The Fall of Freud

By Neuroskeptic | June 30, 2010 9:00 am

The works of Sigmund Freud were enormously influential in 20th century psychiatry, but they’ve now been reduced to little more than a fringe belief system. Armed with the latest version of my PubMed history script, and inspired by this classic gnxp post on the death of Marxism, postmodernism, and other stupid academic fads I decided to see how this happened.

As you can see, the number of published scientific papers related to Freud-y search terms like psychoanalytic has flat-lined for the past 50 years. That represents a serious collapse of influence, given the enormous expansion in the amount of research being published over this time.

Since 1960 the number of papers on schizophrenia has risen by a factor of 10 and anxiety by a factor of 80 (sic). The peak of Freud’s fame was 1968, when almost as many papers referenced psychoanalytic (721) as did schizophrenia (989), and it was more than half as popular as antidepressants (1372). Today it’s just 10% of either. Proportionally speaking, psychoanalysis has gone out with a whimper, though not a bang.

The rise of Cognitive Behavioral Therapy (CBT), however, is even more dramatic. From being almost unheard until the late 80’s, it overtook psychoanalytic in 1993, and it’s now more popular than antipsychotics and close on the heels of antidepressants.

What’s going to happen in the future? If there is to be a struggle for influence it looks set to be fought between CBT and biological psychiatry, if only because they’re pretty much the only games left in town. Yet one of the reasons behind CBT’s widespread appeal is that it hasn’t thus far overtly challenged biology, has adopted the methods of medicine (clinical trials etc.), and has presented itself as being useful as well as medication rather than instead of it.

One of the few exceptions was Richard Bentall’s book Madness Explained (2003) in which he criticized psychiatry and presented a cognitive-behavioural alternative to orthodox biological theories of schizophrenia and bipolar disorder. Bentall remains on the radical wing of the CBT community but in the coming decades this kind of thing may become more common. Only time will tell…

CATEGORIZED UNDER: freud, graphs, history, mental health
  • Anonymous

    Looked at another way, there is a perfect correlation between what you term “The Fall of Freud” and the rise of the very corrupt field of “Market-Driven Medicine” or biological psychiatry. And what has been biological psychiatry's treatment yield for those suffering from mental illness? Isn't the best treatment for severe melancholic depression still ECT? Isn't the best mood stabilizer and the only one with both antidepressant and anti-manic properties still lithium? Second generation anti-psychotics trump the first generation agents in efficacy? Not on your frigging life. Just decide if you want diabetes and obesity versus TD. SSRI's versus the older agents? Same f-ing story. No better; mostly placebo and just different side effects. Magnets on the brain? Gimme a break! Outcome for schizophrenia better in the industrialized nations as compared to third world countries? Nope again! For all of the non-psychodynamic “research” filling up journals (much of it funded and therefore slanted and faked by Big Pharma), there really hasn't been much in the way of progress for our patients.

  • Anonymous

    If papers referencing “psychoanalysis” have flat-lined for 50 YEARS at about 600 a year, how can you say there has been a “collapse?” When? 50 YEARS ago? Were there EVER more than 700 papers a year published referencing psychoanalysis? All you illustrate is that there has been an explosion of papers published in psychiatry, most of it probably junk science, and psychoanalytic publications, far from “collapsing” have remained STABLE! LOL.

  • Anonymous

    Proportionally speaking

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Quite – 50 years ago, most papers about psychiatry referred to psychoanalysis. Now the vast majority don't.

    I actually have a lot of time for Freud. He had some obsession with sex and some ridiculous ideas about kids. But ignore those bits and he could be pretty insightful.

  • http://www.blogger.com/profile/04103502029181168438 E

    Anon @ 13:14

    I would like to see the evidence for your assertion for ECT being the most effective treatment for melancholic depression (whatever that is) or for Li being the only mood stabiliser with antidepressant and anti manic properties. These are both effective treatments certainly but where is the evidence for your assertions?

    As for second generation (atypical) antipsychotics it is true that they are scarcely any more effective at treating psychosis than the first generation medications but they are far better tolerated than the old anti-psychotics and as compliance was half the battle I would say that was a significant factor in their favour. Read what crazy meds (http://www.crazymeds.us/) has to say about Olanzapine for instance.

