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Happy (Belated) Birthday, Dr. Freud

Happy (Belated) Birthday, Dr. Freud Public Health Perspective
Howard Markel, MD, PhD
Analyzing Sigmund Freud, on the 150th anniversary of his birth (May 6, 1856) in Freiberg, Moravia (now Pribor in the Czech Republic), presents a challenge. He, more than any other figure in the last century, conditions the ways that we think about the way that we think. Today, however, the medicine of the mind that derives from Freud has abandoned some of his central precepts — ones that we, well or ill, disregard at our peril.

For his 150th birthday, many made a pilgrimage to the legendary apartment house, now a museum, at Bergasse 19, in Vienna, Austria. An ornate staircase leads to what was once the Freud family’s spacious second-floor flat, and pilgrims can take the very same steps as the Wolf Man, the Rat Man, and other memorable Freudian personages.

Most will be moved upon entering the study where Freud explored the vast, richly landscaped realm of the unconscious. Here, among his books, beloved ancient artifacts, and Persian rug-covered couch, he transformed how we perceive the world and ourselves.

Dr. Freud was hardly an overnight sensation. His fame was the product of years of patiently contemplating the vexing connections between the brain and the mind.

Freud’s Vienna was home to splendid hospitals, a superb medical school, and distinguished healers. After completing his medical studies in 1881, the young Dr. Freud took additional training to become a neurologist, but struggled to make a reputation. At first, having few patients, he spent many afternoons at the gemutlich Cafe Landtmann, nursing eine kleine Braunen (a short cup of black coffee) and puffing a cigar.

By the 1890s, Freud was seeing a growing number of upwardly mobile and decidedly nervous Wieners, whose psychic problems had somehow transmogrified into physical complaints or limitations in daily functioning. In an era before the dawn of modern psychiatry, when physicians had difficulty connecting the brain to the mind, it made perfect sense to these suffering patients to consult a neurologist who might root out a physical cause for what ailed them.

His patients’ problems led him to his theories on the importance of dreams; the battling factions of the mind that he called the id, the ego, and the superego; the primacy of sex in psychological development and daily thoughts; and the basic tenets of psychotherapy.

The impact of these findings was seismic. After Freud published his classic Interpretation of Dreams in 1900, other physicians migrated to Vienna to become psychotherapists, and even more patients flocked to their clinics to be analyzed.

Today, Freud’s id, ego, and superego may seem quaint to some, but to others, they are a remarkably prescient means of describing what neurobiologists identify as the discrete anatomic portions of the brain that guide human emotions, impulses, and actions.

Freud deserves the credit for introducing the age-old art of confession into the clinical arena. What we glibly call “talk therapy” is an elaborate process to get the patient not only talking about himself or herself, but also, more importantly, reconstructing repressed memories through interpretation and free association.

Today, many doctors and patients are quick to deride Freud’s theories as mired in bourgeois Viennese ennui, or, in an ever more pharmacologically driven world, simply out-of-date.

However, talk therapy sometimes helps solve the seemingly insoluble problem. For example, several studies of the treatment of depression, the most commonly diagnosed mental illness today, demonstrate that many patients do better with a combination of talk therapy and medication than with simply the use of one or the other.

Sadly, ours is a culture that is overdiagnosed, overprescribed, and overpathologized. Everyone is complicit in the dash to the well-stocked medicine chest. If a patient tells his or her doctor that he or she has been sad lately — a distinctly different entity from clinical depression — that patient is likely to leave with a prescription for an antidepressant. If a teacher complains loudly about a student’s overwhelming exuberance, which may or may not be attention-deficit disorder, there’s a good chance that that child may be slowed down a bit with some medication.

For many people with mental health problems, psychoactive medications can and do work wonders. However, we all need to recognize that, for some, these potent drugs have the potential to induce serious side effects and a host of unintended consequences. Physicians, especially, need to take more time to sort out patients who need medication and psychotherapy from those who may simply need to talk about their problems.

Perhaps, then, it is most fitting to celebrate Dr. Freud’s birthday by reflecting on the profound patience that he exhibited throughout his career — whether treating patients or developing ideas.

Freud understood, better than most of us, the healing power of listening to others and ability of this process to inspire great insight.

All of us, clinicians and patients alike, can benefit from incorporating this critical finding into our daily lives.

Howard Markel, MD, PhD, George E. Wantz Professor of the History of Medicine, Professor of Pediatrics and Communicable Diseases, Director of the Center for the History of Medicine, University of Michigan, Ann Arbor; author of When Germs Travel: Six Major Epidemics and the Fears They Have Unleashed, now available in paperback edition from Pantheon Books

Disclosure: Howard Markel, MD, PhD, has disclosed no relevant financial relationships.

Medscape Public Health & Prevention. 2006;4(1) ©2006 Medscape

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