Freud vs. Jung

Freud and Jung co-founded depth psychology, then split over what drives the human mind. Freud traced adult character back to repressed childhood urges, while Jung saw a lifelong journey toward wholeness, a divide that still shapes today’s psychodynamic approach.

Sigmund Freud and Carl Jung were both influential figures in the development of psychology, but they had significant theoretical differences, leading to a split in their relationship around 1912-1913.

Here is a summary table comparing Sigmund Freud and Carl Jung:

Feature	Freud	Jung
Key Concepts	* Unconscious mind * Id, Ego, Superego * Defense mechanisms * Psychosexual stages * Oedipal complex * Transference * Dream analysis	* Collective unconscious * Archetypes * Individuation * Active imagination * Dream analysis
Focus	Uncovering and resolving unconscious conflicts rooted in early childhood experiences, particularly those related to sexual and aggressive drives.	Fostering individuation, the process of integrating conscious and unconscious aspects of the self to achieve wholeness and self-realization.
Nature of the Unconscious	Primarily a repository of repressed desires and instincts, often stemming from unresolved childhood conflicts.	A layered structure comprising the personal unconscious (similar to Freud’s concept) and the collective unconscious, which holds archetypes, universal patterns of thought and behavior shared by all humanity.
Role of Sexuality	Central to personality development; unresolved sexual conflicts in childhood can lead to neuroses in adulthood.	Libido represents a broader life force encompassing psychic energy, not just sexual energy; sexuality is one aspect of human experience but not the primary motivator.
Dream Interpretation	Dreams are disguised fulfillments of repressed wishes; dream analysis focuses on uncovering the latent content (hidden meaning) by interpreting symbols.	Dreams offer glimpses into the unconscious, potentially revealing pathways to growth and individuation; they may contain archetypal imagery and symbols that connect the individual to the collective unconscious and provide guidance for self-discovery.
Therapeutic Goals	Making the unconscious conscious, bringing repressed thoughts and feelings to awareness to alleviate psychological distress.	Facilitating the process of individuation, helping individuals become more aware of their unconscious and integrate it with their conscious self to achieve a sense of wholeness and purpose.
Techniques	* Free association * Dream analysis * Interpretation of transference * Analysis of resistance	* Dream analysis * Active imagination * Symbol analysis * Exploration of archetypes * Dialogue with the unconscious
Criticisms	* Lack of empirical support for some concepts * Overemphasis on sexuality * Deterministic view of personality development	* Lack of empirical support for concepts like archetypes and the collective unconscious * Mystical and abstract nature of some ideas

Nature of the Unconscious

• Freud viewed the unconscious primarily as a repository of repressed memories and desires, mostly sexual and aggressive in nature.
• Jung saw the unconscious as a creative, spiritual force containing universal archetypes and symbols shared across cultures.

This fundamental difference reflects their broader orientations: Freud’s focus on pathology and sexual repression versus Jung’s interest in growth, meaning, and spiritual dimensions of human experience.

Freud’s View of the Unconscious:

Freud regarded the unconscious as primarily negative. It was a place where disturbing material was banished.

For Freud, the unconscious mind acted as a storage vault for thoughts, feelings, and desires, deemed too uncomfortable for conscious awareness.

This content was once conscious. It was pushed out of awareness to protect the individual from anxiety and distress.

Freud called this process repression and believed it played a major role in the development of psychological disorders.

Freud believed that unconscious material could be accessed through dream analysis, slips of the tongue, and neurotic symptoms.

Jung’s View of the Unconscious:

Jung agreed that a personal unconscious exists. But he gave it a smaller role than Freud did, placing it closer to the surface and linking it less to repressed childhood memories.

Beneath it, Jung proposed a second, deeper layer with no counterpart in Freud’s model. He called it the collective unconscious. It holds archetypes, universal symbols and themes shared by every human being.

Unlike Freud’s personal unconscious, built from repressed memories, its contents were never conscious to begin with. They are inborn.

Archetypes are universal symbols and themes expressing common aspects of human experience. They surface in dreams, myths, legends and art worldwide.

