Psychoanalysis Should Be Available to Everyone

Often associated with the middle class, psychoanalysis is a means of reflecting on human suffering that should be accessible to all.

For Freud, the impulse toward psychoanalysis’s democratization lies not only in expanding the kind of patient that is offered psychic treatment, but also in its dissemination through general culture. (People Images / Getty Images)

The COVID-19 pandemic occasioned two shifts in psychoanalytic practice: the demand for therapeutic treatment increased (one in six British people are reported to have started some form of therapy during COVID-19), and analysts came to rely on online technology in unprecedented ways. Digital forms of psychotherapy and psychoanalysis provided an immediate remedy for national crises in mental health across both sides of the Atlantic that were intensified by the experience of living through a time of crisis and upheaval.

Amongst the psychoanalytic community, the move online prompted much discussion. Many of its members remain skeptical of the capacity of a digital form of therapy to replicate in-person treatment in a profession which places embodiment at the heart of its practice. These changes have forced a reckoning with the merits of the confines and constraints of the analyst’s office, and with the profession’s own investment — one might even say fetishization — of a particular kind of psychoanalytic practice.

Two new books — Ankhi Mukherjee’s Unseen City: The Psychic Lives of the Urban Poor and Hannah Zeavin’s The Distance Cure: A History of Teletherapy — speak to this unfolding debate about these new mediated forms of psychoanalysis. At stake in both discussions is the question of whether these adaptations open the path to a more democratic model of treatment which does not only cater to the middle-class but recognizes the importance of offering affordable psychic care to all.

Turning to less traditional — ambulatory and teletherapeutic — practices, the studies trace an idiosyncratic and democratic history of psychoanalysis and investigate how the profession has adapted in response to the emergence of the twentieth-century welfare state, anti-colonial thought, and information technology to make space for a less traditional patient. The question which these studies put to the fore is: How flexible might the format for psychoanalysis be without sacrificing the constraints integral to its practice?

Another Psychoanalysis

In making the case for a more flexible and low-cost mode of psychoanalysis, Mukherjee and Zeavin turn to the innovations that are often obscured in more conservative narratives of the profession’s history. Many of the debates in psychoanalysis have turned on endless scuffles about Freud’s legacy (the so-called “Freud Wars”), but in Freud they find a thinker who, from the beginning, was constantly open to reevaluating the fundamental questions of his discipline. The image of psychoanalysis that emerges from Mukherjee and Zeavin’s studies is of a constantly adaptive rather than static profession, which moves forward by reckoning with the limitations of its own practice.

Psychoanalysis started as a middle-class affair: in this respect, things have largely remained unchanged. Freud himself conceded that the cost of treatment meant that therapy was essentially inaccessible to people outside the middle class. Initially this did not present a problem for Freud who saw the neuroses that he diagnosed as primarily middle-class phenomena — the psychic manifestations of the gendered and sexual constraints of bourgeois life.

In the wake of the catastrophic deaths occasioned by World War I, which had a severe material and psychic effect on his own family, and the Spanish Flu, which would claim the life of his daughter Sophie, Freud revised his position that money was essential to the contract between analyst and analysand. Changing his mind, he argued that psychoanalysis might indeed have something vital to offer to everyone. He proposed a socially democratic vision of psychoanalysis where treatment would be free. This fundamental rethinking of the place of psychoanalysis in social life resulted in the founding of the Free Clinic Movement in 1918, which helped to create a dozen cooperative mental health clinics across Europe in the 1920s.

These clinics have been largely forgotten, but their conception was central to forging the connection between psychoanalysis and social justice. Freud, alongside Wilhelm Reich, Erik Erikson, Karen Horney, Erich Fromm, and Helene Deutsch — who are collectively known as the “activist generation” — saw that psychoanalysis might not simply be a means of diagnosing the gendered and sexual ills of the Viennese bourgeoisie. The profession might, they believed, also provide the resources that are essential to addressing the psychic elements of social welfare, and thus recognizing the life of the mind as vital to the health of society, not just the individual.

Although the working-class patient would continue to remain on the periphery of psychoanalysis, in his 1919 essay “Lines of Advance in Psycho-Analytic Therapy” Freud connected the free clinic practice to a revolutionary politics. Coming as close as he would ever do to insights of the socialist tradition, he wrote that “the conscience of society will awaken and remind it that the poor man should have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery.” A year earlier at the fifth international congress of psychoanalysis in Budapest he conceded that since “it may be a long time before the State comes to see these duties as urgent,” it is most likely that “these institutions will be started by private charity.”

