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Theory of Mind

The year is 1900, and Ida Bauer cannot speak today. She feels like she is choking on air. Ida has had difficulty breathing and an inability to speak for some time now, and her father is concerned.Drawing of a face

Ida is 18 years old. She lives with her parents and her brother, who is a year and a half her senior. Her father was treated for a paralytic attack four years ago, but nothing in her family’s medical history explains Ida’s symptoms. There is no neurological explanation for loss of voice or problems breathing, or for her periodic migraines or fainting spells. Yet Ida has sporadically suffered variations of some of these symptoms since age eight. Her father decides to forgo the visits to more conventional physicians and has brought Ida straight to Dr. Sigmund Freud, the inventor of psychoanalysis.

Ida’s case is a typical example of Dr. Freud’s early analysis, so typical that he finds Ida, and her case, utterly unexciting.
In her conversations with Freud, Ida reveals that she has a recurring dream. Ida’s father awakens her: The house is on fire, the house is on fire. She dresses and prepares to leave, but her mother refuses to go. She must find her jewel case first. Ida’s father cries out that he won’t let himself and his two children die for the sake of the jewel case. I won’t have it. Before the house burns down, Ida awakes.

Freud believes that most dreams fulfill a wish, a desire of which the dreamer is not conscious. That each of us has these unconscious wishes is still a radical new idea in 1900. Freud will attempt to understand Ida’s unconscious mind by analyzing her dream. His basic theory of the unconscious imagines the mind as a force field, like the one a magnet induces in space. He sees it in the room with Ida as he encourages her to free associate, urging her to say whatever comes to her mind, slowly bringing unconscious thoughts to the conscious level. Free association liberates Ida from the social norms that have always constrained her. When Ida interrupts herself, Freud invites her to talk about what stopped her, and why.

Modern theories of the unconscious, while building with new blocks from fields like cognitive science, will be based on Freud’s discovery that everyone has motivations of which he is not aware.

Freud’s wilder theories have been discredited again and again, and the story of how the influence of psychoanalysis has waned since his time is a familiar one. Still, there are those who are drawn, for whatever reasons, to the discipline he established, including a sizable community of psychoanalysts in New Haven.

Marshal Mandelkern is a member of that community. Before his training as a psychoanalyst, he remembers writing a letter he was ambivalent about mailing. As he asked himself whether he should mail it, he decided to look up the address just in case. He searched his entire desk drawer, where he always kept his address book, but couldn’t find the book, and couldn’t mail the letter.

He set the letter aside. A week later, he was reaching for his stapler, and saw his address book sitting on top of the desk drawer, where it had always been.

“I had been looking for it, but couldn’t see it,” he says. “Not because I was blind, or because it was dark, but because psychologically, I created this blind spot. A conflict I was having could unconsciously emerge as a physical symptom like this, of not being able to see something.”

This incident is an example of a parapraxis, the clinical term for a “Freudian slip,” and it prompted Mandelkern to apply to the Western New England Institute for Psychoanalysis. Mandelkern wanted to understand the levels of the mind beneath his consciousness.

The main floor of the institute’s building on Bradley Avenue has four classrooms, for classes of ten or fifteen people (one classroom doubling as a kitchen) and a library. Comprehensive psychoanalytic libraries are infamously difficult to maintain, and with Yale’s many libraries down the street, Western New England’s collection of books and journals is treated more like a reading room. Training includes five years of courses in these classrooms, and usually requires eight to ten years altogether.
To graduate from the institute, students must complete a major paper and submit to psychoanalysis themselves. Training at Western New England is in orthodox or classical Freudian psychoanalysis, which differs from more conventional psychotherapy in that analysis requires more weekly sessions in which doctors participate more actively. This means four or five one-hour appointments a week, and it means time, money, and emotional commitment that most people cannot afford.

Freud first developed orthodox psychoanalysis, which was governed by a few major thinkers for decades. Eventually, devotion to the original model declined, and the psychoanalytic umbrella opened—to shelter a new generation, conflict within the field, and divisions that couldn’t have existed in 1900.

Most of the forty trained psychoanalysts at Western New England spend a minority of their time performing orthodox psychoanalysis. Mandelkern spends two thirds of his time practicing general psychiatry at St. Raphael’s Hospital, where his patients generally have obvious psychiatric disorders, and a third of it at his own private practice, where patients usually come in unhappy for various reasons. Mandelkern’s time at his private practice is not spent practicing orthodox psychoanalysis. His patients come in once or twice a week, not four or five times.