Jung’s concept of archetypes suggested that certain symbols and patterns are hardwired into every human psyche:

• The Hero archetype appears in stories from Jesus to Luke Skywalker.
• The Great Mother archetype manifests as Mother Nature, Gaia, the Virgin Mary.
• The Wise Old Man shows up as Merlin, Gandalf, Dumbledore.
• The Trickster appears as Loki, Coyote, Prometheus.

For Jung, this wasn’t just about healing trauma. It was about accessing a deeper wisdom that could guide personal growth and provide meaning.

He saw dreams not just as expressions of repressed wishes, but as messages from the unconscious offering guidance and insight.

Human Motivation

• Freud’s theory emphasized sexual drive (libido) as the primary motivator in shaping human behavior.
• Jung suggested that human motivation was driven by a more general life force, encompassing motivations like creativity, spirituality and intellectual pursuits.

This difference reflects their broader split: Freud’s more mechanistic, biological view versus Jung’s more spiritual, meaning-centered approach. Jung’s perspective opened up a wider range of human experience as fundamentally meaningful rather than as mere derivatives of sexual drive.

Freud’s Sexual Drive Theory:

Freud believed that sexual drive, or libido, is the primary motivator of human behavior. Even unrelated activities are powered by it, in his view.

He might interpret an artist’s passion for sculpting as sublimated sexual energy, for example. Religious devotion, too, becomes a redirected form of sexual longing. Even learning and creativity are transformed sexual energy in this account.

He saw the unconscious as a battleground of repressed sexual desires, particularly those stemming from early childhood experiences.

Freud’s theory of the Oedipus complex captures this pattern. Children, he argued, unconsciously desire their opposite-sex parent.

Freud believed that unresolved sexual conflicts from childhood can lead to neurosis in adulthood.

Jung’s Broader Life Force Concept:

Jung disagreed with Freud’s emphasis on sexuality.

He redefined libido as a more generalized life force. It encompasses all psychic energy, not just sexual energy, expressing itself in creativity, spirituality, and a need for meaning and purpose.

Jung acknowledged that sexuality plays a role in the unconscious. He simply felt that Freud overemphasized its importance.

For example, Jung would see an artist’s drive to create as its own legitimate form of psychic energy, not necessarily a transformation of repressed sexual desires.

He believed humans were naturally drawn toward meaning, growth, and self-actualization through various channels, with sexuality being just one aspect of a broader life force.

Personality Development

• Freud focused heavily on early childhood experiences and traumas.
• Jung emphasized continued psychological development throughout life (individuation) and introduced personality types (introversion/extraversion).

Freud maintained a deterministic view rooted in biological drives and early childhood experiences. Jung adopted a more holistic perspective that incorporated spiritual and cultural dimensions, viewing personality development as an ongoing process of self-discovery and integration rather than primarily a product of early conflicts and their resolution.

Freud’s Psychoanalytic Theory:

Freud’s theory of personality, psychoanalytic theory, centres on the unconscious. It holds that hidden thoughts, feelings and impulses drive most of what we think, feel and do.

He modelled the psyche as three agencies: the id, ego, and superego. The id is primitive and instinctual. It runs on the pleasure principle from birth, seeking gratification without regard for logic or morality.

The ego mediates between the id and reality, using reason to negotiate. The superego, meanwhile, is conscience: society’s internalised rules and values.

Freud believed personality develops through a series of psychosexual stages, each built around resolving conflicts tied to a specific erogenous zone.

Early childhood, especially the relationship with parents, matters most. Repression and fixation are the mechanisms that stamp personality in place.

Jung’s Analytical Psychology:

Jung’s theory of personality, known as analytical psychology, is more complex and mystical than Freud’s.

He believed personality develops across the whole lifespan, not just childhood. Its goal is individuation, a process of integrating the conscious and unconscious self to achieve wholeness.

Jung also built a framework of personality types. He distinguished between introverted and extroverted orientations, alongside four psychological functions: thinking, feeling, sensing, and intuition.

Jung gave the psyche its own structural anatomy too, built from archetypes rather than agencies. Four elements do the work:

• Persona: the social mask a person presents to the world.
• Shadow: the repressed, disowned side of the personality the ego refuses to own.
• Anima/animus: the unconscious contrasexual figure that shapes how a person relates to the opposite sex and their own inner world.
• Self: the archetype of wholeness at the centre of the psyche, the goal individuation works toward.

