Psychoanalytic Identity and the External World: Interaction Between Psychoanalysis and Health Service Systems in Sweden1

Psychoanalysis is questioned in the public debate and in the managed care system. The Swedish experience of negotiating with representatives of the public welfare system clarifies how important it is to have a wide network. The author argues that there is great risk that psychoanalysis will sink back into the private sphere if psychoanalysts cannot accept a third party to support the treatment situation. Were this to be our future, the choice of becoming a psychoanalyst would be more a choice of vocation than a choice of a profession. This line of thought related to the first medical revolution is the introduction of scientific medicine within a socio-economic context in which the main part of medical care is organized in a private setting. Sigmund Freud's consulting room was firmly situated within the private sphere. Although through his entire life he struggled to get psychoanalysis officially recognized, and thereby strived to place it within the public sphere, the original concept of psychoanalytical treatment was related to the family as a unit of production. Within this unit, Freud invented the analytical setting. The second medical revolution is the introduction of a general social security system of welfare including the main part of medical-health care. In Sweden, as in many Western welfare societies, psychoanalysis was included in public insurance systems. The third medical revolution is the introduction of methods for assessment and accountability, with the consequence that the main part of the medical health sector is organized by managed care methods. These methods question whether or not psychoanalysis should be included in public welfare systems.