members would gather together into a small room. Spitzer would sit with a mid 1970s “portable” computer and raise a provocative question. “And people would shout out their opinions from all sides of the room. And whoever shouted loudest tended to be heard. My own impression was … it was more like a tobacco auction than a sort of conference.” So much for using the same techniques as those used in medicine. Listen to the NPR story, “The Man Behind Psychiatry’s Diagnostic Manual” for the above information on Spitzer and the DSM.

But the real driving force behind the revisions made by Spitzer and others was because a “psychopharmacological revolution” couldn’t begin with the diagnostic process that existed before Spitzer and the DSM-III. Allen Frances, the chair of the next revision, the DSM-IV, acknowledged as much in his comments before the American College of Neuropsychopharmacology in 2000. Frances said the DSM-III was an innovative system that focused on descriptive diagnosis and provided explicit diagnostic criteria. “In many ways this aided, and was aided by, the knowledge derived from psychopharmacology. . . . The diagnostic system and psychopharmacology will continue to mature with one another.”

The psychopharmacological revolution required that there be a method of more systematic and reliable psychiatric diagnosis. This provided the major impetus for the development of the structured assessments and the research diagnostic criteria that were the immediate forerunners of DSM-III. In turn, the availability of well-defined psychiatric diagnoses stimulated the development of specific treatments and increasingly sophisticated psychopharmacological studies.

In the Foreword to his book, The Anatomy of an Epidemic, Robert Whitaker explained how he first wandered into the “minefield” of psychiatry by writing in the mid 1990s about research practices such as rapidly tapering schizophrenic patients off of their antipsychotic medications and then giving them a drug to exacerbate their symptoms. This “research” was done in the name of studying the biology of psychosis. Jeffery Lieberman took part in some of those studies, using methylphenidate (Ritalin, Concerta) to deliberately provoke psychotic symptoms in schizophrenic patients. Read “Psychiatry, Diagnose Thyself! Part 2” for more information on Whitaker’s articles and Lieberman. Incidentally, the series of articles Whitaker co-wrote for the Boston Globe was a finalist for the Pulitzer Prize for Public Service. Whitaker said in the Foreword to Anatomy of an Epidemic:

I began this long intellectual journey as a believer in the conventional wisdom. I believed that psychiatric researchers were discovering drugs that helped “balance” brain chemistry. These medications were like “insulin for diabetes.” I believed that to be true because that is what I had been told by psychiatrists while writing for newspapers. But then I tumbled upon the Harvard study and the WHO findings, and that set me off on an intellectual quest that ultimately grew into this book, The Anatomy of an Epidemic.

Maybe there is a stigma against psychiatry for more than just the past use of ice pick lobotomies or insulin comas or ice baths or the electroshock treatment shown in One Flew Over the Cuckoo’s Nest. But simply changing the name of what we now call psychiatry will not change the opposition against a medical specialty that no longer treats patients’ souls. And perhaps that is really why the field is in decline.

08/18/14

Sigmund Freud was a Cocaine Evangelist and Addict

Sigmund FreudSo here is the continuing story on Sigmund Freud and cocaine begun in “Raising the Stakes in the War on Cocaine Addiction.” To give a quick recap, Freud began experimenting with cocaine in April of 1884. He used it to treat depression, saying it was a “magic drug.” He hoped that with his help cocaine could “win its place in therapeutics by the side of morphine.”

According to Paul Vitz, Freud’s evangelism of cocaine seems to have been driven by three things:

  1. his intense desire to get married to his fiancée and fear of losing her (a separation anxiety, in Freudian terms);
  2. his drive to become a medical success story in championing the positive effects of a new drug, thus advancing his career and financial prospects (so he could marry); and
  3. to treat his personal struggle with depression (largely induced by his separation anxiety).

When describing his personal experiences in treating his depression with cocaine, Freud said he felt “exhilaration and lasting euphoria, which in no ways differs from the normal euphoria of the healthy person.” He saw an increase in his self-control and capacity for work. He had no unpleasant after effects, as with alcohol and “absolutely no craving” for more cocaine, even after repeated use. “In other words, you are simply normal, and it is soon hard to believe that you are under the influence of any drug.”

He recommended cocaine to family, friends and professional colleagues alike. A friend of Freud’s, Dr. Ernst Fleischl became addicted to morphine while attempting to treat a painful neurological disease. Freud attempted to counteract his morphine addiction with cocaine. At first, cocaine was a helpful substitute for the morphine.