Treatment Approach

• Freud’s psychoanalysis centered on uncovering repressed memories and resolving childhood conflicts.
• Jung’s analytical psychology focused on integrating different aspects of the psyche and exploring symbolic meanings.

Psychoanalysis delves into the individual’s past, uncovering and resolving unconscious conflicts, while analytical psychotherapy focuses on a broader journey of self-discovery and integration.

Freud’s Approach to Therapy:

Freud’s approach to therapy, known as psychoanalysis, focuses on uncovering and interpreting the repressed contents of the unconscious mind.

The goal of psychoanalysis is to make the unconscious conscious so that the patient can gain insight into their conflicts and work through them.

Key techniques in psychoanalysis include:

• Free association: The patient is encouraged to speak freely about whatever comes to mind, without censorship or judgment. This allows unconscious thoughts and feelings to surface.
• Dream analysis: Dreams are viewed as disguised fulfillments of repressed wishes. Psychoanalysts analyze the symbols and themes in dreams to understand the patient’s unconscious desires and conflicts.
• Interpretation of transference: Transference occurs when the patient unconsciously projects feelings and attitudes from past relationships, often with parents, onto the therapist. The therapist analyzes transference patterns to reveal the patient’s unresolved conflicts.
• Analysis of resistance: Patients may resist confronting painful or threatening unconscious material. The analyst helps them understand and overcome this resistance, facilitating deeper exploration.

Psychoanalysis typically involves long-term therapy, with sessions occurring several times a week.

The therapist maintains a neutral stance, fostering a safe space for the patient to explore their unconscious.

Jung’s Approach to Therapy:

Jung’s approach to therapy, known as analytical psychotherapy, is more focused on the present and the future than on the past.

It emphasizes the importance of the therapeutic relationship, where the therapist and patient work together to explore the patient’s unconscious and help them to integrate different aspects of the self.

Jungian therapy also uses techniques such as dream analysis, active imagination, and symbol work to help patients access and understand their unconscious material.

Treatment techniques in analytical (Jungian) psychotherapy include:

• Dream analysis: While Jung agreed with Freud that dreams offer insights into the unconscious, he believed they could reveal pathways to growth and individuation, not just repressed desires. Dream analysis in analytical psychotherapy explores archetypal imagery and symbols, connecting the individual to the collective unconscious and providing guidance for self-discovery.
• Active imagination: This technique encourages patients to actively engage with their unconscious through imagination and creative expression, such as journaling, drawing, or storytelling. It helps them access and understand unconscious content and integrate it into their conscious awareness.
• Symbol analysis: Analytical therapists work with patients to understand the symbolic meaning of their dreams, fantasies, and experiences, revealing underlying unconscious patterns and archetypes.
• Exploration of archetypes: The therapist helps the patient identify and understand the archetypes that are active in their psyche, such as the Hero, the Shadow, the Anima/Animus. This exploration can lead to insights into the patient’s motivations, relationships, and life purpose

Jungian analysis typically involves longer-term therapy, though it may be less frequent than psychoanalysis.

The therapist and patient engage in a more collaborative relationship, exploring the unconscious together.

Contrasting Treatment Approaches:

While both psychoanalysis and analytical psychotherapy utilize dream analysis, their interpretations and goals differ.

Psychoanalysis sees dreams as primarily revealing repressed desires, while analytical psychotherapy views them as offering a broader perspective on the individual’s journey toward wholeness.

The therapeutic relationship also contrasts:

• Psychoanalysis: Therapist maintains a neutral stance, focusing on analyzing transference and resistance.
• Analytical psychotherapy: Therapist and patient engage in a more collaborative relationship, exploring the unconscious together.

Similarities and Common Ground:

Despite their differences, psychoanalysis and analytical psychotherapy share some common ground:

• The unconscious: both acknowledge its power in shaping thoughts, feelings, and behaviors.
• Talk therapy: both use it as a primary treatment method, encouraging patients to explore their inner experiences.
• Early childhood: both recognize its importance in personality development, although analytical psychotherapy emphasizes a lifelong process.

Dream Analysis

Both Freud and Jung placed emphasis on dreams as keys to understanding the unconscious mind.