The new flexibility of psychoanalytic practice which we are currently witnessing should be understood as continuing this earlier legacy of democratizing the profession. Disseminating psychoanalysis to a wider culture, as Freud notes, “compels us to alloy the pure gold of analysis freely with the copper of direct suggestion,” if we still await the state’s assistance.

Analysis on the Periphery

For Mukherjee, a professor of English and world literatures at Oxford University, a more democratic psychoanalysis would be one that dispenses with its own investments in imperialism. Unseen City combines literary theory with case studies in three global cities, drawing together a cultural and material investigation that shows how psychoanalysis has — or in many cases has not — served the poor.

Mukherjee turns her attention to psychoanalysis’s tendency to dismiss the realities of poverty and the way that its emphasis on gender and sexuality has obscured its reckoning with, and indeed investment in, race and class structures. Drawing on research which links mental health and social class, Mukherjee sets out to show how mental illness is both a predictor and consequence of poverty. The book is both a call for a state-funded health care and a case for the interpretative humanities to make cultural interventions in current debates around mental health.

In her first section on London, Mukherjee turns to consider a horticultural psychotherapeutic group run by two Turkish analysts in collaboration with the Tavistock Centre, a not-for-profit public health corporation, which provides over half of Britain’s National Health Service (NHS)’s mental health provision. For Mukherjee, the still-marginal practice of group therapy, initiated by Wilfred Bion at the Tavistock Centre during and after World War II provides therapists with a way of addressing the collective traumas of migration, displacement, and state violence by which many of the cities inhabitants have been affected.

For Freud, the impulse toward psychoanalysis’s democratization lies not only in expanding the kind of patient that is offered psychic treatment, but also in its dissemination through general culture. In her attempt to show the failure to think the psychic lives of the poor, Mukherjee’s analysis moves from literary depictions of psychoanalysis’s roles in cities to psychoanalytic practice.

In the case of Mumbai — one of her three global cities (alongside London and New York) — she turns to the conjuncture between a cultural fascination — and indeed romanticization — of the city’s slums, and their continued existence as shadows of urban prosperity, as a specter of the postcolonial city. Mukherjee’s discussion takes a more theoretical turn in this chapter, where she uses the concept of the uncanny, developed by Freud in 1919, to describe the strange sense that something is out of place.

Mukherjee wants to show the relationship between our inability to imagine the psychic lives of the poor and the lack of treatment available for them. Where treatment does exist for the poor in India (if not in the slums themselves), it is under nonideal conditions which make traditional analysis difficult. At National Institute of Mental Health and Neurosciences (NIMHANS), one of India’s foremost public sector mental hospitals in Bangalore, and its adjacent clinic, the Samadhana Counselling Centre, treatment is short, sometimes lasting for just two or three sessions. The impetus is directed toward finding pragmatic, workable, patient-focused, and outcome-oriented solutions.

Mukherjee shows how these ambulatory, unorthodox methods of analysis are a pragmatic compromise which analysts, practicing under ideal conditions in the West, are all too quick to dismiss. The desire to sanitize the image of analysis has the effect of relegating the poor, Mukherjee observes, to the unconscious. The best way to ensure that psychoanalysis is politically accountable might, then, be a situation where psychoanalysis — understood in its most orthodox sense — undergoes considerable revision.

Away From the Couch

For Zeavin, a lecturer in English and history at Berkeley, the anxieties around maintaining a “pure” form of psychoanalysis, which views teletherapeutic modes as a diluted, lesser version of in-person treatment is to look at the argument the wrong way. Distance, she argues, is not the opposite of presence. Instead, we might think of psychoanalysis — as Freud himself did — as a constant negotiation and response to new forms of technology, and the novel kinds of intimacy and embodiment they occasion.

“Screens,” she writes, “are part of human relations. Anything can and will travel across them: violence and trust; empathy, however slight or temporary; connection and disconnection; presence and absence.” The book traces the history of psychoanalysis’s use of media from Freud’s letters to Wilhelm Fliess to Donald Winnicott’s use of the radio as a form of nationwide therapy during and after World War II. Addressed, too, in this account are the less psychoanalytically aligned practices of telephone suicide hotlines, which were first pioneered as a form of Christian pastoral outreach in the 1950s, as well as computer-based analysis which were developed in the 1960s.

World War II forced psychoanalysis to rethink the role that it should play in public life. New pressures placed on the profession by the war were understood by the discipline’s luminaries not as an occasion for reinforcing its framework, but rather a catalyst for extending its social reach. First and foremost among these changes was the foundation of British welfare state and the NHS, which the free clinic at the Tavistock Centre became part of in 1948, until funding was stopped in 1990.

