But then Freud, by his own admission, was much less interested in healing the sick than in pioneering the “science” he called psychoanalysis. So he would have been dismayed to learn that, by the turn of the millennium, most psychiatrists would view his theories in roughly the same way chemists viewed alchemy: as a faintly embarrassing remnant of their field’s unscientific prehistory. “Freud’s ideas”, declared a major history of psychiatry in 1998, “are vanishing like the last snows of winter”. Ironically, Freud’s single surviving legacy in Western medicine looked set to be the use of talk therapies largely cleansed of psychoanalytic content.

This was a brutal demotion in status for a man whose impact was compared, in his lifetime, to that of Darwin. And even if that comparison was Freud’s own, it says a great deal that he wasn’t laughed out of Vienna for making it. Just as Darwin had uncovered the evolution of species by studying the flora and fauna of the Galapagos Islands, Freud believed he had uncovered the evolution of the mind by studying the unhappy patients on his couch. Many eminent contemporaries took him at his own estimation: Einstein wrote him fan mail, and Bertrand Russell campaigned for him to be awarded the Nobel Prize in Medicine. And Freud’s ideas came to hold such sway that through the Seventies the DSM-II, the American “bible” of psychiatric diagnosis, comprised a medley of psychoanalytic terms like “hysterical neurosis” and “schitzoid personality”.

Within a generation, university students were becoming more likely to encounter Freud’s ideas on a course in literary theory than one in psychology or psychiatry. One reason was the new discovery of primary sources which, in the Eighties and Nineties, turned assassinating Freud’s character into something of a public bloodsport among intellectuals. The wise and humble doctor eulogised by Auden now stood accused (irrefutably) of clinical ineptitude and scientific recklessness verging on fraud, (plausibly) of conducting an affair with his wife’s sister, and (absurdly) of attempted murder and child abuse.

Suggested reading

Why CBT won't set you free

By Nina Lyon

But far more damaging for Freud’s ideas was the rise, in the latter half of the 20th century, of an alternative view of mental illness based on three things: genes, brains and drugs. The decoding of the complete human genome promised to unveil the origins of psychological suffering in our parents’ DNA rather than in their care-giving styles. New brain imaging technology would enable us to observe psychiatric disorders in the contours of grey matter rather than rooting around for them in the murk of the unconscious. And new medications to treat mania, psychosis and depression were already replacing the hours of aimless chat prescribed by psychoanalysis. Freud began to look more like the founder of a religion than a scientist, and his followers like disciples zealously but fruitlessly interpreting his sacred texts. “Biomedical” psychiatry had seemingly triumphed; the real scientists would take over from here.

So it may come as a surprise that, decades after the study of the neuroses was replaced by that of the neurotransmitters, a prominent clinical psychologist has published a new book that includes a game attempt to make a scientific case for Freud. In Mortal Secrets: Freud, Vienna and the Making of the Modern Mind, Frank Tallis dares to take a harder line than most other Freudian holdouts. When their discipline came under siege from biomedical psychiatry, most psychoanalysts — turtlenecked figures who could quote Proust and Lacan but had never seen the inside of a lab — retreated to Hampstead, pulled up the drawbridge and turned inward. Adam Phillips, perhaps the most famous of them, now argued that Freud’s ideas cannot be false but, like poetry, only “more or less interesting, more or less inspiring”. Sounding like High Church mystics in the age of modern science, the psychoanalysts in effect helped downgrade their own field from a mighty branch of medicine to a (more inspiring, interesting — and expensive) rival to astrology.

By eschewing such relativism, Tallis may be out of step with contemporary psychiatry — contrast his subtitle with that of the 2006 work Freud: Inventor of the Modern Mind — but unlike Phillips et al., he at least takes Freud seriously on his own terms. After all, Freud fulminated against those like Jung who doubted the literal truth of ideas like penis envy and the oral and anal stages of sexual development. “We don’t reject Copernicus, Kepler or Galileo because they produced horoscopes,” Tallis points out. This is true, but some might object that there is rather more evidence that the earth travels around the sun than there is for the idea that the central trauma of a little boy’s life is his terror of being castrated by his father as punishment for wanting to sleep with his mother.

More from this author

WG Sebald's cure for trauma

By Matt Rowland Hill

Boldly (or, perhaps, rashly) Tallis attempts a review of the science. Freud’s ideas, he assures us, have had unspecified “seismic after-effects” in the field of biology. There have been conferences of something called the International Neuropsychoanalysis Society (among whose attendees, we are gravely informed, was Oliver Sacks). In support of Freud’s claim that dreams represent symbolic wish fulfilment, Tallis quotes a neuroscientist who writes that “‘wishing’ might be subserved by the mesocortical-mesolimbic dopamine circuitry of the brain”. There is certainly a pungent, science-y whiff to all this. But readers will decide for themselves whether it adds up to what Tallis calls “Freud’s scientific rehabilitation”.