• Freud saw dreams as primarily about wish fulfillment and the disguised expression of repressed desires. His dream analysis aimed to uncover the hidden meanings behind dream symbols and reveal the underlying conflicts and neuroses driving the individual’s behavior.
• Jung viewed dreams as more complex and multifaceted, offering insights not only into past conflicts but also into future possibilities and the individual’s potential for growth and individuation. His dream analysis focused on exploring their connection to the collective unconscious and the archetypal patterns of human experience.

While they initially collaborated, their interpretations and theoretical frameworks regarding dreams diverged significantly, highlighting a fundamental difference in their understanding of the human psyche.

Freud	Jung
Dreams conceal meaning	Dreams reveal meaning
Universal sexual symbolism	Personal and cultural symbol interpretation
Past-oriented (childhood)	Future-oriented (psychological growth)
Wish fulfillment	Psychological compensation
Free association technique	Amplification method linking personal and collective meanings

Freud’s Dream Theory: Wish Fulfillment

For Freud, dreams served as disguised fulfillments of repressed wishes, primarily originating from infantile desires and instinctual drives, often of a sexual and aggressive nature.

He posited that the unconscious, harboring these unacceptable desires, utilizes dreams as a safe outlet for their expression, preventing them from disrupting conscious awareness and sleep.

Freud’s concept of dreamwork explains the process of transforming latent content (raw, unacceptable impulses) into manifest content (the actual dream narrative we experience).

This transformation involves:

• Condensation: Multiple ideas or feelings are compressed into a single dream image or symbol.
• Displacement: Emotionally charged thoughts or desires are shifted onto less threatening or symbolic objects.
• Symbolization: Unacceptable impulses are represented by seemingly innocuous symbols.
• Secondary revision: The dream’s bizarre elements are woven into a more coherent, though often illogical, narrative.

The analyst’s task, according to Freud, is to decode the dream’s symbols, trace them back to the individual’s personal history and repressed experiences, and reveal the underlying latent content.

Freud believed that analyzing these hidden meanings could unlock the secrets of the unconscious and provide insights into the patient’s neuroses and psychological conflicts.

Freud’s emphasis on the individual’s personal history and the role of sexuality in shaping the unconscious is evident in his dream theory.

He saw dreams as rooted in the individual’s unique experiences and conflicts, particularly those stemming from childhood.

Jung’s Dream Theory: Pathways to Individuation and the Collective Unconscious

Jung, while acknowledging the significance of personal experiences in shaping dreams, proposed a broader and more symbolic interpretation.

He viewed dreams as expressions of the unconscious’s attempt to communicate with the conscious mind, offering guidance for self-discovery and individuation.

Jung believed that dreams could provide glimpses into future possibilities, helping individuals move towards wholeness and psychological balance.

He also emphasized the role of the collective unconscious, a universal realm of archetypes and primordial images shared by all humanity, in shaping dream content.

Key aspects of Jung’s dream theory include:

• Dreams as Compensatory: Dreams often present images and themes that compensate for the one-sidedness of the conscious attitude, bringing forth aspects of the psyche that are neglected or undervalued in waking life.
• Prospective Function: Dreams can offer glimpses into potential future developments and challenges, providing guidance and preparation for the individual’s journey towards individuation.
• Archetypal Imagery: Dreams often draw upon archetypes from the collective unconscious representing universal human experiences and motivations. These archetypes can provide insights into the dreamer’s current psychological situation and potential for growth.
• Amplification: Jung’s own method, distinct from Freud’s free association. He stayed with a dream image and enriched it with parallel motifs from mythology, religion and folklore to unfold its meaning.

Jung’s dream analysis focused on the symbolic meaning of dream images and themes. He traced their connection both to the dreamer’s personal experiences and to the broader archetypal patterns of the collective unconscious.

He believed that by working with the dream’s imagery and exploring its potential meanings, the dreamer could access deeper levels of self-understanding and move towards greater psychological integration.

Why did Freud and Jung split?

Jung was initially a supporter of Freud, becoming president of the International Psychoanalytical Association at Freud’s request.

They met for the first time in 1907 and spoke for 13 hours straight.

Freud and Jung’s theoretical differences, particularly their contrasting views on the unconscious mind and the role of sexuality, ultimately led to their break in 1913.

