Culture

Why Psychoanalysis Matters

It has taken a back seat to pop psychology, pills, and other therapies in recent years. But now, thanks to Tony Soprano (and new neuroscientific research), the “talking cure” is sexy again

From the September 2005 magazine
Image courtesy of HBOImage courtesy of HBO

Tony Soprano is sitting in Dr. Jennifer Melfi’s office and he is not a happy guy. As the don of New Jersey, he can’t really talk about his feelings. And he doesn’t put much stock in this therapy bullshit anyway. But he’s passing out from panic attacks and the medical tests came back negative and his family doctor sent him for a shrink consult. Tony’s office is the Bada Bing, a local strip club. He is so out of his element on Melfi’s turf, he looks like a man about to be garrotted.

“This isn’t going to work,” he says. “I can’t talk about my personal life.”

“What line of work are you in? ” asks Melfi.

“Waste management consultant.”

“Any thoughts at all on why you blacked out? ”

“I dunno. Stress maybe.”

Tony is filled with dread. He feels like the sad clown, laughing on the outside, crying on the inside. His wife is on his case. His teenage kids are slip-slidin’ away. His mother is giving him grief about going into a retirement home. And she’s a ball-buster, the biggest. “My mother wore my father down to a little nub. He was a squeaking little gerbil when he died.”

“Quite a formidable maternal presence…” observes Melfi.

Work’s no fun anymore, either. He has the feeling that he has come in at the end of things, when the best is over.

“Many Americans, I think, feel that way,” she says.

She prescribes antidepressants. “With today’s pharmacology, nobody needs to suffer with feelings of exhaustion and depression.” The drugs will take care of his symptoms, but her real interest resides in what lies beneath.

She probes, he resists. He is a master at evasion, flirting, shutting down. But she presses on. “Anxiety attacks are legitimate psychiatric emergencies,” she explains—not something to be taken lightly. He flips out.

“Let me tell you something. Nowadays everybody’s gotta go to shrinks and counsellors and go on Sally Jesse Raphael and talk about their problems. Whatever happened to Gary Cooper, the strong silent type?… Now it’s dysfunction this and dysfunction that. I have a semester and a half of college so I understand Freud. I understand therapy as a concept, but in my world it does not go down. Could I be happier? Yeah. Who couldn’t? ”

“Do you feel depressed? ”

“Since the ducks left, I guess.”

“The ducks that preceded your losing consciousness—let’s talk about them.”

He storms out.

But eventually he comes back. Therapy is beginning to intrigue him. She is beginning to intrigue him. Over time, under Melfi’s gentle but steely gaze, he admits that he has felt depressed since the ducks that were making a home in his swimming pool flew away. The ducks enthrall Tony as nothing in his life has done for some time. When they left, he lost consciousness. Ducks equal loss. Loss spells depression. The ducks are a clue.

After taking the Prozac, Tony starts to improve, and his wife, Carmela, notices he’s in better spirits. He’s smug, thinks he’s cured, figures they should wrap things up.

“It’s not the medication,” says Melfi. “Prozac takes several weeks to build up effective levels in the blood.”

“Well, what is it then? ”

“Coming here. Talking. Hope comes in many forms.”

“Well, who’s got time for that? ” he snaps.

Then he tells her about a dream. In the dream his belly button was a Phillips head screw, and when he managed to unscrew it, his penis fell off. He picked it up and was looking around for the guy who could screw it back on when a bird swooped down, grabbed it in its beak, and flew away.

“What kind of bird? ”

“I dunno, a seagull or something. I saw The Birds last week on cable. Do you think maybe that planted the idea? ”

“A water bird…? What about ducks? ”

This is it—the moment of psychoanalytic insight, when the apparently random fragments of unconscious experience coalesce into consciousness with such illuminating force, it’s as if a meteor has just come careering out of nowhere into the earth’s atmosphere. Tony is shaken.

“Those goddamned ducks.”