    “There is no better medication if you or a loved one are in some kind of mental health crisis! Seriously, if someone is flipping out due to schizophrenia, some form of bipolar mania or several other flip-outs, Zyprexa (olanzapine) is just the thing to calm them the hell down right now and let them think straight about long-term treatment options. Maybe it will be part of their long-term med cocktail, maybe not, but until you can think straight in the first place, you can't make any long-term decisions. Fast-acting and effective, it's great to have in the medicine cabinet for bipolar emergencies. When combined with the right antidepressant, it could be just the thing to conquer that treatment-resistant depression that nothing else will deal with.”

    Has anyone else noticed that the predominant theory of mind for any period of time appears to borrow heavily on the technology of the time? In Freud’s time the dominant technology was steam power and what images does Papa Freud’s theory of psychodynamics bring to mind with it’s subconscious desires bubbling to the surface displacing ideas and transferring our emotions from one place to another? Today it is CBT with it’s notion of the brain as a giant supercomputer that can be debugged, reprogrammed and rebooted to work free of the glitches and viruses that plagued its earlier operation. Darian Leader at the Guardian is very anti CBT but then as a fully paid up member of the Ooo-be-do school of psychological thought he would be.

  • dearieme

    To the man-in-the-street, who, I'm sorry to say, is a keen observer of life,
    The phrase Freudian Therapist suggests straight away a man who's untrue to his wife.

    [Auden, adapted]

  • Anonymous

    E:
    Consult any standard psychopharmacology textbook or just ask any psychiatrist and you will have your “evidence” that lithium is the only agent with both anti-depressant and anti-manic properties. The rest of the so-called mood stabilizing agents only have anti-manic properties.
    As for “melancholic” depression, it is, here in the US seen as the old endogenous depression, characterized by debilitating neuro-vegetative signs, extreme guilt, and ideation paralysis. Drugs don't touch this puppy (even with the rip off drug Abilify as an add on). ECT does, and has done so for about 60 years.
    I agree with your comment that Zyprexa can stop mania in its track. But Zyprexa has no anti-depressant action, so my prior comment holds. And, as we know in the States, Zyprexa (and Risperdal and Seroquel) will make you fat as a pig in short order, with diabetic complications to follow in short order. Again, pick your poison.
    On another note, I find your observation that culture dictates the predominant model of the mind as fascinating and insightful. I agree whole heartedly and applaud your insight.
    Neuro:
    Do you have kids? Have you ever hung around children and observed them closely? Have you ever had the experience of a daughter coming up to their mother and announcing that they were going to marry “Daddy” one day? Have you ever attended a parent-teacher conference where the art work of pre-schoolers was on display, and witness how often family pictures by little girls depict fathers with penis'?. Apparently not. Freud shed light on infantile sexuality, and I don't think this should be news to you or any other informed observer (or parent) of the human condition.

    PS I love your blog!

  • http://www.blogger.com/profile/14972394536850151087 jonathan

    wonder what the graph would look like for autism from 1970 to 2010. Probably higher than any of those others.

  • Anonymous

    Jonathan:
    EXACTLY. But then Neuro would have had blog an article entitled: “The Fall of Psychiatry.”

  • http://www.cephalove.blogspot.com Mike Lisieski

    Anonymous:

    “Freud shed light on infantile sexuality”

    Describing a phenomenon (for example, a little girl drawing a picture of daddy's penis) and explaining it using mechanisms that can never possibly be directly observed or measured is hardly “shedding light” on something, in the scientific sense. Whether Freudian psychotherapy works for certain behavioral problems or leaves patients feeling better are different questions, but I can't agree that Freud did much to illuminate the workings of the mind besides, perhaps, popularizing psychology and giving other, perhaps less imaginative, scientists a fad to decry, or simply daring to mention behaviors that nobody felt comfortable enough with to talk about.