But Fleischl had to increase his cocaine dose as tolerance set in. After one year of cocaine use he was taking a full gram of it daily—TWENTY TIMES the dose Freud personally used. Fleischl was now dually addicted to opiates and cocaine. He soon developed a full-fledged cocaine psychosis, with visions of “white snakes creeping over his skin.”

Freud and other physician friends had little success in weaning Fleischl from his drug use. By June of 1885, Freud thought his friend had about six months to live. Fleischl remained alive for another six pain-filled years. Freud later acknowledged he might have hastened his friend’s death, by “trying to cast out the devil with Beelzebub.”

In July of 1885 a German authority on addiction began publishing a series of articles on cocaine as an addictive drug. A friend of Freud’s, originally favorable towards cocaine, reported that it produced severe mental disturbances. One prominent doctor said Freud had unleashed “the third great scourge of mankind.” The first two were opium and alcohol.

By 1890, the addictive and psychosis producing nature of cocaine was well documented. Freud had moved on in his search for fame and fortune to other interests. And when he co-authored Studies on Hysteria with Joseph Breuer in 1895, psychoanalysis was born. However, Freud continued to use and prescribe cocaine until at least 1896.

Freud 1893 script

image credit: Robert Edwards Auctions.

A handwritten prescription for a “white powder”, signed by Sigmund Freud in 1893, is evidence of his continued cocaine use. In 2004, Robert Edwards Auctions sold this prescription for $2,875.

Freud’s letters to a friend and fellow cocaine user, Wilheim Fleiss, contained several references to his ongoing cocaine use. On January 24, 1895, Freud described to Fleiss how a “cocainization” of his left nostril helped him to an amazing extent. He wrote on April 20, 1895 that he pulled himself out of a miserable (depression?) attack with a cocaine application. On June 12th, 1895, Freud wrote: “I need a lot of cocaine.”

Several scholars have debated whether Freud’s use of cocaine influenced his developing theories. Both Fredrick Crews and E. M. Thornton have argued that Freud’s use of cocaine had a significant influence on his developing theories, especially their emphasis on sex. Thornton claimed that Freud’s psychological theory was the natural outcome of his extensive cocaine usage.

Paul Vitz took a more nuanced approach in Sigmund Freud’s Christian Unconscious, stating that much of Freud’s psychology was evident before he began using cocaine. Freud’s cocaine use may have contributed to sloppy thinking at times. It could have contributed to his preoccupation with sex, or made his depressions darker and more difficult to fight. “But cocaine did not create the primary content and structure of Freud’s mind and thought.”

Yet Thorton presented some rather convincing evidence of Freud’s cocaine “problem” and its potential influence on his theories. Freud himself said that psychoanalysis began with his research into hysteria: “The Studies on Hysteria by Breuer and myself, published in 1895, were the beginnings of psycho-analysis.” Freud began to have heart problems (one of the side effects of cocaine abuse) early in 1894. He suffered from “fainting” spells—four of which were publically witnessed by others. He had an obsession with dreams; some paranoid traits and a tendency towards grandiosity.

In The Interpretation of Dreams, Freud recounted a dream he had in 1895 where he saw a patient with scabs on her turbinal bones, which recalled a worry he had about his own health:

At the time I frequently used cocaine in order to suppress distressing swellings in the nose, and I had heard a few days previously that a lady patient who did likewise had contracted an extensive necrosis of the nasal mucous membrane. In 1885 it was I who had recommended the use of cocaine, and I had been gravely reproached in consequence. A dear friend, who had died before the date of this dream, had hastened his end by the misuse of this remedy.

By 1895 Freud had probably been using cocaine (nasally) for over two years. Physically, the effects of this heavy usage would have been essentially identical to the catalogue of symptoms noted by Fleiss as those for “nasal reflex neurosis” (headache, vertigo, dizziness, acceleration and irregularity of the heart, respiratory difficulties, etc.). So the physical problem that Freud treated with cocaine (nasal reflex neurosis) was essentially caused by his use of cocaine.

His paranoia was evident in the public breakups he had with formerly close associates like Breuer—with whom he wrote Studies in Hysteria (1894), Fliess (1900), and Jung (1913). Freud’s interpretation of Jung’s dream in 1907, just after they met face-to-face for the first time, was that Jung wished to dethrone him and take his place in the psychoanalytic movement.

Do you think that Freud’s cocaine use had any influence on his psychoanalytic theories?