Other factors that contributed to the split included:

• Jung’s interest in spirituality and paranormal phenomena, which Freud dismissed as unscientific.
• Freud’s dogmatic personality and need for control, which Jung found stifling.
• Jung’s feeling that Freud was trying to exert paternal authority over him, which may have stemmed from Jung’s unresolved issues with his own father.
• Jung publicly criticized Freud’s theory of the Oedipus complex and his emphasis on infantile sexuality while on a lecture tour of America in 1912.

The Freud-Jung split was a significant event in the history of psychology. It led to the development of two distinct schools of thought: psychoanalysis and analytical psychology.

Both schools have had a profound impact on the field of psychology and beyond, influencing therapy, art, literature, and popular culture.

Their split also highlights the complexity and diversity of the human mind and the need for multiple perspectives to understand it fully.

Critical Evaluation

Freud’s and Jung’s grand theories face real scientific challenges. But the picture is not one of simple rejection.

• Falsifiability: Karl Popper argued that psychoanalytic and Jungian concepts explain any outcome and therefore forbid none, disqualifying them as science.
• Case studies: both theories were built from small, uncontrolled clinical cases open to the analyst’s own confirmation bias.
• Weak Jungian evidence: archetypes and the collective unconscious are especially hard to test, and cross-cultural symbols may simply reflect shared culture rather than biological inheritance.
• Freud’s dream theory: neuroscience’s activation-synthesis model traces dreaming to random brainstem activity, challenging the idea that every dream disguises a repressed wish.
• The Myers-Briggs caution: Jung’s typology, filtered into the MBTI, shows poor test-retest reliability and weak predictive validity as a personality measure.

The Falsifiability Problem

The philosopher Karl Popper made the most influential methodological attack on both traditions (Popper, 1963). Their central constructs, he argued, are flexible enough to fit any observation. If a man behaves lovingly, the theory is confirmed.

If he behaves cruelly instead, a Freudian can call it a reaction-formation, and the theory is confirmed again. A construct that fits every outcome forbids none, which for Popper disqualifies it as science rather than merely as difficult science.

The charge lands hardest on each system’s most interpretive core.

It hits repression and the Oedipus complex for Freud, archetypes and the collective unconscious for Jung. It does not touch the outcome research on psychodynamic therapy, which makes falsifiable predictions of its own (see Contemporary Research, below).

Reliance on Case Studies

Both theories were built largely from uncontrolled clinical cases interpreted by the theorist himself.

Freud drew on a small set of patients, among them Dora, Little Hans and the Wolf Man. Jung drew on his own clinical work and cross-cultural readings.

Such evidence is vulnerable to confirmation bias. An analyst who expects to find Oedipal wishes, or archetypal motifs, tends to find them, and the interpretation cannot be independently checked by anyone else.

Freud’s own samples were also unrepresentative: a small number of mostly affluent Viennese women. That makes his leap to universal claims about human nature harder to justify.

The philosopher Adolf Grünbaum pressed the point further. He argued that psychoanalysis cannot validly infer the causes of a patient’s neurosis from clinical data the analyst’s own suggestion has already contaminated (Grünbaum, 1984).

Weak Evidence for Jungian Constructs

The archetypes and the collective unconscious are especially hard to test. Direct empirical support for an inherited, universal layer of symbolic images is scarce.

Where symbols do recur across cultures, a simpler explanation usually fits better: shared culture, common human experience and basic cognitive universals, rather than a biologically inherited image bank. This is a point developed inside analytical psychology itself.

A review by Christian Roesler reconceives archetypes as patterns transmitted by culture and development rather than fixed in the genes (Roesler, 2012). Jung’s more mystical commitments, synchronicity among them, sit outside anything mainstream science can evaluate at all.

Four archetypes carry this risk most.

Persona, shadow, anima/animus and the Self are all treated as universal and inherited in Jung’s model. If their recurrence is cultural rather than biological, they describe common patterns without proving the inherited psychic structure Jung claimed.

Problems with Freud’s Dream and Drive Theory

Freud’s wish-fulfilment theory of dreams has been directly challenged by neuroscience, decades after it was first proposed in 1900.

The activation-synthesis model (Hobson & McCarley, 1977) argues that dreaming starts as essentially random brainstem activity during REM sleep. The forebrain only stitches this activity into a narrative afterwards.

