The question of the future, if any, of psychoanalysis in America has been a subject of debate for some time. I will give you my quick answer, which is Yes, and I will be discussing how recent political and institutional changes in the American Psychoanalytic Association (APsaA) are helping to enhance the future prospects of psychoanalysis. It is no surprise that this argument is deeply politicized. Opponents of the various forms of the psychoanalytic status quo have used the picture of a dire future as a weapon in support of change, and not without justification. The proponents of the status quo often held the benighted belief that a contracted field is fine; it would be characterized by higher standards and thus more elite.
A powerful underlying theme here is the extent to which the organizational politics of American psychoanalysis (APsaA) has been a major impediment. The focus here will be upon psychoanalysis in the USA, although psychoanalysis elsewhere faces many similar challenges. In recent decades progressive forces within APsaA have begun to erode decades of harm done to the vitality and viability of the field.
It is instructive to investigate the background reasons as to why this has been such an entangled and at times combative issue. Psychoanalysis has for many years considered itself to be a true exception to the rule that substantive change and ongoing challenge to established theory and practice is inevitable and indeed a sign of health. This attitude has ex-pressed itself in unwelcome ways in APsaA's politics (Hale, 1995).
Several ongoing attitudes have been prevalent in the field since its inception and they have been detrimental. They are in many ways interrelated. I will mention them here to establish a context and will then discuss them further. There is the concept of “splendid isolation” championed by Freud (1909) which has held us apart from interchanges with other disciplines (Fonagy, 2003; Levy 2004). Another long-standing belief though not usually stated explicitly albeit powerfully implicit is the
sense of a “psychoanalytic exceptionalism.” One manifestation of this exceptionalism is the contention that with our ability to mine down into the unconscious we can extract the “truths” about human motivations which are inaccessible to anyone else or any other discipline. Thus we do not necessarily need dialogue with other disciplines. The field has also engaged in an ongoing struggle to diminish any ideas that are not consistent with Freud's canonical corpus. While this is somewhat true in other fields founded by a charismatic and autocratic innovator, it is especially characteristic of ours. The comparison of psychoanalysis to a religion or even a cult has at least some merit. This obeisance has also spawned a profound rigidity in defining the theory and practice of psychoanalysis to the point of seeing efforts at innovation as “deviations.” Oftentimes the gatekeepers of these ideas purport themselves as adherents to very “high standards,” but what they really are adhering to are usually requirements and not standards (Kirsner, 2009). Perhaps the most frequently argued and divisive issue is the persistence of the Training Analyst (TA) system. This target of controversy has been under attack for decades. The system is adhesively attached to the idea that only analysts whose cases have been reviewed by a select group of other analysts are able to conduct analyses of aspiring candidates. Luminaries such as Kernberg (2014) and Reeder (2004) have long called for the ending of the TA System. Especially suspect within the TA system has been the prerequisite of APsaA endorsed certification. Proponents see it as a necessary measure of insuring quality and “protecting the public” (a public which consists of a very small number of analysands) but opponents see it as exclusionary and arbitrary while also perpetuating a very traditional and unchallengeable form of analysis.
We can begin by looking at the concept of “splendid isolation,” the premise that psychoanalytic ideas are unique, primary and supraordinate. Thus the field could separate itself from the rest of the world of thought. Currents will shift in any body of thought but indeed there were many who thought that the body of work formulated by Freud constituted a set of ideas that could be accepted as foundational and “truth.” Freud, despite his brilliant observations, has indeed been villainized by many who have seen him as not only producing a body of work that would not allow any dissent but spawning several generations of followers willing only to promulgate his canon. Indeed, early colleagues, such as Jung,
Adler and Rank, who sought to innovate were extruded from the field. One can only imagine how our theory and treatment might have evolved if creative thinkers such as they had remained in the field. Frederick Crews (2017) has produced a very recent jeremiad which examines this subject in great detail. Crews scores some very impressive critiques amid his excesses.
