To the Editor: I was most interested in the article on Freud’s practice of analysis by David J. Lynn, M.D., and George E. Vaillant, M.D. (1). The authors convincingly argue that Freud mostly did not follow his own recommendations about the conduct of psychoanalysis. They suggest that Freud’s actual behavior (at least regarding his relaxed approach toward anonymity and neutrality) was more in tune with the current approaches to self-revelation and therapy. Clearly, Freud’s frequent and overt breeches of confidentiality rightly trouble them.

I would agree with Drs. Lynn and Vaillant that while Freud’s openness and obvious humanity in the treatment of his patients is refreshing and may have been a major factor in the therapeutic successes he achieved (although his results seemed often quite equivocal), there are other messages we might take from these observations. First, I believe Freud’s behavior highlights the danger of VIP treatment. Freud, as the developer of psychoanalysis, seems to have felt himself above the rules that he set up. When a clinician sees himself or herself as important or skilled, there is a strong inclination to take liberties with treatment. Self-assurance can produce the willingness to take helpful risks but can also evoke the fantasy that "I can do no wrong" and result in dangerous therapeutic bravado. Also, treating a VIP patient can lead a therapist to bend the rules in ways that would otherwise be uncharacteristic, often to the ultimate detriment of the patient.

Furthermore, I believe that Freud’s behavior points to the dangers of practicing therapy in a setting in which there are goals or considerations extraneous to the treatment. Freud was constantly concerned with the health and vitality of his "movement." He seems to have often treated patients with some of his attention on their potential as benefactors. A good example is the discussion of Freud’s treatment of Edith Jackson (1). Also since many of Freud’s patients were in or closely connected to his circle, his attention seemed to also cover their personal behavior and relations. His brief treatment of Otto Rank, for example, was an attempt by Freud to smooth out their personal and professional relations after Rank published his controversial (and ultimately prescient) work on the "birth trauma" (2) (wherein he developed the concept of separation anxiety).

I believe that these considerations continue to be quite relevant. What we might take from Freud’s treatment recommendations is not a series of static, legalistic suggestions but the notion that always when treating patients our primary concern should be to keep our eyes on the patient and the treatment and not on the results of the study, the bottom line, or whatever else may distract us.