    Also, the use of the abbreviation “CBT” for cognitive-behavioral therapy is funny to me because it's also used by the fetish and body-mod community to refer to “cock and ball torture,” defined by the BMEzine wiki as “sexual play involving some degree of pain applied to the male genitals specifically.” I imagine that there have to be a few guys at every conference who get giggly when people start throwing that term around nonchalantly.

  • bakunin

    Great work both you and gnxp on this meta-analysis!

    In the same respect, I just did a pubmed search that shows medical interest in Asia related topics peaked in 2008!

    Good to know Asia is becoming less relevant today — on the decline as it were. (Read sarcasm.)

    Talk about idiocy, gnxp's conclusions most of all — Feminism and Marxism is like an infection!?

    In perhaps an ironic coincidence, publications on ethics peaked in 2005.

    Let's hope you don't think ethics is of dwindling importance because pubmed has increasingly less articles on it!

    (references:
    - on Asia: http://www.gopubmed.com/web/gopubmed/1?WEB01e1dv65qa6w9iI9gI1I00h001000j100500001001000000120
    - on ethics: http://www.gopubmed.com/web/gopubmed/1?WEB01e1dv65qa6w9iIazI1I00h001000j100500001001000000120 )

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    bakunin: Well there's always a lag such that the current year, and also to a lesser extent the last year, don't get as many hits as they should. So if something “peaked” in 2008, I always take that with a pinch of salt – notice that the same is true for most of the lines of my graph, but I don't think that's real, I do not think interest in CBT has peaked yet.

    As for Ethics, it does seem to have leveled off since 2005. I'm not sure what that means though…

    With psychoanalysis, you have to admit that the trend (or lack of one) is dramatic: and no-one could deny that the influence of Freud's ideas has declined. It's interesting that it happened so gradually and in such a way. And I'm not saying anything about whether it should have happened.

  • http://www.blogger.com/profile/04103502029181168438 E

    Annon @ 02:08

    I asked the psychiatrist in our team and while she agreed that Li has the best anti-depressant/ anti-manic properties she did not agree it was the only mood stabiliser with both effects (wouldn’t be a mood stabiliser otherwise I suppose). Depakote comes a close second followed by Lamotragene and Carbamazipine (in that order).

    According to our team Doctor Deapakote is more popular in the US with Li more popular in the UK, (make of that what you will Neuroskeptic has already blogged on the malign influence on direct to customer drug advertising) , Li is more toxic on the kidneys where Depakote is harder on the liver so that would be another factor to consider when choosing what drug to prescribe.

    Some of the other Consultants are keen on an antipsychotic such as Olanzapine augmented with an SSRI for Bi Polar which is another alternative. We don’t tend to use the term melancholic depression over here it’s usually called severe uni-polar depression and like you I have seen people literally sparked (no pun intended) back to life by ECT.

    On a similar note SSRI’s are not thought to be much of an improvement in terms of efficacy over the old tri-cyclics but they are a hell of a sight safer in overdose which is reason enough for prescribing them

  • Tierra Ortiz-Rodriguez

    Howdy Neuroskeptic, I disagree! Freud's sphere of influence to-date is stable and pervasive, albeit subtle, and it's even receiving cross-disciplinary support. It's true: you may not find as many formal papers today on psychoanalysis as in mid 20th century, but there's a steadily growing literature providing empirical support for some of his core insights, like the unconscious.

    I'd recommend reading “The scientific legacy of Sigmund Freud: Toward a psychodynamically informed psychological science” by Westen (1998). Here's a more recent validation of a Freudian offshoot, psychodynamic psychotherapy: http://www.sciencedaily.com/releases/2010/01/100125094501.htm.

    There are legitimate critiques of Freudian theories and reasons why psychoanalysis is no longer a dominant therapeutic modality (however, let's not ignore how health care systems shape what is considered as best research and practice, why and by whom), but I think it's too soon to proclaim the fall of Freud. The diffusion of Freud seems more accurate! The number of recent papers referencing psychoanalysis is a weak proxy for assessing the state of Freud's legacy, but I applaud your spirit of deconstruction! We need to explore and challenge our foundational belief systems, whichever theory they stem from.

