Arnold Richards is well known for his nuanced reflections on the institutional history of psychoanalysis, organizational power games, and the politics of exclusion (see Richards, 2017). He is worried. So am I. We are in crisis on many fronts: from dubious public perception to antagonism from empirical science, mainstream academe, exclusion from university and hospital training environments, interference by regulators, corporate managerialism, insurance denials, private industry privileging profit over quality care, and our own narcissistic hubris of superiority over competing mental health disciplines only shoots us further in the foot. We are losing our credibility: unwilling to compromise or play the game, engage in dialogue with allied professionals, encourage and support research, and engage in outreach to the greater public only marginalizes us more. What makes matters worse is that we are internally divided over our own discipline (Eagle, 2003; Mills, 2017; Summers, 2008). We can't even agree upon a common definition or come to a consensus on what constitutes psychoanalysis (Mills, 2012), let alone with precision and clarity, which only adds to the problem. Dogged by social, political, and financial pressures to conform to conventional medicalized expectations of measurable outcomes, marketplace demands for economic utility, expediency, and efficiency, and the loss of autonomy and control we once enjoyed in providing treatment based upon our own professional sensibilities and training is further eroding our profession (Eisold, 2007).
As we anticipate our impending demise (Bornstein, 2001), Richards chides the oligarchs, demigods, and religious cult proselytizers who christen the baptized with holy water only to alienate the rest of the uninitiated who fears drinking the Kool-Aid. Hegemony, elitism, and pretension of the supervising and training analyst caste system only distances psychoanalysis further from the mainstream. Straddling a precarious and ill-defined fence between science and the humanities (Dauphin, 2008), aversion to empirical research or proof (Ratner, 2018)—let alone
demonstration, not to mention seeing its value—is political suicide. Despite recent attempts at progress and innovation (Axelrod, Naso, & Rosenberg, 2018; Govrin & Mills, 2019), psychoanalysis appears to be fizzling out, at least in classical practice. But there may to be some hope if it modifies its image, scope, and outreach, which I will turn to shortly. Where it holds its ground is as an intellectual contribution to offering a rigorous study of mind, human nature, social relations, and philosophy of culture motivated by unconscious psychological dynamics.
Whereas I have been concerned with the ideologies of science (Mills, 2015), Richards (2015) has focused his attention on the ideologies of the profession. As it has been argued from sociology to the Frankfurt School, every social collective is conditioned on a substrate of ideologies, particularly psychoanalysis, or Freud would have had no need to assemble a Secret Committee to safeguard his “new science” and keep undesirables out. As Barnaby Barratt (2013) has noted, “there is no stepping out of some sort of ideological web” (p. 170). Certain “ideals” permeate the psychoanalytic canon like any other social configuration with recalcitrant fantasies that color the way things “ought to be” regardless of the validity of their premises:
Ideology consists of a relatively fluid set of representations that constitute social subjectivity, together with a core of communal practices that condition the unconscious libidinal investments of subjects in their political community. These libidinal investments are structured by unconscious social fantasy and ballast the subject's political allegiances with a kernel of enjoyment, which determines a relatively fixed loyalty to the institutional rituals of the political community. (Boucher, 2014, p. 128)
In other words, ideologies are necessary illusions based on collective identifications that allow for social cohesion only on the condition that certain unconscious fantasies may be entertained and enjoyed. Over much of his career, Slavoj Žižek (1989) has focused on various aspects of ideology that interpellate the subject through reinforced modes of institutionalization. Here we may extend this to the institution of psychoanalysis—it's snootiness, dogma, protectionism, and reinforced loyalty—as gatekeeper to the holy grail of truth guarded by oligarchy. As
a result, the old guard is dying off without replacements in the ranks, while the youth resist authority, are suspicious of wisdom dispensers, distrust guild mentality, and are vociferously critical of traditions that demand conformity while silencing critique.