“What is it about those ducks that meant so much to you? ”

“I don’t know. It was just a trip having those wild creatures come into my pool and have their little babies….”

He tears up, reaches for a Kleenex. Then… bingo.

“I lost the ducks. That’s what I’m full of dread about. It’s always with me.”

“What are you so afraid’s going to happen? ”

But Tony cannot say. It is early yet. For now, all he and Melfi have to go on are the ducks and his inchoate fear. And so begins the quest to find the source of the clanging dissonance in the darkest reaches of his tortured soul.

Much has been written about hbo’s hit television series The Sopranos as a Rorschach for postmodern American culture. Trying to decipher the show’s multi-layered meanings is a lot like being in psychoanalysis. Nothing is simple. You have to peel back the layers one at a time. But when clarity comes it is deeply moving. According to critic Ellen Willis, writing in The Nation, the show is a “meditation on the nature of morality, the possibility of redemption and the legacy of Freud.” But at its primal level, “the inkblot is the unconscious.”

The unconscious, I think, is the real star of the show. The stage on which its drama unfolds is the relationship between Tony and Jennifer Melfi, a pas de deux blistering with so much heat, and so authentic in its depiction of what actually happens in psychoanalytic psychotherapy, you feel as if you’re in the room, eavesdropping on another patient’s session. “…[I]t took several years for many viewers to get over their transference to Dr. Melfi,” writes Nancy Franklin in the New Yorker. “In The Sopranos, we were in therapy.”

(Point of information: Melfi is a psychoanalyst as well as a psychiatrist—we know this from the couch in her office—but Tony is in psychoanalytic psychotherapy, which is different. In psychoanalytic psychotherapy, the patient usually goes once or twice a week and sits in a chair facing his therapist; in psychoanalysis, the patient goes three or more times a week for years, lies on a couch without looking at the analyst, and free-associates, which is a significantly different experience in texture and intensity.)

The Sopranos has done much to add lustre to the profile of psychoanalysis, which has been on life-support in the public gaze for several decades now. Since its zenith in the fifties, when it enjoyed exalted status and was considered the Rolls Royce of psychiatric treatments, it has travelled a rocky road to marginality, supplanted by the feel-good values of the sixties, the glittering promise of redemption through pharmacology, and a culture of betterment proffering seductive therapies to transform your life now. So long Dr. Freud. Hello Dr. Phil.

But, almost single-handedly, The Sopranos has made the talking cure sexy again. It has turned klieg lights on the unconscious, spawned a flurry of academic treatises analyzing the import of psychoanalysis, and heightened public awareness about how the psychoanalytic process works. As a result of Tony’s twice-weekly appointments, many therapists have reported an increase in male patients. The show is such a brilliant advertisement for what contemporary psychoanalytic psychotherapy is all about, and Melfi such a dead ringer for the genuine article, that at their annual convention in December 2001, the American Psychoanalytic Association gave Lorraine Bracco, who plays Melfi, a special award for portraying “the most credible psychoanalyst ever to appear in the cinema or on television.”

The Sopranos offers an astonishingly nuanced depiction of the psychoanalytic process. It conveys how it works and why it’s so important. It illustrates why it’s so slippery to define and so tempting to dismiss. It demonstrates eloquently how valuable psychoanalysis can be. And its passionate following is a blazing missive from the zeitgeist signalling that the show is channelling a deep craving in our culture for this particular brand of truth-telling, however unconscious that desire may be. It also heralds a subtle shift in perception: after prolonged exile from psychiatry and the public discourse as a valuable treatment, psychoanalysis is finally emerging from the Dark Ages.

The fall from grace of psychoanalysis began during the 1960s, when studies emerged discrediting some of Freud’s theories, fodder for anti-Freudians who denounced his science as flawed and his ideas as crackpot. As well, a backlash arose against what some in the medical establishment viewed as the psychoanalytic community’s more extravagant claims. Drugs became the fashionable avenue to mind expansion, and the counterculture’s touchy-feely ethos ushered in an era of psychobabble and alternative therapies such as Gestalt and est.