But perhaps instead a case can be made for the enduring relevance to psychiatry of Freud’s worldview without resorting to scientific credulity or postmodern mystification. Indeed, millions of readers are already familiar with it by way of bestselling books based on a growing body of research on the effects of trauma. When Bessel van der Kolk argues that the human body “keeps the score” of the mind’s suffering, or that “traumatised people have a tendency to superimpose their trauma on everything around them and have trouble deciphering whatever is going on”, he can sound uncannily like Freud (whose work he liberally quotes). Likewise the Canadian physician and intellectual Gabor Mate when he writes that our early experiences can leave us trapped in a “physio-emotional time warp”. Van der Kolk and Mate place strong emphasis on “attachment theory”, first developed by the psychoanalyst John Bowlby, which explores how the effects of our early entanglements reverberate through our lives.

What’s more, the claim that Freud’s notions are unsupported by science no longer cuts as deep as it once did — because, as it turns out, so are some of the fundamental assumptions of the “biomedical” psychiatry that supposedly usurped them. The decoding of the human genome, completed in 2003, did not show that mental illness is predestined but, rather, that hereditary vulnerability interacts with our environment in enormously complex ways. Optimism around psychopharmacology has waned, as new psychiatric drugs have failed to appear and doubts about the efficacy and safety of the old ones has grown. And hopes brain imaging would transform psychiatry have petered out, as new technologies like fMRI have so far shown no utility in the diagnosis or treatment of mental illness. In 2022, a new history of psychiatry gloomily concluded that “biology is a bet whose payoff has been far more limited than its architects promised”.

None of this means that the Gothic edifice of Freud’s theories, with its vaults and gargoyles, is about to be rebuilt. But a sober assessment of what modern psychiatry can and cannot tell us suggests that, in broad outline if not in many of its details, his approach continues to hold much value. Our past loves and terrors can haunt us in the present. We are often opaque to ourselves, riven by conflicts we only half understand, our passions barely kept in check by external constraints. If we can be helped to overcome the thousand ways we protect ourselves from self-knowledge, we may see that our distress is not some random affliction but a meaningful response to the conditions of our development. Our suffering has a story, and it makes sense.

Freud once likened the way we repress unwanted thoughts to the ejection of a disruptive audience member from an academic lecture so that the event can continue smoothly. Now 30 years after Freud himself was manhandled from the podium of psychiatry and shut out of the lecture hall, the authorities who replaced him are faltering — and he can still be heard, banging on the door outside. Even if, as Auden wrote, “often he was wrong and, at times, absurd”, his voice cannot altogether be silenced. Perhaps the most canny assessment of him came from his wronged patient Horace Frink, who when Freud was dying was asked if he had any words for his former idol. “Tell him he was a great man,” said Frink, “even if he did invent psychoanalysis”.

In their understandable desire to get on with trials that might help people who are suffering, many researchers have sidestepped the question of what depression actually is. Instead, they’ve simply agreed on a definition and stuck to it. The Beck Depression Inventory is a questionnaire routinely used to diagnose and define depression: if you’ve ever spoken to your GP about feeling low, you might have come across it. It’s named after Aaron Beck, one of the most important figures in the history of psychiatry (who died aged 100 on November 1st this year). He came up with 21 questions that cover guilt, feelings of failure, weight loss, insomnia, and suicidal thoughts, among other common depressive complaints.

The problem is that the medical profession, and psychiatry researchers, might be relying a little too much on that list of symptoms. Indeed, in an odd, unintentional, circular move, they might have actually turned lists of symptoms into the very definition of depression. An essay by the eminent psychiatrist Kenneth Kendler argues that this is a fundamental mistake: the number of boxes a patient ticks on the list of symptoms that get you a diagnosis isn’t the same as “depression” (nor is their Beck Depression Inventory score) — even if psychiatrists and researchers often act like it is. The Inventory is very often used as the criterion for improvement in studies of treatment: if you achieve a 50% drop in symptoms as measured on his questionnaire, you count as having been positively affected by the treatment. But these criteria are a decent index of many of the common symptoms — not all of them. We know anxiety commonly comes alongside depression, Kendler notes, but it’s not on the standard diagnostic list. If we confuse the disease itself with a useful-but-limited list of its manifestations, we’ll find it harder to truly understand patients’ experiences.