These disciplinary indiscretions have had a distinct and at times detrimental influence upon the profession. They have unfortunately exerted a very undue effect on organizational politics, which has indeed disaffected many members and prospective new members. One key measure of an organization's ongoing vitality is its membership. Most unfortunately APsaA, our professional organization, has suffered a major decline in its active membership category, those in prime productive years and, critically important for its ongoing viability, those who pay full dues. Over a nearly 20-year trajectory this component of APsaA has drastically contracted, by 36%, from 1,775 active members to 1,144 in 2020. A bit less ominous is the decline in candidate member numbers. Here we have 15 years worth of data, illustrating a 22% decrement from 629 to 494. Perhaps a slightly more hopeful metric is that the total number of candidates which presumably includes those candidates who choose not to become members of APsaA (this is a separate but important problem) has seen less erosion over the last 15 years (from 897 to 831, a loss of 7%). It is difficult to know why the number of candidates who have joined APsaA is not higher. It was 59% in 2020, but at the least it does suggest that there may well be a problem which may serve to continue to suppress our membership numbers.1 An especially ominous element of the membership decline is that it has occurred in the context of APsaA's demonstrating an increased willingness to expand its tent. The once loftily spoken sentiment that other psychoanalytic institutes do not meet “our high standards” has been softened as APsaA has seen a number of those institutes become part of the organization. Yet the membership decline has continued unabated. A related issue, worthy of intensive discussion, has been the field's neglect of a variety of diverse communities, such as LGBT and the many non-Caucasian ethnic groups.
Membership data was obtained from the Annual Reports on Membership presented at APsaA's biannual meeting.
For many progressive APsaA members, the ongoing nemesis in any broadening or liberalization of the organization and the profession has been the persistent adherence to the TA system (Reeder, 2004). This has been an extraordinarily complex problem fraught with many difficulties and it has been highly politicized his historically TA's exerted great control over candidates. Indeed there was a time when candidates could not terminate their analyses without the explicit consent of the TA, no doubt leading to at least some instances of financial exploitation, emotional exploitation and a great reluctance to challenge the system. There were, of course, other problems, including the restricted and/or exclusionary methods of selecting TA's and that at least some candidates became near clones of their TAs. One particular irritant to many has been with the long standing and some cases continuing requirements of APsaA certification for TA status. Admittedly there have been some reforms in the TA system especially in recent years, but at least for some APsaA Institutes, these restrictions remain in place, for now. However the winds of change are definitely upon us.
Despite these obstacles, APsaA has indeed survived for 100 plus years and while we are not in robust health, we are not quite on life support. There are several areas of strength but many of these areas are more related to the academic side while not directly related to the practice of psychoanalysis. Classic multiple-times-per-week-on-the-couch analysis, however, is likely close to needing life support. This should not be a surprise. The profession and its professional organization need to accept that a four time per week treatment, at a fee reasonably in line with comparable professionals, is simply too costly and time consuming for all but a fortunate few. We would be wise to not pivot our future on the viability of formal four time per week psychoanalysis.
Despite all these obstacles, a newer membership has courageously taken on these long-established shibboleths and pushed for reform, slowly succeeding, largely to the benefit of psychoanalysis (Kirsner 2009).
One very salubrious development within APsaA has been directly initiated politically. That is the rising influence of the Executive Council (now known as the Board of Directors) which has rightfully wrested control over much of the organization from the BOPS (Board of Professional Standards) or standard setting side. For many years BOPS, with its major
focus on “standards,” controlled much of APsaA's activity and its overall ambience. The effect of this hegemony was often stultifying, negatively impacting membership, training and even treatment. Membership, for example, for many decades remained firmly and rigidly under the control of BOPS with its restrictive requirements, including the need for certification as a prerequisite for full membership. This had a souring effect on members who found the certification process far too rigid, arbitrary, even humiliating but who by eschewing certification could not become full members. It wasn't until the early 2000's when then President Newell Fisher moved boldly to take control of membership out of BOPS and relocate it within the Executive Council. While this has been a refreshing and welcome development, with many positive outcomes, it has not turned back the tide of ever declining membership.
An area of strength which probably was never envisioned and which must continue to be nurtured is our relationship with the academic world. This I think has been an acquired taste for academia, where early on there was a wariness of Freud's radical ideas, especially about infantile sexuality. However, as time has advanced, many academic disciplines have warmed to psychoanalytic ideas and have found psychoanalytic inquiry very useful in expanding scholarly understanding in fields as varied as anthropology, literature, history, art, philosophy and religion, to name only a few. This relationship has not been without bumps and bruises but it has fortunately developed and has even shown signs of ongoing blossoming. A greatly beneficial development with academics that initially met with considerable ambivalence has been the concept of the “research candidate.” At first many in APsaA feared that this would be a backdoor into clinical practice for individuals who lack the requisite clinical background. Some feared competition for psychoanalytic patients. But over many years APsaA was very pleasantly surprised to discover that many of these candidates were enormously talented scholars who made significant contributions to their own field and to ours. And indeed those interested in practice had, with proper assistance, often been able to become clinicians, even outstanding clinicians. While still a relatively small group among our overall members, they are a most vital component, especially in the domain of analytic ideas and creativity. In a broader sense, the academy's embrace of psychoanalysis has further ensconced us in a much wider world of thought, thus reducing our
“splendid isolation” (Levy, 2004). Our reach needs to expand further yet to embrace those communities who have been ignored by us, such as LGBT and various minorities.