Over the next two decades, its influence continued to wane due to a health care marketplace demanding short-term, results-driven, and comparatively inexpensive treatments such as medications and behavioural therapies. As well, startling advances in neurology and psychopharmacology led to the discovery that mental illnesses such as autism and schizophrenia—which analysts once blamed on bad mothering —were neurological in origin and best treated with psychotropic drugs and shorter-term therapies. As North America morphed into a Prozac-guzzling culture smitten with yes-you-can psychology and fix-me-now solutions, speculations arose that one day talk therapy would go the way of mesmerism. If you can trace the source of psychic suffering to faulty brain chemistry and fix it with a pill, the idea of a prolonged, costly treatment to talk your troubles away seemed strangely antiquated.

And then there was the Woody Allen factor—the widespread perception that psychoanalysis was an interminable, pointless exercise in self-indulgence for urban neurotics. (“I’m gonna give him one more year and then I’m going to Lourdes,” says fifteen-year couch veteran Alvie Singer, Allen’s alter ego in Annie Hall.) Today, many observers doubt whether psychoanalysis will survive at all.

But epitaphs are premature. Over the past few decades, largely under the radar, in Canada, the United States, and internationally, psychoanalysis has been undergoing a remarkable transformation. It has opened its formerly cultish institutes (where once only medical doctors could apply and anyone who deviated from strict Freudian norms risked expulsion) to an eclectic range of practitioners including social workers, psychologists, and philosophers, all of whom have fostered a climate of openness.

Psychoanalysis has also broadened its formerly rigid theoretical stance to incorporate such diverse ideas as object relations theory, which identifies the desire for relationship and interpersonal relations—especially between mother and child—as the primary motivating force in life, rather than instinctual drives as Freud argued. Relational thinking—the cutting-edge theory constituting the third wave in psychoanalytic thought and the hallmark of contemporary psychoanalysis—views the analytic relationship as a two-person system in which both participants make vital contributions to the alliance. It is spawning a new breed of analyst and model of practice that would be alien to Freud—and Woody Allen.

The big news, however, is in the field of neuroscience, in which researchers are now using imaging technology to look inside the brain, chart the unconscious, and objectively confirm much of what Freud believed about its mysterious workings. They are demonstrating how the brain is hard-wired for relationships and providing a solid empirical basis for understanding phenomena that analysts have long known but never really been able to explain—such as when a patient experiences, although doesn’t consciously feel, certain emotions. They are amassing proof that much of our decision-making process is unconscious. They can now see brain waves showing that a person has made a decision to do something before becoming conscious of having decided. Findings such as these are making this the most exhilarating moment for psychoanalysis since Freud first broke ground.

All in all, it is a heady time for the impossible profession.

Psychoanalysis stands in defiant opposition to just about everything our culture holds sacrosanct. You won’t see it featured on Oprah. It is not about twelve-step solutions or happy endings. It doesn’t trade in happiness at all. Psychoanalysis offers no easy answers. As therapies go, it is expensive and time-consuming, making it available, if treatment is not covered by health insurance, only to the relatively privileged. Patients see an analyst three, four, or five times a week for fifty-minute sessions, for three to eight years or more. Five years on the couch in the United States (or with a non-medical analyst in Canada), can cost anywhere from $10,000 (with a training analyst) to $50,000 (with a senior practitioner). In Canada, depending on the province or territory, treatment by a medical analyst is either fully or partially covered under the health care system. Canada is one of the few countries in the world to underwrite such treatment.

If analysis is successful, its rewards ripple outward to society at large. Those who have experienced its benefits speak of gaining compassion and of becoming better colleagues, spouses, parents, and citizens. The idea of a sociopath in psychoanalytic psychotherapy to deal with his demons is a dazzling conceit, of course, but in many ways Tony Soprano is a prime candidate for psychoanalysis, if not—so far anyway—a poster boy for its transformative effects.