  • http://www.blogger.com/profile/04103502029181168438 E

    @ Tierra Ortiz-Rodriguez

    “but there's a steadily growing literature providing empirical support for some of his core insights, like the unconscious.”

    Empirical evidence for something which is not available to the conscious mind? Like a black hole bending the light around it but otherwise invisible to the naked eye? Mmmmmm not sure about that myself. What is this “evidence” to which you refer?

    @ Mike Lisieski

    CBT – Cock and Ball Torture, not heard that one made me laugh ?

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Once you learn about the “other” CBT, you will never be able to say stuff like 'CBT session' with a straight face again.

  • http://www.blogger.com/profile/06340730498047128203 Dr. Deb

    As a recently trained psychoanalyst, I can attest that interest in training has waned over the years. I believe strongly that insurance-managed, short-term cost benefits guides the market share and are responsible for shaping this trend. Despite the numbers being down, there is still great public interest in this form of therapy. My practice is thriving and successful.

  • bakunin

    Here's another to make my point:

    “Behaviorism” peaked in 2000 on pubmed.

    But obviously many principles of Behaviorism — such as training animals for experiments — aren't less important today than they were a decade ago.

    My point, using key word trends to make substantive claims about a discipline is extremely dubious.

    (ref: “Behaviorism”, http://www.gopubmed.com/web/gopubmed/WEB1lOWEB10O00h00100090000100h001000j100300.y )

  • Anonymous

    E:
    Your dismissal of “scientific” evidence that does not involve conscious experience is a bit naive and a throw back to William James' problems with this issue about a century and half ago. Frankly, I don;t think anyone would dispute the “reality” of automatic or unconscious mental processes influencing behavior. And you don't have to resort to psychoanalysis for this conclusion. Why, just turn to all the neuroscience fMRI studies that show that brain imaging is a better predictor than conscious thought patterns as to the decisions people make. There is a study in the current issue of the Journal of Neurology which makes this point regarding who will buy sunscreen, despite their stated intentions! Brain imaging evidence for the existence of the unconscious indeed!

  • Anonymous

    Hey Neuro:
    I just did a quick statistical analysis of posts to your subject stories for the past three months and and found that Freud and psychoanalysis seems to be pretty popular, proportionally so, that is! 19 posts and counting! The only competitors are from dating studies, psychopaths, happiness and fish, SSRI's and suicide, and labeling one as mentally -ill (bipolar). Seems like Freud can still spark a hard on for many readers!

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    19 posts? I think not, if you take a look at the tags you will see only 4 Freud posts. Even Oliver James has 4 posts. Actually, now you put it that way, Freud should have more posts. No-one deserves to be on a level with OJ.

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    bakunin: That's a good point actually, but the fact that publications about “behaviorism” peaked in 2000 does tell us something: it tells us that, although scientists are still using behavioristic methods (Pavlovian conditioning, etc.) – and I'm sure publications using these methods will have been increasing – they're not doing so while concious that they relate to the theory of behaviorism. They're just using the tools.

    So yes one could argue that psychiatry is still Freudian, it just doesn't explicitly acknowledge it; but I think prima facie that seems unlikely given that psychiatry today is so biological.

    Whereas I think that objection is a lot more serious when applied to the gnxp post (the fact that people aren't talking about “postmodernism” doesn't mean we're not thinking like postmodernists.)

  • http://www.blogger.com/profile/04103502029181168438 E

    Anon @ 02:02

    I think you are confusing the sub-conscious with the un-conscious. I know many people who would dispute the very existence of the sub-conscious in Freudian terms but are quite comfortable with the idea of the unconcious.

    I think Neuroskeptic has already blogged about fMFI scans and corresponding conscious states and I believe the conclusion was that brain images are a far from reliable indicator of what, if anything, a subject is thinking of far less what they may or may not be intending to do at some point hence depending on this or that eventuality.