Some researchers have gone a step further: should we stop using the concept of “depression” entirely? One study of thousands of depression patients found over 1,000 unique combinations of symptoms that all still count as “depression”. Maybe it’s time, argue some, to focus on understanding subtypes, or even just specific symptoms, rather than the monolithic entity of “depression” itself.

Suggested reading

Is the WHO inventing diseases?

By Tom Chivers

In some senses — and perhaps ironically — this accords with Beck’s philosophy: he was known for being sceptical of focusing on the ultimate, root causes of mental illness. Which brings us to the other major contribution for which he is remembered: Cognitive Behavioural Therapy. Beginning in the 1960s, Beck reacted against the most popular form of therapy at the time, which was based on Freud’s psychoanalytic theories of the mind. Beck — who himself was originally trained to administer psychoanalytic therapy — began to doubt that depression symptoms were always caused by childhood traumas and unconscious repression. Some of the Freudian theories were rather far-fetched — as Tony Soprano says to his psychoanalytic therapist, after she suggests for the umpteenth time that he might be harbouring some Oedipal desires: “I don’t wanna fuck my mother! I don’t give a shit what you say — you’re never gonna convince me!”

Instead, Beck suggested a much more proximal reason for the disorder: depression patients (and those with other disorders) are suffering from “thought distortions”. For example, they might catastrophise, blowing minor unfortunate occurrences in life out of all proportion. They might overgeneralise, thinking that a fallout with one friend means that they’re hated by everyone they know. As well as focusing his Depression Inventory on these kinds of thought patterns, Beck argued that therapy should target them and train patients out of them, rather than looking for some underlying explanation for all their symptoms.

Beck won the argument: although psychodynamic therapy still exists, CBT has now become the most popular — and by far the most studied — type of psychotherapy. New guidelines, announced this week, give patients the option of group CBT as the first line of treatment for mild depression; but even before then, it was extremely widely used. Its application goes well beyond depression: the language of CBT, with all its ideas about catastrophising and perfectionism and self-blame, is now, as Scott Alexander has memorably argued, “in the water supply”. But “popular” and “culturally influential” doesn’t necessarily mean “good”. What do the studies say about whether it works?

Suggested reading

Psychoanalysis doesn't work

By Tomiwa Owolade

Despite the sheer volume of research, the evidence is actually quite poor. The meta-analyses (reviews of all the studies that have looked at a particular question) do conclude that CBT works compared to doing nothing (a common control group, to which the therapy is compared, is made up of people who are on a waiting list for treatment). But it’s worth remembering that positive studies are more likely to be published than ones concluding that the experiment in question doesn’t work. And the overall literature on psychotherapy does show signs of this kind of bias.

So, even if the studies are right that CBT is beneficial (and in my view they most likely are), the extent of the benefit might be somewhat exaggerated. Those meta-analyses compare CBT to other common forms of psychotherapy, including the psychoanalytic kind (these days usually called “psychodynamic” therapy). The general picture is this: the effects of CBT are essentially the same as any other kind of psychotherapy. They all reduce depression symptoms, and they all still seem to work up to a year later (this particular kind of meta-analysis has to assume all the trials are comparable, though — and that’s often quite a big assumption).

It’s a very similar story for drugs: the meta-analyses show that essentially all forms of antidepressant work better than placebo. But these effects are likely a bit overblown by all the dodgy practices in the scientific literature. And the evidence for one antidepressant being substantially better than another is, to use the kind of language one often sees in the review studies, “limited” (which means researchers only have the vaguest clue).

More from this author

Never trust a scientist

By Stuart Ritchie

Although this is good news in one sense, it’s worrying (even depressing) in another. There is evidently a gaping hole in our evidence base on treating depression. If essentially all the major therapy types work to the same degree, despite being based on entirely different — often opposing — principles, it’s pretty difficult to pin down exactly why they work. What exactly are the therapists doing in their sessions that makes the treatment effective? Can we really say that Beck was correct about CBT being the best treatment if other forms of therapy, which take an entirely different approach, can do the same job?

Maybe it doesn’t matter whether therapists stick to Beck’s plausible cognitive theories or Freud’s absurd psychosexual ones. Maybe just having a regular interaction with a smart, sympathetic, well-organised person who focuses on your problems is what helps. That wouldn’t explain, though, why the analyses showed that some forms of self-directed therapy can also make a difference. Either way, all this raises the question: how can we make our therapies better if we don’t know the active ingredients? But then, how can we establish the active ingredients if we don’t even know what we’re treating?

You can call Samaritans for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.