In psychoanalytic terms, Tony is split—so split, he’s an ambulatory San Andreas fault line. One part of himself—the thrill-seeking mob boss trying to cling by his brass knuckles to a world where nobody plays by the rules anymore—is alienated from the other part, the devoted family man trying to survive in the quicksand of Nero-fiddling-while-Rome-burns middle-class suburban America. It’s a toss-up which culture is more empty, dysfunctional, and corrupt. In any event, the breach is causing him grievous suffering. Tony tries to put up a wall between the two worlds, but inevitably they start to bleed into each other. The more he tries to ignore or paper over the cracks, the more his psyche rebels. He has anxiety attacks, blacks out, tumbles into a depression.

Tony may be in denial about why his system is on red alert, but it is impossible to watch the show without developing an armchair theory. Willis thinks—credibly in my view—that Tony’s “gangster persona provides him with constant excitement and action, a sense of power and control, a definition of masculinity. Through violence rationalized as business or impersonal soldiering he also gets to express his considerable unacknowledged rage without encroaching on his alter ego as benevolent husband and father. But when the center fails to hold, the result is panic, then—as Melfi probes the cracks—depression, self-hatred, sexual collapse and engulfing, ungovernable anger. There are glimmers along the way…. But the abyss always looms.”

Tony’s panic attacks are an undeniable signal that his defences are deserting him. Melfi knows that personality is the “soil from which symptoms emerge,” writes Glen Gabbard, a psychoanalyst of considerable reputation who co-edits the International Journal of Psychoanalysis, teaches psychiatry at Baylor College of Medicine in Houston, Texas, and is the author of The Psychology of The Sopranos. For Melfi, the heart of the matter is Tony’s tortured relationship with his mother, Livia, who is so manipulative and malevolently narcissistic, many critics have likened her to Medea. Therapy stirs the swamp and Tony begins to have traumatic memories. In one flashback to boyhood, his mother threatens to gouge his eyes out with a fork if he doesn’t stop nagging her. All of which makes you wish, for Tony’s sake, that there were a pill to deal with this stuff, because it’s ugly and messy and painful as hell.

Psychoanalysis proceeds from Freud’s idea that each person’s ego—and therefore behaviour—is shaped by unconscious drives. The unconscious is where the real work of analysis takes place. As Freud saw it, we basically spend our lives unconsciously replaying a tired old script memorized in childhood through endless rehearsals with our parents and siblings. We leave home but we never really move on. We just take the show on the road, casting everyone we meet in supporting roles while we play the part of Macaulay Culkin. Analysis is about learning to relinquish that dog-eared script once and for all.

Free association is the patient’s tool to chip away at the fossilized past. Patients lie on the couch and, technically, are not supposed to censor any material that floats into consciousness, although free association rarely happens so purely. All patients have a story, but the real story is never the one that they are eager to tell.

Everything that patients say, and do not say, has meaning. The analytic task is to uncover the meaning. To that end, Freud famously counselled analysts to use their own unconscious “like a receptive organ toward the transmitting unconscious of the patient.” The analyst’s job was not to try to improve the patient. It was to bring bad news, to tell the patients over and over what they did not want to hear, “to tear [them] out of [their] menacing illusion.” Only then could patients relinquish the fantasy life story to which they had so assiduously been clinging.

According to Dr. Norman Doidge, a psychoanalyst, writer, and psychiatric researcher at the University of Toronto and Columbia University’s Center for Psychoanalytic Training and Research, in a good and “deep” analysis “one re-experiences warded-off states of mind one experienced in childhood—both good and painful. This is essential because just as a building needs a foundation that is very solid, so, too, do we have to have solid foundations to build relationships. And often, there is something slightly ‘crooked’ or off-centre in the foundation. For instance, all deep relationships require the capacity to trust another person. But the capacity to trust develops very early in life. Sometimes, one has to ‘go back’ and re-experience how that initially broke down. The way that happens in analysis is that the patient, who can’t remember these early stages, actually starts to relive them. This is something I wouldn’t expect anyone to believe if they hadn’t either seen it, or experienced it, but it happens, and it is one of the differences between analysis and most kinds of psychotherapy.”