Also beneficial has been the addition of institute sanctioned programs in psychodynamic psychotherapy, probably now in place for two to three decades. As with so many proposed innovations directed at a broader audience, behind the oftentimes splendidly isolated notion of strictly defined psychoanalytic treatment, initially this idea was met with at least some degree of skepticism. One of the biggest apprehensions was that these students would present themselves as faux analysts lacking the formal training of a candidate program and might mislead patients and perhaps take them away from those analysts who had indeed fulfilled the rigorous requirements of formal psychoanalytic training. It has never ceased to amaze many of us that so many colleagues are afraid of losing patients to therapists they view as far less qualified. Somehow the idea that patients can make their own wise judgment about therapeutic efficacy is not accepted. The concept of exceptionalism is intertwined with these apprehensions. As has often been the case with these fears, they were largely unrealized. The psychotherapy programs have proven very valuable to many of our institutes. One very practical way is by supplying needed income during the time of ongoing declines in membership and in numbers of candidates. Of course many institutes have encountered financial difficulties and psychotherapy programs have been an asset. In addition, by inviting the broader psychotherapy community into our institutes, the value of psychoanalytic psychotherapy became even more widespread and, of course, at least some of these students found their interest stimulated towards psychoanalytic training. Some psychoanalytic institutes are creatively embracing combining their psychoanalytic candidates with their psychodynamic psychotherapy students in the earliest years of their curricula (Fritsch and Winer, 2020). Fortunately, for many the era of splendid isolation is indeed receding along with psychoanalytic exceptionalism. Psychotherapy had often been viewed as a dross alloy compared with the brilliance of “pure gold” couch-based analyses.
Another constructive development also along the lines of decreasing our isolation is the embracing by some members of the concept of psychoanalysts assuming a position as public advocates. This brings at least some colleagues into the political arena, which in earlier years was clearly seen
as inappropriate, violating the usual boundaries of the psychoanalytic situation and, of course, ignoring isolation and anonymity. Such colleagues often endured the criticism that such activities were “not analytic.” One objection has been that this would open analysts to being viewed in a more “real” way by their analysands, and a violation of the time-honored notion of anonymity to preserve transference. To some this is a price well worth paying for applying psychoanalytic insights to certain public problems and, to some, ever more important is the demonstration that psychoanalysts are not imprisoned in their consulting rooms but genuinely want to assert a voice in influencing public opinion and policies based on psychoanalytic ideas. Furthermore, the idea of psychoanalytic anonymity is being seriously questioned. Some members have managed to become powerful advocates for certain positions and have achieved positions of influence. Psychoanalytic organizations have also taken up lobbying activities. APsaA has a specific committee dedicated to maintaining a legislative presence in Washington, D.C. A prominent example of the worth of this activity has been APsaA's ability to influence various regulations related to health care and mental health care privacy and there have been other accomplishments. Organized psychoanalysis rather shamefully passed on an opportunity to follow up on the America Psychiatric Association's leadership in depathologizing homosexuality (; Lewes, 1988; Isay, 1996; Drescher, 2008). We lost an enormous opportunity for good will with many collegial psychotherapeutic and academic disciplines and with the LGBT community. Fortunately in our practice we now, hopefully, avoid the equation of homosexuality with mental illness. Another very harmful missed opportunity was our long-term refusal to admit psychologists and other mental health professionals into our organization. It took a major lawsuit (Wallerstein, 1998: 2002) for this to happen but few would deny that it has eventually strengthened our discipline.
We have also been significantly aided by the recent decline in the number of institutes maintaining fealty to the traditional TA system. This has occurred concurrently with the Executive Committee assuming greater control over the affairs of APsaA. The BOPS has made a major change and has moved outside of the organization. This has led at least some institutes to decide to no longer adhere to the traditional BOPS directed standards for TA including the certification prerequisite. This
has created a vacuum of sorts, a lack of uniform APsaA policies for TA, or the lack of a “national standard,” a catastrophe to some but a welcome increase in flexibility to others. A number of institutes have established a variety of approaches ranging from essentially allowing any graduate with a certain number of years of experience to be able to analyze candidates up to some sort of more collegial case review as a necessary prerequisite. This has eased the path by which some perspective candidates have been enabled to enter psychoanalytic training. It is remarkable that despite longstanding calls for its overdue retirement the TA system somehow escapes internment.