Richards points out that psychoanalysis once enjoyed esteem among the public and intelligentsia alike. Now it has lost respect and earned mistrust. What happened? It hasn't kept up very well with the times. Given the exclusionary history governing the educational and organizational life of psychoanalysis (Bergmann, 2004; Eisold, 2018; Kernberg, 2016), including excommunicating heretics and dissidents, tribal dysrecognition, infighting among rival factions and groups, the frequency and furniture wars, and the need to control training and restrict who gets accepted into the club, hence leading to the lawsuit against the American and International Psychoanalytic Associations—how do we present a unified front when we are far from unified or inclusive? The hierarchy separating medical psychiatry from psychology, which still exists, is bad enough, where psychologists are seen as tawdry lowbread citizens, let alone the inferior social worker or psychotherapist, or even worse, the lowly mental health counselor pissant, for we can't even find common ground to unite as a profession due to these differences despite mutually shared identifications. When micro-aggressions are inflicted on a perceived inferior class, they will leave, unless their transference needs for inclusion remain masochistically intact. What should we expect the public to think when one professional body is hostile toward another ally? It does not bode well for a collective shared vision of the value and status of psychoanalysis when professions devalue alterity, camps bash each other simply because they belong to a different theoretical orientation, school, or come from an alternative type of education or training, where comparative discourse is pooh-poohed, and otherness is expected to take its proper place in the back of the bus.
We have not properly educated the public and professional groups on the value of psychoanalytic thought—in the consulting room and the academy; nor have we highlighted the fact that psychoanalysis has gone through many iterations, historical developments, and evolutions since the time of Freud. This is evident by the fact that the public and other
disciplines alike, academic or otherwise, do not even know what contemporary psychoanalytic theory and praxis is about. Psychoanalysis is no longer confined to five days on the couch, penis envy, and the anal stage. Despite the fact that different emendations and redirecting shifts in perspective and emphasis have saturated the psychoanalytic domain, including incorporating psychodynamic thinking into psychotherapy training and praxis, the masses largely remain ignorant of our conceptual and technical advances that have utilitarian significance in today's societies. We need to do a better job at public education and outreach, politicking among the various stakeholders, lobbying the insurance sector, serving on health policy advisory boards, providing legislative consultation, and shaping the parameters and attitudes toward mental healthcare delivery and choice of interventions. Richards asks, what is stopping us? Laziness and arrogance, I suggest, among other things. The mindset is: “I'm better than you; I can't be bothered with your nonsense.” Individual practitioners are too insular and worried about their solitary affairs, hence unwilling to step outside of their bubble, while academic appointments have all but disappeared in the US. Analysts and scholars seem content on publishing in their own venues and periodicals—not in multidisciplinary journals, teaching at independent Institutes and training programs—not universities, and preaching to the choir.
Given the evidence-based movement, why would the discipline chose not to engage in dialogue rather than step out almost entirely from framing the debates, politics, and policy issues involved? It has failed to participate in key strategy initiatives with major stakeholders—insurance companies, private industry, public healthcare, university departments of psychology and psychiatry—who make decisions on our behalf, and who have almost entirely cut us out of the discussion because we have refused to sit at the table, listen, talk to others, and educate. Regulators, policy analysts, insurance panels, actuaries and underwriters concerned about premiums, public healthcare administrators, and governmental bodies that determine legislation would all profit from input by psychoanalytic organizations lobbying for our profession. If psychoanalysis continues to be estranged from the politics of mental health, then it's digging its own grave. We need to reverse our public perception and rehabilitate our image problem.
Third-party payers can affect the legitimacy of psychoanalytic practice in significant ways: they demand evidence, a credible treatment plan, treatment monitoring and outcome measures, disclosure about the type of therapy conducted and its frequency, and require intrusive data, such as the demand for clinical notes and records in order to fund the treatment (Mills, 2014, 2020b). When psychoanalysts identify the type of treatment being delivered, they run the risk that their patients may not have access to their workplace or extended health benefits, or their claims may be denied when submitting receipts for reimbursement. Of course practitioners have ways of getting around such impositions, but it is more like playing a game rather than being open and honest about what we do. Medical doctors can say they practice medicine or psychiatry, psychologists practice clinical psychology, social workers conduct clinical social work and so on, where they can skirt the issue of what kind of therapy they practice or treatment they provide; or when pushed on the issue by a third-party funder they simply claim they practice psychotherapy or an eclectic approach tailored to the unique needs of each client, or avoid answering the question so treatment approval or funds are not thwarted. But this is not entirely genuine and produces discomfort when confronting insurance adjusters who demand to know if you are practicing “evidence-based” interventions that are “scientific” out of the list of “approved” services they consult on their guidance charts or in their data bases.