All this high drama is played out against the landscape of one of the most extraordinary elements of psychoanalysis: the transference. Freud stumbled upon the concept of transference when he sought an explanation (other than his own irresistibility) for why his female patients kept falling in love with him. When transference happens, the patient projects or transfers onto the person of the analyst all of his or her loving, hostile, desperate, exalted, erotic, volatile, bitter feelings about key figures from infancy and childhood. (At one point in The Sopranos, Tony’s erotic transference to Melfi is so intense that he becomes besotted and has her followed to see who she’s dating.) To the patient in the grip of an intense transference, the feelings can often feel wildly out of control, which is why Freud counselled analysts to remind the patient again and again that what they were both experiencing had nothing to do with the analyst, but was a ghost from the past.

Through the transference, the patient re-experiences and works through unresolved conflicts or developmental problems from early life in order to remember and avoid repeating them in the future. Meanwhile, in the counter-transference, the analyst is also immersed in a cauldron of displaced emotions from his or her own past. (Melfi’s up to her ass in the mucky-muck too. No oracle pronouncing brilliant interpretations from an analytic throne like analysts of old, she’s a flawed human being grappling with her demons and frailties, just like Tony. At one point, unravelling because of counter-transference issues—she finds the bad boy both repellent and deeply alluring—she revisits her own analyst for a tune-up and confesses that treating Tony is like watching a train wreck. As treatment proceeds, she becomes unhinged and starts drinking heavily.)

Ideally, the analyst—all are required to undergo analysis as part of their training—must vigilantly analyze the counter-transference feelings to avoid imposing them on the patient, following that river to its source to ensure that they don’t muddy the treatment. In this way, the counter-transference, which is a vital and anticipated part of the process, becomes a rich resource in helping to decipher what transpires in the consulting room. Because the transference is potentially incendiary, and because, mismanaged, it can rage out of control and cause patients devastating harm, Freud cautioned that it required strict boundaries; otherwise, analyst and patient were at risk of re-enacting a fraught childhood relationship instead of defusing its power through analytic scrutiny.

What the analyst does, in large measure, is create a safe place where patients can experience feelings and fears that they have repressed their entire lives. The analyst also delicately leads patients towards self-awareness, helping them to understand when they are falling back on defence mechanisms—joking or telling a charming story or forgetting something key or pushing away a feeling or retreating into stony silence or dazzling with intellectual pyrotechnics or dodging with rationalization or simply lying their way out of a tight spot.

Given its rigour, few people enter psychoanalysis casually. Patients find their way to the consulting room because of longstanding symptoms or relationship problems based both on early childhood difficulties, abiding unconscious conflicts and some inhibition of an important aspect of psychological development. They may be otherwise highly competent but have tendencies that seem immature and infantile—tendencies that they themselves may recognize but are powerless to control. They may be leading chronically unfulfilled lives. They may have tried drugs or less intensive treatments and found them helpful but wanting. Other therapists may have given up on them. Whatever the reason, they have one thing in common, as Janet Malcolm, who has written brilliantly on the subject, eloquently observed. They go into analysis because they are in pain.

The pain of a neurosis, in which one part of the self is dissociated from another part of the self, is what compels the patient to keep coming back. “You want to be thoughtful,” says Doidge, “but to a certain person you are always dismissive; you want to make love to your loving girlfriend, but are excited by someone who would eat you alive; you want to grieve a loss, but can’t; you know it is ridiculous to entertain certain obsessive thoughts, but can’t stop. That anguish helps drive the treatment.”

Tony’s anguish is palpable. And in his therapeutic relationship with Melfi, so is a great deal more. It’s all there: the tenderness, the intimacy, the denial, the lies, the embarrassed silences, the dead ends, the bolts from treatment, the boredom, the magnetic pull of the transference and counter-transference, the evasiveness, the hostility, and the eureka moments whose full import can only be recollected later in tranquility.