Yet few fields are so dominated by one founding figure. There are and will always be reading groups, courses, and seminars devoted solely to Freud at Western New England.

In their sessions, Freud “uses the couch” for Ida. Using the couch means two things for the patient. She lies down—relaxing her body while free associating—and, as the doctor sits behind the couch, she does not have to see his reactions to her associations. Nor must the doctor control his face as he listens. They are both further freed from social conventions, cues, and anxieties.

Since beginning treatment, Ida has experienced coughing attacks lasting three to five weeks, attacks so severe she has lost her voice several times, slowing down the unraveling of her story. Yet slowly but surely it does unravel: the powerful attachment to her father; his recovery from tuberculosis in a town away from home; the couple (“Herr K.” and “Frau K.”) he meets and grows close to while there; Ida’s many encounters with the K. family children as their babysitter; Herr K.’s sexual advances onto Ida; Ida’s father’s close friendship and possible long-term love affair with Frau K. despite his impotence; Herr K.’s and Ida’s father’s insistence that she had imagined the advances.

Ida had the dream about the fire three nights in a row while staying at the lake where Herr and Frau K. live after Herr K. kissed her unexpectedly. Freud considers aloud facts relating to the dream, for example that Herr K. once gave a jewel case to Ida as a gift and that “jewel case” is slang for female genitals. He interprets the dream as Ida’s desire to protect her “jewel case” and her conviction that if anything happened, her father would be to blame. The dream expresses all of these unconscious feelings in the opposite, meaning Ida has repressed a sexual attraction to Herr K. He notes that she loses her voice for the same amount of time that Herr K. is away, and in a poetic sweep Freud solves the case: because speech has no meaning when the person she loves is not there to hear it, her loss of voice is a small demonstration of her repressed desire for Herr K.

Mandelkern’s choice to limit orthodox analysis in his practice is modern, as is his prescription of medication as treatment. For many patients, drugs are more reliable and cost-effective. Today, more than one in ten Americans over the age of twelve is on an anti-depressant. Use has quadrupled in twenty-five years.

During and after the Second World War, psychoanalysis enjoyed a heyday that lasted until the 1960s. In those years, there was nowhere else to turn, and psychoanalysis seemed to be able to treat almost anything. “Seem” was the crucial word. Starting in the 1970s, new disciplines of medicine developed and began to compete with psychoanalysis, and the field was slowly marginalized. There was no return to the golden age: doctors, patients, and skeptics continue to refer to the decline of psychoanalysis.

Talking was already going out of style by the 1960s, when effective medications for depression, anxiety, and various psychotic disorders were designed. In those booming postwar years, sessions became less frequent, patients’ stays in analysis became shorter, and analysts began to interrupt patients more freely, deliberately influencing progress instead of acting as a blank vessel. As doctors engaged more with patients, patients were talking less.

Phillips, however, thinks Western New England stands today on the cusp of a resurgence of interest in psychoanalysis, both in the general public and in the academy. Just as lofty notions of the power of psychoanalysis were deflated following its golden age, so the sexiness of biological psychiatry is fading, and views of these medications are becoming more realistic.

“The be-all end-all antidepressent medications that they thought would solve everything, don’t, and what’s more is they have a lot of side effects,” said Phillips, who uses medications with his own patients.

Dr. Carole Goldberg agrees that there will always be a place for psychoanalysis despite the commitment of time and money it requires. Also a member of Western New England, Goldberg serves as the director of the Sexual Harassment and Assault Response and Education Center at Yale and practices sex counseling at Yale’s Mental Health & Counseling and in her private practice.

Goldberg believes there is a movement back toward asking “how we explore our inner world in a meaningful way,” rather than medicating the ups and downs of emotions. She sees a parallel in the medicalization of sex therapy with the invention of medications like Viagra and Cialis to treat erectile dysfunction.

“They helped with these disorders, and they were terrific. But in medicating these issues, we lose the opportunity to talk to one another. And the most intimate thing you do with another person is to talk to them,” she said. The combination of medication and psychotherapy works better than either one alone, and Goldberg attributes the allure of psychoanalysis to the self-understanding it can provide, something medication cannot offer.

Mandelkern said that psychoanalytic ideas and insights recently have been considered more useful, and in more ways. He predicts an organic incorporation of newer fields into the psychoanalysis of the future.