    Is that William James 11/01/1842 – 26/08/1910 American psychologist and philosopher? If so then his assertion that a true belief is one that is useful to its believer would appear to support your position rather than mine although his assertion that we are scared of the bear because we choose to run away from it rather than we run away from the bear because we are scared might argue against the idea of a Freudian subconscious influencing our conscious self especially as some of those fMRI studies you mentioned earlier show that the action potential in muscles is building before the brain is consciously aware of the reason for moving

  • Anonymous

    Neuro:
    I didn't mean that you wrote 19 posts on Freud or psychoanalysis. I was referring to the number of responses to this post; now it is 23 and counting. And this has been one of your most responded to posts in a long time. So yes the old guy can still get a rise out of people even though he has been dead and buried for about 70 years.

    E: Let me get you the link to the recent Neurology article about how fMRI's were better predictors of future behavior (buying suntan lotion) than consciously stated intents of subjects.

  • anonymivorous

    Anonymous,
    To note the power of ECT, Li, and antipsychotics, and then conclude from this that we should move AWAY from bio and TOWARD the psychodynamic is……… idiosyncratic.

    I would have thought that powerful psychodynamic treatments, not powerful biologic treatments, would constitute evidence for the value of psychodynamic research.

  • http://www.blogger.com/profile/15509443197147729977 Sean Wills

    That gnxp article is a lot more hostile than it needs to be.

    It's also not very well informed. I don't doubt that the data are correct, but the idea that postcolonialism and feminism (feminism, of all things) are now dead buried is ludicrous – as is the idea that either of them were just a 'big joke'.

    And I really wish people would stop acting as if the Sokal hoax somehow destroyed every single bit of postermodern thought in existence. Read the prefaces to their book – they were debunking the very specific (and silly) habit some French postmodernist writers had (have?) of trying to use scientific terminology in ridiculous ways. 'Postmodernism' is a lot more than just those authors.

    I'll be the first to admit that there's a lot of crap literary and cultural studies, but I wish people would dig a bit deeper before they denounce an entire field as pointless.

  • Anonymous

    “Since 1960 the number of papers on schizophrenia has risen by a factor of 10 and anxiety by a factor of 80 (sic).”

    What is the “sic” for? Is that supposed to be for emphasis?

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Yes. I found it very surprising.

  • Anonymous

    anonymivorous:
    Ah, just who said we should “move away from bio and TOWARD the psychodynamic”? I simply pointed out the very poor and inconsequential yield of biological psychiatry research in terms of new and innovative treatments for the mentally-ill. I find your rejoinder to my post as … well both idiosyncratic… and inane.

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    I agree that the last 50 years of research in biological psychiatry haven't provided the advances that people (not unreasonably) hoped for in say 1960.

    However it would be wrong to say there have been no advances. SSRIs for example really are a lot safer and better tolerated than TCAs (no antihistamine or anticholinergic effects) and are effective for OCD and anxiety, albeit maybe not as good as TCAs for depression… and atypicals may not be as good as they were first hyped, but I for one would rather have diabetes and weight gain than tardive dyskinesia, if only because you can treat diabetes.

    As to why the last 50 years haven't panned out as they could have, that's another story.

  • Anonymous

    Neuro:
    So if I read you right, you are basically saying that the advancements made in psychiatry, with the possible exception of OCD spectrum phenomena, largely come down to providing our patients with a greater range of side effects to choose from and endure. Yeah, that's progress.

  • http://www.philosopher-animal.com/ Keith Douglas

    Seems that lots of discussion of the (very dubious in my view, but that's another story) legacy of Freud and psychoanalysis turns to “discovered the unconscious”. There are a *lot* of precursors to that view: Leibniz, Nietzsche, and most importantly, Schopenhauer. The latter, as far as I can tell, is the most important link.

  • Paul

    May be wrong but not sure Bentall is seen as radical within the CBT for psychosis camp… He's certainly a big influence but perhaps it does him a disservice to label him as radical? He was one of the main authors on what I see as a sort of manifesto for CBT for psychosis (www.understandingpsychosis.com)

    In terms of CBT vs meds, we're doing an RCT now of CBT for people experiencing psychosis but not taking antipsychotics (cbt plus standard care vs standard care). Not vs meds, but simply trying to generate evidence for effective treatments in those refusing or discontinuing antipsychotics (i.e., the majority – e.g., CATIE trial).