Tony’s a case, that’s for sure. A complex, charismatic, lovable, tortured, sadistic, irresistible case. For obsessed fans, the need to deconstruct Tony’s psychopathology is so intense that after almost every episode of seasons three and four Slate.com featured a panel of psychoanalysts decoding every twitch and nuance of the characters’ psychologies; their post-mortems read like a seminar at an analytic training institute. Panellist Glen Gabbard is so impressed with the show’s psychiatric realism, he uses videotapes of episodes showing Dr. Melfi masterfully stick-handling Tony’s erotic transference to instruct his residents at Baylor College.

Numerous studies have measured the efficacy of psychoanalysis; collectively they have determined that it works as effectively as most mainstream medical treatments (i.e., about 80 percent of the time) for patients who have been properly selected. Research has also shown that analytic patients make fewer visits to their doctors and to hospitals, miss fewer work days, and are less likely than psychotherapy patients to need further treatment. There is even some indication that psychoanalysis may be a factor in promoting longevity. One particularly intriguing study entitled “The Mortality of Psychoanalysts” in the Winter 2001 Journal of the American Psychoanalytic Association followed approximately 1,100 analysts to determine their mortality rates. It found that psychoanalysts (white male medical American ones, anyway) had slightly more than half the chance of dying in any given year as the average American male. Tracked for thirty years, their mortality rates were lower than virtually every other occupation. Two factors that normally predict lower mortality—higher education and income—didn’t explain the numbers: the analyst-physicians had far lower mortality rates than the non-analyst physicians in the same brackets, and the analyst-psychiatrists had far lower mortality rates than non-analyst psychiatrists, who had the second-highest mortality rate of all physicians. Then there is this to consider: Freud lived until eighty-three in an era when most people died at around age fifty.

While scientists have been able to demonstrate that the talking cure works, they are now amassing compelling evidence to explain what actually happens inside the brain as a result of talk therapies. A fledgling scientific specialty called neuropsychoanalysis, marrying both disciplines, is objectively mapping the effects of psychoanalysis and, for the first time, tackling the complex psychological questions that once interested only psychoanalysts. Its infant journal, Neuro-Psychoanalysis, launched in 1999, is governed by luminaries in both fields, among them neuroscientists Antonio Damasio, Oliver Sacks, Allan Schore, and psychoanalysts Peter Fonagy and Mark Solms.

Freud began as a neurologist, and his 1895 paper “Project for a Scientific Psychology” was an attempt to wed psychoanalysis to the neuroscience of his time. Brain science was too crude for him to continue his investigations, but he always ensured that his findings were congruent with its principles. Until recently, neuroscientists were more interested in phenomena such as perception, sensation, and rational capabilities. The more they have learned about the brain, however, the more they have realized their discoveries are consistent with much of what Freud theorized about the unconscious and human emotions.

For instance, Freud believed that human beings were largely motivated by unconscious drives, specifically aggression and libido. Although their primacy as determinants of behaviour has been questioned over the last several decades, researchers are now discovering that these drives do indeed exist, and that they reside in the limbic system—a part of the brain responsible for primitive emotional responses. At the University of Iowa, neurologist Antonio Damasio studied various types of brain-damaged patients and discovered, as Freud believed, that emotion often drives what we reason about, and not the other way around. He argues that, as a species, our ability to feel predates our ability to think, and that we are still, primarily, sentient creatures. Furthermore, scientists now know that feelings and thoughts in their purest form originate in different brain areas and seem to be different mental functions—suggesting that a therapy focused on changing thought patterns alone will be insufficient for the treatment of some disorders.