“It’ll be a younger generation, younger than me, that takes what’s good out of psychoanalysis, that takes what’s good from cognitive science, from various cognitive behavioral therapies, from a variety of other interventions, and creates new paths forward, without feeling like they have to pay undue homage to the past. Which has been a big factor for psychoanalysis, tracing everything back to Freud.”

Psychoanalysis is still emerging from underneath the Freudian penumbra, according to Mandelkern—and the process has lasted for twenty or thirty years. “Just now the field is willing to move on and say, ‘Yes, Freud was a great thinker, with great insights, and great creativity, but he had certain limitations and we have to move on,’ ” he says.

Mandelkern owns a pair of slippers bearing a cartoon of Freud’s face—Freudian slippers.

Whether she is aware of it or not, so much depends on Ida’s “jewel case.” Her emotions and her body are thoroughly intertwined.
Ida wakes up from her dreams smelling smoke. Freud understands the odor as a clear sign that Ida is conflating her father, Herr K., and the doctor himself—all three smokers in her life, all men toward whom he believes she has felt sexually. This is an instance, then, of transference, a redirection of her sexual feelings from Herr K. to Freud himself.

As it was in Freud’s time, psychoanalysis is as much about the doctor as it is about the patient. In Mandelkern’s private practice, though he is more active than a typical therapist might be, he usually doesn’t use the couch. He decided about ten years ago that having the patient on the couch was too impersonal for him, and he now sees patients sitting up.

“I was suffering from a lack of interaction, a lack of contact,” he says.

It is a small example. Freud wrote in a paper called “Analysis Terminable and Interminable” that people never finish analysis, that they leave it and return to it in all their lives. No patient of psychoanalysis—and certainly no doctor of psychoanalysis—is ever “fixed” by, or finishes with, analysis. Most doctors feel their own psychoanalysis was the most important part of their training—more important than the reading or the classes. Before they can be doctors, they must be patients.

At some point it becomes a technical question whether analysts are also undergoing analysis, because the way they think and feel about their lives is so informed by their fundamental quest to gain access to unconscious minds, including their own. To fully empathize with their patients, doctors must understand their own minds as deeply and as richly as possible, unconscious warts and all. They must be not only able to tolerate pain, anxiety, stress, despair, but also deeply willing to face it—in themselves and in others.

It’s a lonely profession. “You’re not hearing thousands of people at a time, and you’re not writing stuff that changes the lives of millions of people,” Mandelkern says. “You’re talking to one individual at a time, and you have to be willing to accept that.” Institutionalized professional interactions are necessary breaks from the day-in and day-out aloneness of a psychoanalyst’s office. Doctors don’t usually share ideas about their work with their patients, especially not psychoanalysts, and they need to gather occasionally with similarly minded shrinks to let it all out. Western New England has about forty members, a relatively tightly knit and socially agreeable group. Each doctor in the group knows most of the others, likes them, and gets along with the group.

When analysts get together, there is what Kirsten Dahl, the director of psychoanalysis for children and adolescents at Western New England, calls “a terrific social awkwardness.” “What is it about analysts?” asked a friend of Dahl’s who came with her to a conference. “All they do is walk around looking at the floor and talking about the weather.”

These analysts come to Western New England as full-fledged psychiatrists, psychologists, and clinical social workers before embarking on the process of becoming a psychoanalyst. The training necessarily takes place after all other training. It does not guarantee by any means a raise in income. The process is notoriously long and difficult. Dahl posed the question: Why in the world would anybody ever agree to do this?

The short answer: analysis has affected them personally and intensely. Most go in primarily wanting psychoanalysis for themselves and, after years of talking about their own difficulties and sufferings for five hours a week, leave wanting to practice it for others. The necessarily painful, painfully necessary nature of psychoanalysis will generate intellectual interest in the field, not the other way around, Phillips said. For Mandelkern, personal and intellectual interest came together the day he recognized the blind spot he created for himself where his address book sat on his desk.

Self-discovery was at the core of Mandelkern’s journey into psychoanalysis, and it is at the core of psychoanalysis itself. Patients are urged to talk about things they are likely to discuss with no one else, to give their analysts privileged access to their minds. Above all, though, it is their own unconscious to which analysts seek a special kind of access. As Phillips puts it, every interpretation that an analyst makes begins with self-analysis.

Illustration: Andrew Sotiriou

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