    Effect sizes will always be lower for CBT compared to meds but CBT probably more acceptable. Drop-out rates in CBT trials (often lasting 6 months or more) are very low – drop-out rates in drug vs placebo trials are astonishingly high over 6-12 weeks. Recent Lynch et al meta-analysis totally ignored this, despite move in drug trial community to use drop-out as a principal outcome (wrongly in my view).

    CBT vs meds for schizophrenia with drop-out as principal effectiveness outcome? I'd put my money on CBT!

  • anonymivorous

    I take the view that there's not that much new under the sun. It's kind of amazing how much of Nietzsche seems to be taken right outta Pascal, Stendhal, and Heine. But the way Nietzsche did it up was different in subtle but robust ways.

    So maybe Freud also made some subtle-robust additions. But I'm not going to bother trying to find out. The man has too many stunning anti-credentials, such as his Oedipus theory, his consummate anti-Judith Rich Harrisness, and so on. Whatever has happened to him vis-a-vis medicine, evo psych and Harris have smashed him vis-a-vis philosophy and overall pictures of man and the world. Presumably all “third culture” types laugh at him — and will probably slowly influence lit crit types to do the same (not that that matters).

  • http://www.pointlessincessantbarking.com Allison

    The assertion that the fall of Freudianism and rise of CBT is related to our culture and level of technology was indeed interesting. I'd guess that the trends in scientific research don't necessarily reflect current practices. I would guess that there are very few therapists, even the ones that call themselves behaviorists, that have never asked the client about their childhood, or their parents. And everyone who receives training on how to be a therapist learns about psychodynamic theory and transference/countertransference. It's ridiculously hard to study these things, however. How can you possibly construct a controlled imaging study on psychodynamic therapy that would make it into any journal with an impact factor greater than 2?

  • Davigo

    Neuroskeptic:

    It's interesting, but I wanna know how did you get the result for the term “cognitive behavio(u)ral therapy”.
    In fact, I've checked your data of 2009 in PubMed site. All other results are correct, but I think the result of this three-word term is problematic for two reasons:

    1) If I did a search with “cognitive behavioral therapy”, I've got 2047 results, and with “cognitive behavioural therapy” 1906 results. But I could't add this two results arithmetically to get a number similar to yours, because there would be too many double entries. So I combined the search formulas, which you can find at the right side of the result page, and got 2190 results.

    2) But they still contain some irrelevent results, where I can find the three word (“cognitive”, “behavior”, “therapy”), but no topic of psychotherapy.
    An example: http://www.ncbi.nlm.nih.gov/pubmed/20518230

    To remove these results, I have to refine the formula, which would reduce the number of results, and I couldn't have the number you've got.

    So I wanna know which formula did you use for the result.

    Davigo from Paris
    (Sorry for my awkward english. I'm a Korean guy…)

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Hi Davigo, Thanks for the comment. I actually can't remember exactly how I got the CBT figures. As you point out, it's complex.

    I think I'll have done it by searching for cognitive+(behavioural OR behavioral)+therapy.

    I just ran that search and it gave 2812 hits for 2008… which is about 1,000 hits less than on my graph. Hmm. Oh dear.

    I'll need to check up on this again, I may have done something stupid when I made the graph like adding the results of two search terms and thus counting papers twice. If so, the CBT line will be too high but I think the shape is still correct.

  • Davigo

    Hi Neuroskeptic, Thanks a lot for the response. I agree with you about the shape, I just wanted to point out a common pitfall to avoid when searching with multi-word terms. So don't take it personally…

    If you want to try, the best formula I've found is like this:

    “cognitive therapy”[MeSH Terms] OR “cognitive therapy”[All Fields] OR “behavior therapy”[MeSH Terms] OR “behavior therapy”[All Fields] OR “behaviour therapy”[All Fields] OR “cognitive behavoiral therapy”[All Fields] OR “cognitive behavioural therapy”[All Fields] OR CBT [All Fields]

    (Don't forget the quotation marks.)

    With this formula, I've got 2842 results for 2009, and 2603 for 2008.

    P.S. I fell across this blog thanks to a Korean blogger who introduced your graph on a post.

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About Neuroskeptic

Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.

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