If the activation-synthesis account is right, most dream content need carry no disguised, repressed wish at all. This cuts directly against Freud’s central dream-work mechanism.

More broadly, reducing human motivation to sexual, and later aggressive, drive is now regarded as empirically untenable as a complete account.

The finding reshaped how psychologists study dreaming, shifting attention toward the brain processes that generate dream content in the first place, not toward a censored, symbolic disguise.

The Myers-Briggs Caution

Jung’s typology of introversion, extraversion and the four functions fed directly into the popular Myers-Briggs Type Indicator, one of the world’s most widely used personality tools. Its scientific standing has not kept pace with its popularity.

A review by David Pittenger found that the MBTI’s forced type categories show poor test-retest reliability (Pittenger, 2005). Many people are sorted into a different type when they retake the same test just weeks later.

The instrument also forces genuinely continuous traits into an either/or split the underlying data do not support. The cultural success has outrun the science.

None of this stops the MBTI’s popularity in workplaces and career counselling, but a psychology student should treat its four-letter types as descriptive labels, not scientifically validated categories.

None of this adds up to a wholesale dismissal, though. A growing body of research rehabilitates part of the tradition, above all the therapy it produced, detailed next.

Contemporary Research

Modern research no longer tests Freud’s or Jung’s nineteenth-century metaphysics directly. It asks a simpler question instead. Does the therapy this tradition produced actually work?

The hierarchy of evidence points to meta-analyses of randomised controlled trials as the strongest answer. The anchor study below put psychodynamic therapy to its most demanding test yet.

• Aim: To test, for the first time with formal equivalence testing, whether manual-guided psychodynamic therapy is genuinely as effective as already-established treatments such as cognitive-behavioural therapy, rather than merely “not significantly different.”
• Method: A systematic review and meta-analysis of 23 randomised controlled trials (2,751 patients), built as an adversarial collaboration between psychodynamic and CBT researchers to guard against allegiance bias, using a pre-specified equivalence margin.
• Results: Psychodynamic therapy met the strict equivalence criterion at the end of treatment (g = -0.153) and at follow-up (g = -0.049), with both confidence intervals falling entirely inside the pre-specified equivalence band.
• Conclusion: Psychodynamic therapy is statistically equivalent in efficacy to other well-supported treatments, a stronger finding than “no difference.” The tradition Freud, and through analytical psychotherapy Jung, began now has robust, high-quality evidence that its therapy works (Steinert et al., 2017).

This converges with an earlier meta-analytic case. Shedler’s review found psychodynamic therapy’s effects comparable to other well-validated treatments, and often more durable after treatment ends (Shedler, 2010).

Evidence for a dynamic, motivationally-charged unconscious is broader but shakier. Neuroscience has argued a Freud-style unconscious has a plausible neural basis, though this case remains more contested than the therapy findings (Solms, 2018).

Direct support for an inherited, universal Jungian archetype layer remains the weakest tier of all (see Weak Evidence for Jungian Constructs, above).

The overall shape is a descending gradient of confidence: secure evidence the therapy works, suggestive evidence for a dynamic unconscious, and little support for the grander Jungian metaphysics.

References

Grünbaum, A. (1984). The foundations of psychoanalysis: A philosophical critique. University of California Press.

Hobson, J. A., & McCarley, R. W. (1977). The brain as a dream state generator: An activation-synthesis hypothesis of the dream process. American Journal of Psychiatry, 134(12), 1335–1348. https://doi.org/10.1176/ajp.134.12.1335

Pittenger, D. J. (2005). Cautionary comments regarding the Myers-Briggs Type Indicator. Consulting Psychology Journal: Practice and Research, 57(3), 210–221. https://doi.org/10.1037/1065-9293.57.3.210

Popper, K. R. (1963). Conjectures and refutations: The growth of scientific knowledge. Routledge & Kegan Paul.

Roesler, C. (2012). Are archetypes transmitted more by culture than biology? Questions arising from conceptualizations of the archetype. Journal of Analytical Psychology, 57(2), 223–246.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378

Solms, M. (2018). The scientific standing of psychoanalysis. BJPsych International, 15(1), 5–8.

Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174(10), 943–953. https://doi.org/10.1176/appi.ajp.2017.17010057