What’s more, by measuring parts of the brain researchers, such as Allan Schore at ucla’s Department of Psychiatry and Biobehavioral Sciences, are learning that the brains of children lovingly nurtured in infancy look markedly different from the brains of children who have been starved for affection. In other words, emotional deprivation during the first two years of life will literally alter the functioning and chemistry of the brain—as well as the individual’s ability to cope with stress and emotional difficulties later in life. Scientists have determined that the early relationship between the mother and child neurologically imprints on the infant’s nervous system, becoming a template for future emotional relationships.

Studies on implicit or habit memory—the ability to recall an experience such as riding a bike without consciously remembering the steps involved—are confirming the biological basis for the unconscious, providing insight into the automatic, visceral ways in which we repeat behavioural scripts learned in past relationships, and suggesting, once again, that intensive, longer-term treatments such as psychoanalytic psychotherapies may be required to unlearn them. Brain scans are revealing that dreams are indeed the royal road to the unconscious Freud imagined, and that certain types of talk therapy, like early life emotional experience, can change the functioning of the brain as well.

As a result, neuroscience is turning out to be a great ally of psychoanalysis. The collaboration is not only sparking explosive insights into psychoanalytic concerns; it is effecting a detente between talk therapy proponents and biological treatment advocates.

In The Sopranos, neuropsychoanalysis serves as the backbone of Melfi’s treatment for Tony. In addition to using meds to manage his biological symptoms, and psychoanalytic theory to probe his unconscious, she also relies significantly on another pillar of neuropsychoanalysis—attachment research, according to Joshua Kendall, writing in the Boston Globe. As Kendall points out, in the late 1950s British psychoanalyst Dr. John Bowlby observed infants and their caregivers and found that early childhood abuse and neglect left them vulnerable to adult psychological problems. According to pyschoanalyst Glen Gabbard, “In Tony Soprano’s case his mother’s emotional abuse—presumably in combination with a genetic predisposition—left his brain hard-wired for a host of behavioural and interpersonal problems. But, as research now shows, the analytic relationship itself can help to heal the brain by establishing new neural networks.”

In one way or another, every character on The Sopranos is grappling with existential issues. In fact, one of the things I like best about The Sopranos is that the abyss gets top billing. The abyss is so much of a presence in this show, it practically needs its own dressing room. In one of the most poignant moments, Tony’s nephew Christopher blurts out that “the fuckin’ regularness of life is too fuckin’ hard for me.” This, I think, is just a more eloquent way of saying that the unexamined life is not worth living. If you look at The Sopranos as a mirror held up to life in all its complexity, or a mirror held up to our lives at this particular historical moment, then it’s pretty clear we’re screwed. On some level, Christopher senses this. He knows there’s no way out. He can run but he can’t hide. What he doesn’t realize is that unless he finds the source of his suffering, he’s doomed to repeat it.

At one point, Dr. Melfi tells Tony that with his symptoms managed, the real work can begin. “Come on,” he says. “I’m a fat fucking crook from New Jersey.” The guy has a point. Five seasons in, he’s pretty much the same Molotov cocktail who walked in the door. “All this fucking self-knowledge. What the fuck has it gotten me? ” he laments. Another good point. But what’s the option? Demons have a way of making themselves heard. In any event, Tony’s demons are our own and there’s nothing to do but stare them down.

But how to crack the code? In psychoanalysis, as in life, meaning is multilayered; insight arrives haphazardly and unexpectedly. In 1998 in an article in the New Yorker, Adam Gopnik wrote about his analysis and how his analyst once told him a rambling story whose point was that worrying about his writing didn’t matter, because nobody really cared—people had troubles of their own.

Gopnik fumes with incredulity. This is the most provocative insight his heavyweight German-born analyst with a direct line to Freud can come up with? “No one cares? People have troubles of their own? My great-aunt Hannah could have told me that.” But fifteen minutes later, riding downtown in a cab, his heart takes flight: That’s right: No one cares! People have troubles of their own! It’s O.K. That doesn’t mean you shouldn’t do it; it means you should do it, somehow, for its own sake, without illusions. Just write, just live, and don’t care too much yourself. No one cares. It’s just banter.”

