High on the list is that infants have complicated sexual desires. Peter D. Kramer, a Massachusetts psychiatrist who popularized the new generation of antidepressants in his best-selling book Listening to Prozac (Penguin, 1993), says that "there is no evidence that infants have sexual desires." Kramer notes that although Freud believed that adult complaints of childhood sexual abuse stemmed from such childhood fantasies, the evidence today is plain that sexual abuse of children is common, affecting up to 20 percent of girls and 10 percent of boys.

Freud also had little to offer the therapist in understanding trauma, which experts now know can cause lifelong problems. Trauma therapy is a relatively new field, built on work with war veterans. Post-traumatic stress disorder is a hot topic in psychotherapy today, one that was poorly addressed before, Kramer notes, because it was not possible to have effective treatment when the theoretical underpinnings were shaky.

Friend, Not Father
Readdressing the basic tenets of psychoanalysis has led to perhaps the most radical change of all: modern psychologists are actually talking to their patients. Freud's original "transference" theory demanded that an analyst remain quiet and aloof so as to serve as a "screen" onto which the patient could project her emotions. But therapists are now sharing more of themselves. "How can I remain opaque when my clients can go online and learn that I love Greek music?" asks psychoanalyst Spyros D. Orfanos, clinic director in psychoanalysis at New York University.

Orfanos says that today's analyst is not an authoritative father figure but a partner in figuring out "the powerful emotional forces that drive behavior." He thinks that having a dialogue with a patient is the best way to work toward change. Many analysts also now agree that empathy is key to the relationship, and empathy requires engagement, not just listening.

Psychoanalysis is also changing in the face of steady competition from other forms of help, such as cognitive behavioral therapy, in which patients try to change certain troubling behaviors, and goal-oriented therapy, which lays out ways to attain, say, certain kinds of relationships. These practices may or may not touch on the patient's past. And to hold its own, psychoanalysis is shedding its image as a privileged treatment for the wealthy; so-called training centers are popping up everywhere that provide low-cost appointments.

Scientists are also attempting to study the biology of the analysis process itself. At New York-Presbyterian Hospital/Weill Cornell Medical Center, psychiatrists Otto F. Kernberg and David A. Silbersweig are recording brain scans of patients before and after analysis. Such studies may help end the debate over the effectiveness of lengthy treatment, notes Kramer, who recently published Against Depression (Viking Adult, 2005), an assessment of mood disorders. "We don't know what works or what doesn't work."

Orfanos is dubious about scanning, maintaining that analysis is a humanistic endeavor that does not necessarily fit into a biology-based medical model. "It's about understanding how your mind works," he says, "so that you can have more choices in your life."

This article was originally published with the title Upsetting Psychotherapy.

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