In the context of these increasingly open and flexible events which have changed psychoanalytic politics and helped to erode many of the long standing shibboleths mentioned above we can speculate on additional steps that will help strengthen our discipline and hopefully at least stabilize our appeal and perhaps even help us expand. First and perhaps foremost is that we expand what is considered “analytic” regarding treatment. In prior times “analytic” was understood to mean only four times per week treatment on the couch, libidinally understood, transference-based and with interpretation as the primary and indeed the ideal element of treatment. It is remarkable to consider that reform minded theorists, Kohut being a prime example, were labeled as “deviant” and their work often derisively termed “supportive psychotherapy” (Strozier, 2001).
This brings us to another future direction which would likely have an exceptionally positive impact on our field. The psychoanalytic community might seriously contemplate a “take over” or a “merger and acquisition” of psychoanalytic psychotherapy. It is an appropriate time for this. In many respects, psychoanalytic psychotherapy is an orphan that has been largely abandoned by many mental health disciplines including psychiatry and psychology. There is a large vacuum much in need of being filled. The dividends to the psychoanalytic world would likely be considerable (Procci, 2013). We have already created a certain amount of the infrastructure necessary to handle this in the form of many of our institutes' psychodynamic psychotherapy programs. We could rapidly expand upon this by boldly approaching psychiatric residency programs and psychology post-doctoral programs and offering classes and training. It is appropriate we should also approach all other mental health training programs.
Psychodynamic psychotherapy is the natural ally of psychoanalysis and not its adversary. A further positive move would be to establish an appropriate path for some meaningful new category of membership for psychotherapy program graduates. There are, no doubt, creative avenues for accomplishing this while still preserving important privileges for the psychoanalytic graduates.
Further solidifying our ties to academia presents another mechanism to help ensure our future. I am suggesting here that we go well beyond the training of the research candidates. Psychoanalytic ideas are a very natural fit with many academic departments and these bridges should be very gladly acknowledged and filled. The concept of “Departments of Psychoanalytic Studies” might be vigorously encouraged and members of the psychoanalytic community who participate should be appropriately lauded for so doing (Levy, 2004). The concept of even more psychoanalytic scholar academics is another intriguing possibility and they would certainly be considered colleagues. And of course, we must continue our efforts to reach out to the various minority communities we have long excluded.
One area that can help us gain credibility in the scientific community, and perhaps with both the health care community and the general public, is greater support for, and the publicizing of, psychoanalytic research. For far too long organized psychoanalysis has not assumed ownership of the value of psychoanalytic research. There needs to be a broad net over what is considered psychoanalytic research but there does need to be a special emphasis on outcome research even if it is not considered on a par with more basic research into underlying mechanisms. Traditionally, the greater health care and scientific communities have believed, falsely, that there is essentially no research and that there is no evidence for the efficacy of psychoanalysis and psychoanalytic treatment. This is simply not true. It is tragic that we have allowed this view to exist, another consequence of the bubble of splendid isolation. In recent years more effort has been put into the support of publicizing our research and that must be accelerated. We now have many investigators such as Mark Solms and Jonathan Shedler who are major contributors, and there are numerous others who are similarly distinguished.
An additional and essential element necessary for our future is that we
be very careful in choosing psychoanalytic leaders. Historically, leadership has often devolved upon those who led the BOPS or “standards” side of the organization and/or those who produced psychoanalytic scholarship. While some were in fact capable and even good or excellent leaders, many simply did not have the necessary “skill set” required to move us forward in the broader communities in which we need to navigate. Ideas fundamental to the optimal functioning of professional organizations similar to ours such as strategic planning and advancement, to name just two, have been ignored and even treated with disdain. Some were adherent to the concepts of isolation and psychoanalytic exceptionalism. Recent leaders in APsaA have more frequently come from background in advocacy or administration, etc., which has helped move us out of “splendid isolation” and from our restricted domain. For example, our current President-Elect has exceptional skills in working with the business community.
So I do believe the field itself and organized psychoanalysis in particular can have a future but we must not remain attached to these outdated concepts such as “splendid isolation”, “exceptionalism”, fetishizing the contributions of our founder, idealizing the concept of standards, etc. Psychoanalytic politics must abandon much of our history and must embrace a much more open and inclusive relationship with the many disciplines with which we have overlapping interests. Fortunately newer members and many progressive members have gained greater control over organizational psychoanalysis, and undoubtedly even further progress will occur. While we may not see increases in membership any time soon, we may well stabilize and forestall further decline. Psychoanalysis is on a path towards a better future, a future with many respectful and nourishing collaborations with other scholarly disciplines.