It does not help matters when other professional researchers and academics publish opinions that conclude psychoanalysis is pseudoscience and ineffectual, if not quackery, which insurance adjusters cite to justify claims denials. What makes matters worse is when the various institutional organizations that speak for the profession do not correct such misperceptions and biases coming from other competing fields of opinion, such as empirical psychology in academic or clinical departments who weaponized data for political purposes in order to boost their own credibility, especially when there is plenty of empirical support for psychoanalytic interventions (see Seitler, 2018) that are ignored or dismissed. All this shows is a lack of advocacy about the value and validity of psychoanalytic paradigms.
In addition to the need to demonstrate public relevance, collaborate with other body politics, engage in psychotherapy integration discussions and research, policy consultancy with vast stakeholders, and educate the layman and corporate culture alike on how psychoanalytic treatment actually works, the discipline is failing to attract early career professionals. This is partly due to its staunch criteria that does not want to compromise on what psychoanalytic training means to those (mostly old men) coming from a classical tradition that requires a minimum of three hourly sessions a week, which is already watered-down from the gold standard of five. The main issue here is the cost, at least in America.
We must face the facts about economic realities. Only the opulent can afford classical psychoanalysis. No one else can afford it or would desire to budget for it, unless they are those in training to become psychoanalysts, which is a prerequisite. In fact, it may not be inappropriate to surmise that the vast majority of those in formal psychoanalysis are those in training, and at great expense. By the time a doctoral level graduate has accumulated substantial debt to earn a terminal degree, which is often over $150,000 in loans in the US, the additional fees to cover postdoctoral education make the whole prospect of psychoanalytic training prohibitive. In other countries that offer subsidized education to its citizens and have a lower scale of economy, this imposition is much less prohibitive. In fact, the “psy culture” in South America is surprising affordable to the degree that most citizens enter into therapy—from taxi drivers to CEOs—because the fees are affordable and the culture is psychologically minded. Psychoanalytic therapists may charge as little as $25 a session in Argentina and Brazil, €40 in parts of Europe, such as Belgium, and £50 in the UK, whereas in Mexico the fee can be as little as $4 USD. The disparities are obscene in comparison to US conventions where some analysts charge as much as $500 a session, such as in Manhattan. The only equivalent to this affordability in the United States are low fee training clinics, and those in private practice training to become psychoanalysts who are so desperate for formal control cases that they will see people for as little as $20 a session just so they can bank their clinical time for supervision hours. From the standpoint of feasibility, for both patients and practitioners, there is no longer an expectation or illusion of initiating or cultivating a traditional psychoanalytic practice in North America. It's a dead dream. Those who still practice from a classical framework are few and far between.
Given that psychoanalytic candidacy is withering on the vine, an argument can be made that an ethical alternative to suicide prevention is to make psychoanalytic training pro bono, introduce substantially reduced fees, or subsidize tuition and supervision as a way of preserving the discipline. Analysts identified with providing psychoanalytic education and instruction may be said to have an ethical obligation to the future of the profession rather than holding onto power in institutional governance where a portion of their income comes from charging candidates through a prolonged cash grab. A modest proposal is to at least make training and supervision affordable.
The majority of psychoanalytic practitioners in the US today are not graduating from formal psychoanalytic Institutes simply because they cannot afford it, nor can they afford to take off time from work. Instead they are receiving training in psychoanalytic psychotherapy, and yet they often feel like second-class citizens looked down upon by the conceited establishment. The likelihood that psychoanalytic psychotherapists will eventually become “feeders” for formal psychoanalytic training is also a fantasy because of the costs and time commitment involved; not to mention the rigid formal requirements for a personal analysis that is selected or approved by the Institute matched with one of their society or faculty members, hence being subjected to the colonization and commodification of the training and supervising analyst system, which is antiquated, exploitive, and incestuous. It is for these reasons that many contemporary Institutes are modifying their requirements around training. And almost every Institute, traditional or otherwise, has already expanded their training curriculums to include a program in psychoanalytic psychotherapy, and even in some cases, a theoretical and/or research track that is entirely academic, which does not require treating control cases and being supervised. This shift toward training in psychotherapy is likely to be the lifeline of formal institutional existence in the future for the simple reason that traditional training is petering out. The field needs to prepare for this shift in focus, identity, and interest whether we like it or not. Here psychoanalysis is destined to become a psychotherapy for the people (Aron & Starr, 2013).