In the years after the war, Winnicott would question the efficacy of his group broadcasts and the possibility of conducting psychoanalysis — speaking to a group patient — on a national scale. Winnicott’s skepticism was not simply the result of his conservatism: it points rather to a fundamental problem in broadening accessibility. The shift from the one-to-one to the many analytic relationship compromises the transference that is essential to psychoanalytic practice. Across the channel, the French analyst Jacques Lacan would come up with his own response to this dilemma, founding a school in 1964 that would experiment with shorter sessions. The International Psychoanalytic Association would reward him for his innovations by revoking his membership.

The 1960s witnessed more unorthodox innovations in psychic care outside the institution itself: with the expansion of the world of communication technology in the United States, therapy entered a new phase. In 1966, computer scientist Joseph Weizenbaum designed the first proto-therapy chatbot ELIZA, named after George Bernard Shaw’s Eliza Doolittle, the prototype imitator and pliable female object (whose merits lie in her ability to transcend her class origins), with the intention of demonstrating the failure of human-to-computer interaction.

Its creation, however, had an unforeseen effect: users were not dismayed by the lack of empathy they found in the absence of human interaction. They instead located in the machine a source of comfort and companionship. The second part of Zeavin’s book traces a fascinating history of these early experiments in computerized therapy, which she situates alongside the invention of Cognitive Behavioral Therapy (CBT), a treatment method that radically transformed mental health, leading to a more cost-efficient, short-term, quantifiable, results-based therapeutic frame.

In 2019, Zachtronics, as Zeavin notes, released an eponymously named visual novel game. In it, the player takes on the role of Evelyn, a young woman who was employed in high-tech industry in Seattle before she burnt out and ended up working as a therapist, without training, for the virtual counseling program, Eliza, named after Weizenbaum’s program. In the world of the video game, the American mental health crisis is ubiquitous. Patients, attached to a heart rate monitor, become not analysands but a data stream. At the end of the session, Eliza is rated, and patients are invited to leave a tip.

The emergence in the past two decades of self-monitoring therapy apps, produced and financed in Silicon Valley, poses the latest challenge to the psychoanalytic frame because the first item that these new approaches dispense with is the therapist. It would be easy to dismiss these automated forms of therapy — as I have been inclined to do — but Zeavin is more generous in her assessment, recognizing the vital role that these computer-based therapies play in offering low-cost forms of treatment. She does, however, also acknowledge the dangers that emerge from the unaccountability of feeding our most private information into an app, and the relative merits of having our psychic life interpreted by a bot.

Apps like Overcoming Depression, designed by the Colbys in 1992, to address the 90 percent of people who suffer from the illness but who don’t seek or receive mental health care — are designed specifically for the “untreated majority” (they are not free to use, though certainly cheaper than long-term psychotherapy or psychoanalysis). But while apps provide essential and adaptive solutions, they are nonetheless a long way from the democratic community that the Free Clinic promised.

Money, which is seen as an essential part of the contract that enables the transference between the analyst and analysand, is for the working-class patient an impediment to even starting the process. Often, teletherapy is the most low-cost option available (except in the case of COVID-19, when supply and demand upped the costs of mediated therapy) and in this respect it provides a vital service — a kind of psychic emergency room — unmet by either state welfare or private practice psychoanalysis.

The mental health crisis exacerbated by the long-term effects of the pandemic presents an opportunity to make the case for a more social psychoanalysis. Against the ambivalence about the efficacies of online and tele-forms of therapy, we might focus instead on making a demand for a more collective, low-cost psychoanalysis and psychotherapy, and an argument against the state’s de-prioritization of mental health.

Such a demand might place an emphasis on government-sponsored psychoanalytic training, and new digital and ambulatory solutions. It might make space for collaborations between psychoanalysts, lay counsellors, and computerized technology that could further the reach of those who can access psychic care.

What makes psychoanalysis political is not only that it advances one of the most trenchant critiques of the motives and methods of power, but that it affords everyone a psychic complexity and a generational history that might otherwise have remained buried within them — and in its acknowledgment of symptoms as signs of social rather than simply personal dysfunction.

The reason that it is important to insist that psychoanalysis is for everyone is not simply to highlight the fact that many people cannot access treatment for the reasons that these studies have clearly shown. The issue is more fundamental. What is at stake is who has the right to an inner life — whose interiority gets mapped, who is allowed to dream, collectively, and whose collective dreams count.