What exactly do we mean when we speak of “mental illness?” To the extent that this phrase has entered the common vernacular, this question should not be reserved for professional psychologists, but should be one that the average person considers. Do we imagine a direct analog between this condition of the mind and the physical diseases we know so well? Or is our use of “illness” a little more complicated in the psychic realm?
The answer to this question will of course have therapeutic implications. If mental illnesses operate according to the logic of the many physical diseases we have on the books, then we would imagine that we could treat them in a similar way. When treating non-mental diseases, our general strategy is to identify their source at a point of pathologic divergence and then look for ways of correcting this divergence, thereby bringing the patient back to health. Of course, with non-mental diseases, our method for correcting the divergence is most often biochemical. We prescribe pharmaceuticals, which the patient is to consume in regular doses to keep the disease at bay. What would be the analogous treatment for diseases of the mind? The Austrian neurologist Sigmund Freud addresses this and related questions, articulating a science of the mind known as psycho-analysis, and advancing it as the best way to treat mental illness. He states in his “Introductory Lectures on Psycho-Analysis,”
“Is our psycho-analytic method a causal method or not…In so far as analytic therapy does not make it its first task too remove the symptoms, it is behaving like a causal therapy. In another respect, you may say, it is not. For we long ago traced the causal chain back through the repressions to the instinctual dispositions, their relative intensities in the constitution and the deviations in the course of their development. Supposing, now, that it was possible, by some chemical means, perhaps, to interfere in this mechanism, to increase or diminish the quantity of libido present at a given time or to strengthen one instinct at the cost of another–this then would be a causal therapy in the true sense of the word, for which our analysis would have carried out the indispensable preliminary work of reconnaissance. At present, as you know, there is no question of any such method of influencing libidinal processes; with our psychical therapy we attack at a different point in the combination–not exactly at what we know are the roots of the phenomena, but nevertheless far enough away from the symptoms, at a point which has been made accessible to us by some very remarkable circumstances” (542).
In this passage, Freud places psycho-analysis’s point of attack somewhere in between the symptoms of the mental illness and their underlying cause. In so doing, he touches on the relationship between the manifest and the latent in the human psyche, a common theme throughout his discussion. According to Freud, we know no way of treating mental illnesses by correcting the original disposition of the patient. This original disposition, which can be viewed as a mixture consisting of varying concentrations of instinctual drives, is a structural feature of the human psyche that lies below the surface of therapeutic influence. We cannot reduce the patient’s libidinal drive, nor can we strengthen his egoistic instinct. On the other hand, psycho-analysis does not attack the symptoms at the surface either. Rather, the treatment positions itself at some intermediate level between symptoms and root causes.
In order to understand what Freud means by this, we must consider Freud’s discussion of the etiology of the symptoms of neuroses. In his lecture on this topic, Freud describes how the libido, or sexual instinct, when deprived of satisfaction, regresses to a fixed point in the patient’s childhood, a point when the patient was able to satisfy his libido in full. The form of satisfaction that the libido then pursues, however, is generally an unconventional one, and often times this gives rise to a conflict in the mind. This conflict takes places between the ego, a feature of the mind which lies in the realm of consciousness, and the libido, which, in pursuing the new form of sexual satisfaction, struggles to become conscious. In a process known as repression, the libido is prevented from reaching consciousness by the ego, which has been socialized to view the new form of sexual satisfaction as perverted and unacceptable. The situation thus generated is one in which the unsatisfied libido is relegated to the unconscious and remains in conflict with the ego. The symptoms of neuroses emerge out of this state of conflict, and they represent some distorted form of libidinal satisfaction, while also incorporating elements of the resistance generated by the ego.
The key to curing the patient lies in the observation that in this conflict, the two forces do not occupy an even playing field. While the ego retains its position of authority in the conscious realm, the libido is forced to remain behind the scenes, inaccessible to our conscious selves. The task of psychoanalysis is then to equalize the playing field and make manifest the latent libido. The only way to do this is to return the patient to the precise moment when his libido was repressed from entering consciousness and hope that within the walls of the therapy session, subject to the therapist’s suggestions and orienting presence, the patient does not make the same mistake again and instead allows the libido to enter into consciousness. At this point, the work of psycho-analysis is complete, and the patient is free to navigate between the forces of ego and libido in full consciousness.
Returning to the question of whether psycho-analysis is a causal method, we may at least state without reservation that Freud’s methods operate at a level below the surface, at the place where the unconscious meets the conscious and the ego acts to repress the libido. In this fact alone, Freud’s methods differ in many ways from those of talk therapy today, which generally focuses on mental processes that the patient is conscious of. The very notion of unconscious mental activity suggests that there are forces which cannot be observed and that nonetheless play a role in shaping individuals’ thoughts and behaviors. We posit the existence of these unobserved forces because they do the best job of explaining the observed phenomenon. We are quite familiar with this process, as it happens all the time in the physical sciences. For example, we believe in a latent electromagnetic force that gives rise to the manifest phenomena of electric power and magnetic attraction. In performing the same analysis on the human mind, Freud developed both a scientific theory and a therapeutic method that was to have a lasting impact on the field of psychology.