In addition to a lack of attracting psychoanalytic candidates is the issue of failing to address and attract candidates of diversity. Whereas in many parts of the world where ethnic difference and multiculturalism
are represented, such as in Latin America, India, and Asian communities, North America has a significantly low representation among visible minorities practicing psychoanalysis, especially black professionals. In fact, the International Association for Analytical Psychology (IAAP) has only 4 African American Jungian analysts worldwide out of a membership of over 3500 (Samuels, 2018). While attempts are being made to become more inclusive, address diversity and social justice issues, and recruit people of color and marginalized groups, such as LGBTQ, or more recently, LGBTQQIP2SAA (lesbian, gay, bisexual, transgender, questioning, queer, intersex, pansexual, two-spirit (2S), androgynous and asexual) populations, even introducing transgender psychoanalysis (Gherovici, 2017; Gozlan, 2015, 2018), our discipline needs to catch up with the times.
Like others before him (Chessick, 2007; Slochower, 1964; Strenger, 1997), Richards further examines how psychoanalysis is both science and art. Indeed, it may be more of an art than science in the traditional sense of the word, for psychoanalysis is artful, generative and productive, has its own aesthetic models of ritual and spontaneity, and is generally a creative meaning-making enterprise. The artistry or techne (τέχνη) of our craft is equally supple and shrewd, and as with episteme (έπιστήμη), they produce their own unique forms of science or knowledge. Even in art there are many applied techniques following a discernable and teachable method on discourse, which flows from theoretical concepts that inform technics, including experimental methodologies. But regardless of the fluidity among techne, science, and knowledge, insurers do not fund art.
Although the scientific status of psychoanalysis has been critiqued and defended at length by both insiders and external critics alike, the debate tends to beg the question on what we mean by science (Mills, 2015). I shall forego an extended discussion here, given it has been done ad nauseam and I have already addressed it elsewhere (Mills, 2007, 2019, pp. 16–19), but for the sake of brevity it may be important to remind ourselves that it was Dilthey (1883) who proposed the distinction between the human sciences based upon investigating and understanding the motivations and meanings inherent to the experiential subject versus that of
the natural sciences, which is concerned with the impersonal forces and organizations of physical nature. Whereas the Geisteswissenschaften focus on the science of mental processes and social systems within a class of human events, the Naturwissenschafhten focus on the domain of the natural world. Therefore, the bifurcation that is often forged between the human and natural sciences takes as its premise that nature and human experience are mutually exclusive categories. However, the distinction lies in the methodology and discourse each discipline employs. What was crucial for Dilthey in positing distinctions between the natural and human sciences is the pivotal concept of “lived experience” (Erlebnis), the irreducibility of subjectivity that prereflectively (unconsciously) encounters the immediate presence of reality, that which is present “to me” as an internal sense, not as a given external object or datum of consciousness, but as an immediate internal mediacy. Here the subject-object distinction is obscured, if not sutured: Psyche is the lifeworld (Lebenswelt).
Because Psyche is the object of psychoanalytic investigation, it can never be examined independent of the lived experience of subjects. To pretend that subjectivity exists independent of mind and hermeneutically informed interpretations of descriptions and explanations of observed events, like the discipline of physics, is to beg the question of ontology and epistemology to boot. But regardless of which approach we adopt, we cannot evade making ontological assertions. To say that a hermeneutic, semiotic, or scientific paradigm describes or explains a phenomenon, even if mired in uncertainty and impasse, is to evoke a referent that it is still about something. The mode of discourse does not displace the signified object(s) in question. We cannot elude the question of truth and realism no matter what discourse we adopt. In other words, metaphysics always has a way of coming back to bite us in the ass.