When he first shows up in Melfi’s office, Tony has no time for navel-gazing. He thinks therapy’s a crock. But he has a dream—about his navel, as it turns out—and the next thing you know he’s connecting the dots. This is a lovely moment because I think that many people unacquainted with the psychoanalytic process feel as Tony does. As one analysand pointedly observed, however, nobody would ever call you self-indulgent if you went to the gym three times a week. Psychoanalysis is reflection in the presence of another, which is quite another matter.

The road is long, and there are no guarantees. Some analysts cross boundaries and cause patients great harm. Some analysts keep patients in treatment far longer than they should. Some analysts and patients are a terrible fit. Some analyses grind to a halt two years in. Some patients should never be in analysis in the first place. In many cases, shorter-term therapies make far more sense.

Psychoanalysis is definitely not for everybody. But if it succeeds, it can alter a life in ways that cannot always be articulated or even imagined. It is the only therapy that can profoundly reconfigure a person’s character; the only therapy that offers the opportunity for deep, expansive reflection; the only therapy that acknowledges how complicated human beings are and not only tolerates that complexity but tries to work with it; the only therapy that requires the therapist to watch him or herself in the process and to draw upon those observations as a rich wellspring.

At its best, psychoanalysis is about transformation. When that transformation happens, it can seem quite magical. It can involve gaining the ability to make previously unthinkable choices or living a life that once felt beyond reach. It can be about achieving the freedom to be oneself instead of feeling inhibited and stuck and frightened. It can be about something as simple and earth-shattering as locating oneself differently in the world. And the people who change in analysis don’t change back. Patients say this again and again. They may slide. They may not get well in all respects. But once they change, they are not the same people they used to be.

As Doidge sees it, self-examination, if it’s done seriously, is actually the opposite of self-indulgence, and analysis actually an anti-narcissistic treatment, or at least a treatment that helps transform more primitive manifestations of narcissism into less self-involved ways of supporting oneself, because the most narcissistic people among us are usually those who know least about themselves. “Narcissists fall in love with an image of themselves that is highly idealized, cartoonish, and bears no relation to who they are and their real insecurities. What they most want not to know about is themselves. In general, I find that the people who are my patients are the ones who are trying to resist the culture of narcissism that we are all having to take a bath in; after all, they are owning that they have difficulties, and are the source of them in some way, and they want to improve themselves, and are willing to put in the hard work to do so.”

In the end, psychoanalysis matters, says Doidge, because the interior life matters. It matters, too, because those who seem uninterested in or who deny having an interior life merely project it onto the world around them. “They project their hopes, fears, and fantasies—their images of what ‘men’ and ‘women’ are, and what ‘love’ is, and what ‘control’ and ‘cruelty’ are about. Analysis is about putting those things back into the head that they came from. Even in the most superficial culture, the interior life will never go away; it will simply become more primitive, because it will be less cultivated by an encounter with consciousness. And in the end, even a superficial society will have to find something like psychoanalysis, because no one… likes to be around a person who doesn’t have a sense of their own interiority.”

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  • Jennifer Kunst

    This is the most compelling, beautiful piece on psychoanalysis that I have ever read. I am a psychoanalyst myself and so I applaud these vivid, carefully chosen words and passion that underlies them. I found this piece, researching a blog post that I am writing: http://www.psychologytoday.com/blog/headshrinkers-guide-the-galaxy/201401/what-is-psychoanalysis.

  • Luc456

    One invests himself in psychoanalysis because he is convinced that he needs too. It is so damned long and expensive and unsettling if not hurtful at times, that one goes into it because previous recipes or attempts to have an happier life don’t work anymore, if they have ever, and it is not anymore an option to continue life the way it has been going so far.

    When psychoanalysis succeeds, the patient takes a look at his life before analysis and thinks and says “No, nerver! Never will I cross that desert again! I am free (or freer) now! And my life now really belongs to me and not to some demon or ghost thought from my past.”