In an attempt to broach a common ground, let me suggest that the scientist, theoretician, and practitioner are all engaged in modes of investigation: they differ only in methodology. Let us call this common ground a theory of discourse. Just as there are different discourses on method, there are also different methods of discourse. But regardless of these differences, they share a common Logos (Λόγος), namely, a rational ground. Theoretical engagement and the empirical method both employ their own modes of discourse as logos in an effort to let something be seen, whether in appearance or reality, as phenomenal description or
demonstrated fact, with the stipulation that some discourses are more persuasive than others.
This brings us to ask, Does logos as discourse have to meet the challenge of science? At face value, yes, but with stipulations. Science attempts to explain while discourse may serve many functions science cannot. But this all depends upon what we mean by science, hence to know (< Lat. scientia, from scire, to understand). In the social sciences—psychoanalysis for instance, to offer a theory that explains psychological conditions and states of mind within social collectives, discourse attempts to present the complexity of intrapsychic, intersubjective, and communal arrangements within a given culture, an unconscious manifestation of the need to make the unconscious conscious. For psychoanalysis, discourse reveals in disguised forms all of humanity's desires, conflicts, defences, emotions, traits, dispositions, longings, and complexes that expose the personal and collective plight of humankind. Here logos—as word, as paradigmatic model—has psychological significance for masses and functions in psychic economy unconsciously. In this way, discourse as functionalism serves the overdetermined systems of meaning in society, and provides regulation to constant change, such that there is order, purpose, and structure to socio-cultural networks via the narrative. A narrative in turn provides meaning, which is at once open to interpretation, even when attempts at explanation fail. Yet the notion of explanation is itself controversial.
An explanandum describes a phenomenon to be explained, not the phenomenon itself, while an explanans seeks to adduce an answer or explanation to account for the phenomenon—its reason(s), purpose, origins, and so forth. While the explicandum is that which gets explicated, the explicans is that which gives the explication. Although an explanation attempts to account for the coming into being of a phenomenon, it is more than that. It always implies, if not literally evokes, the question of causality by attempting to explain the ground or preconditions that bring something about, such as certain antecedent events or the necessary conditions (not sufficient ones) that are temporally and materially a priori. Richards (2015) seems to agree. But everything is overdetermined: a science that only looks at material-efficient causation is bankrupt and collapses into ontological reduction. The most we can say is that there are correlations to observation and the phenomenon being
observed, which still ushers in the problem of description and explanation; hence science can be no better than myth (Mills, 2020a), as they both rely upon a narrative or discourse to justify their premises and conclusions. So contrary to predicate or propositional logic, which is merely concerned with the meaning of words or expressions and their formal systemic relations and operations, or statements that make something comprehensible, an explanans is much more far-reaching—it is about ontology.
On the one hand, an interpretation is an attempt to describe a phenomenon, on the other, an explanation attempts to offer more, that is, how and why a phenomenon occurs. But so does an interpretation—each are about explication. So how does an interpretation differ from an explanation? When applied to the question of discourse, scientific or otherwise, I argue that both interpretive and explanatory models are equally making ontological claims, even if they are tarrying in epistemic uncertainty when it comes to the question of causality. Recall that for the ancients, a cause (αιτία) was the reason or explanation for something happening, which is always overdetermined.
If psychoanalytic theory or science—hence empirical research—is a declarative attempt to make phenomena comprehensible, then we must contend that it is offering an explanation of phenomena, even if contestable, or it would not have any currency to grant meaning to the human mind. Whether it is true or false is another issue, one we should adjourn for this discussion. In the end, modes of discourse offer narratives that signify, describe, and explain phenomena. But why should we grant the narrative—the “story”—the status of offering a theory of causality? Why should we assume an explanans has anymore epistemological weight or verity to phenomenal description—to the explanandum? Does not an explanation have multiple threads, multiple significations, hence an overdetermination and surplus of meaning and value, not to mention causal-semiotic strands of deferral to an infinite chain of associations and signifiers? This logically implies that no single explanation is ever complete or unequivocally valid, rather only a partial attempt at conceptualizing and describing phenomena. This applies to scientific methodologies and conclusions as well as psychoanalytic theoria and praxis.
We have turf wars against academics and empirical researchers in our
field levelled by clinicians (Blass & Carmeli, 2007; Hoffman, 2009) that further debilitate our efforts at scientific legitimacy. This is not helpful, not to mention retrograde politics. In fact, clinical psychoanalysis has everything to gain by endearing itself to scientific verification and empirical replication. Let us not forget that the whole field of modern psychiatry was founded on psychoanalytic inquiry. Diagnostic categories and taxonomies such as anxiety, depression, trauma, OCD, conversion disorders, and character pathology are amplifications of Freud's original contributions to the burgeoning field of modern science. If psychoanalysis is to yield any acceptance, it must conform to the parameters of evidence that is expected in our contemporary scientific world in order to stay in the game.
Richards (2015) is particularly keen to flush out and expose the systemically entrenched oligarchy that dominates traditional institutional life, particularly honing in on the educational, training, and certification protocols established by the Board of Professional Standards (BoPS) of the American Psychoanalytic Association (APsaA). Here he perspicaciously paints a picture of an insular good ole boys club of MDs whose central authority keeps the door locked to the manor as if it were a secret Masonic sect where only a few initiates are allowed entry. One cannot help but see clearly the hegemony behind such practices and the ideology that fortifies them, but to their own detriment. By insulating itself from alterity for a homogeneous body politic, it cuts itself off from other discourses and perspectives, (theoretical, empirical, or otherwise), that can contribute to its sophistication and robustness. As a result, fascinated with its own customary paradigms and conservativism versus competing viewpoints that are questioning of or disenchanted with the status quo (Govrin, 2016), the hegemon keeps itself segregated from building a larger community based on its emotional prejudices, negative transference to otherness, and countertransference to others' theoretical orientations that differ from one's own, thereby extricating itself from criticism and in having to justify itself and its organizational structure to outsiders. As long as there is this type of institutional myopia, power differentials, and inflexibility over its governance, principles, practices, and educational policies, it will gradually shrivel until it virtually becomes extinct.
New generations do not want to be confined by patriarchy nor subjected to thought control, as they are more independent thinkers, disobedient to authority, and driven by personal agency, ethical convictions, democracy, and social justice over past cohorts who merely wanted their parents approval and be allowed in the house. Given the wide range of alternative psychoanalytic training venues now available to all mental health professionals that are less onerous (and expensive) than the APsaA requirements, the old oligarchy is destined to find itself one day sitting in the club parlor bar drinking alone.
Years ago I wrote a rejoinder to Robert Bornstein on his prediction of the impending death of psychoanalysis (see Bornstein, 2001; Mills, 2002). As it turns out, when it comes to clinical treatment, he is right—we are on life support; but not so in the academy, particularly in the humanities. My prediction is that psychoanalysis in North America will continue to live on in education, training, and service delivery mainly through psychotherapeutic interventions while classical psychoanalysis will become invisible, if not obsolete, mainly due to prohibitions in cost and time, which is the direct result of our capitalist climate. In other parts of the world where scales of economy are much less based in disparities and profane divisions of wealth, power, and capital, psychoanalysis will continue to maintain a visible presence in intellectual circles and in helping the masses.
In academe, psychoanalysis is likely to continue to have a say, if not simply because it is an alternative voice of depth to superficial chatter that ignores complex relations between self and society in favor of reductive models that ignore the ontology of the unconscious. Psychoanalysis continues to have a prominent presence in philosophy, literature, cultural and religious studies, the visual arts, film, and media, history of ideas, aesthetics, and in the human, hermeneutic, and semiotic sciences. Due to its theoretical complexity grounded in unconscious dynamics that affect motivational systems and conflicts individuals, groups, and larger social collectives harbor, it is likely to command an authority over less urbane theories of human nature that are embarrassingly simplistic, naïve, and based in biological reduction, even if mainstream paradigms continue to dominate the contemporary scene.
Psychoanalytic training and education needs to take its lead from liberal academe that does not encourage orthodoxy, blind identification or conformity with the establishment, need to quell or eliminate dissent, nor suppress critical thinking, skepticism, and open critique. Instead it should foster critical inquiry and engage in ongoing dialogue and debate with its various stakeholders—trainees, future students, allied professionals and other related disciplines, governing bodies, corporate culture, public advocacy, collaborative policy consultancy, and political lobbying initiatives that educate social collectives on the value and benefit of psychoanalytic thought.