In the past quarter of a century there has been a progressive development of low-cost psychoanalytic treatment centers in the Institutes affiliated with the American Psychoanalytic Association, to the point where such centers have become permanent fixtures in a majority of the Institutes. The Newsletter has felt that it would be useful to assemble data on all of the treatment centers in the country and to present to its readers a picture of their number, size, and scope. To this end we have sent a questionnaire to each Institute, inquiring about all aspects of existing treatment centers. The response has been gratifyingly complete: questionnaires were returned by all 20 Institutes and by one clinic not directly connected with an Institute. The present article is a report based on the results of this survey. (The terms “treatment center” and “clinic” will be used interchangeably.)
For the country as a whole, the treatment centers carry a total of about 1,000 patients during a year; close to 900 are in analysis and the rest in psychotherapy. This total figure should be evaluated in terms of the nature of the treatment, involving as it does many visits a week, with each visit consuming most of an hour. A more meaningful measure of the extent of the low-cost services may perhaps be found in the fact that a total of approximately 150,000 hours of treatment are given by all the clinics in the course of a year. If we assume that 2 or 3 medical or surgical clinic patients might be seen in the time taken by a single analytic session, the national figure would be the rough equivalent of 300,000 to 400,000 patient-visits in a hospital out-patient department.
The fees are determined by the patients' ability to pay, so that many patients pay as little as 25 or 50 cents a session. The national average comes to around $5.00.
As will be seen further on, the bulk of the treatment is conducted by analytic candidates working under faculty supervision; a smaller number of patients are treated by graduate analysts. For the entire country, some 400 candidates and 170 graduates are involved in low-cost treatment, so that a total of 570 physicians are engaged in supplying, without fee, the 150,000 hours of treatment. Altogether, 242 supervisors teach in the treatment centers, giving 17,265 hours of supervision.
(In the nature of our data these figures are in no sense precise, but they furnish an idea as to the order of magnitude of treatment center operations in the United States.)
Low-cost analysis was pioneered in the United States by the Chicago Psychoanalytic Institute which opened its Clinic in 1932. This was followed a decade later by the Topeka Institute (in connection with the Menninger Foundation), in 1942, the Columbia Psychoanalytic Clinic in 1945 and the New York Psychoanalytic Institute Treatment Center in 1948. These four units are the largest in our survey, followed in size by the clinics of the Boston group in 1954 and the Institute of the Philadelphia Association in 1949. During the 1950's a number of smaller clinics opened, bringing the present number across the country to 17. Of these 17, one is not Institute-operated—at the Psychoanalytic Foundation of St. Louis. One third of the units treat children as well as adults; the Cleveland Clinic is primarily for children, but also treats adults.
The treatment centers obtain their funds from a variety of sources. First are patients' fees, which may furnish from 25% to 100% of the budget. Aside from the fees, the clinics obtain funds from the dues of their Society or Institute members, from private foundations, government grants, individual contributions, and scholarship funds. The smaller units tend to rely entirely on patient fees for their operating expenses, while the larger centers draw more frequently on the other sources mentioned. The Chicago Institute's Clinic is unusual in that only 25% of its budget comes from fees and the remainder from other sources. The smaller St. Louis Clinic and the Child Analysis Clinic in Cleveland are also largely non-fee supported.
The annual budgets of the group of smaller clinics average about $27,500. The average for the larger centers is $78,480 per year. The largest budget reported in our survey was that of the Chicago Institute's Clinic, which in 1966 was $201,000. (The much larger Topeka budget apparently includes other functions.) Since the actual treatment of patients is conducted by physicians who serve without fee, the expenses of the treatment centers are accounted for by other types of costs—paid administrative staff, clerical staff, rent (in some instances) and the usual operating and housekeeping expenses. The fact that many of the clinics derive some of their funds from the dues of Society or Institute members is worthy of note; this is a measure of the extent to which analysts are willing to give financial support to the educational, research, and service goals of their treatment centers.
The treatment centers, like any out-patient clinic, serve a number of purposes simultaneously. For the analytic candidates, they offer a continuous source of clinical material for the supervised analytic work which is an essential part of analytic training. (This is analogous to the teaching value of out-patient work in the training programs of hospital internes and residents.) What is
more, the clinic organization permits the teaching staff to screen patients with a view to selecting those most suitable for analysis by a candidate.
At the same time the treatment center performs a valuable service for the community in which it operates, by offering analysis (and in most cases, psychotherapy as well) to members of the community for whom it would otherwise be unattainable.
The conducting of numerous analyses in a clinic setting, with organized record-keeping and an active teaching staff, offers rich opportunities for research on a great variety of clinical analytic problems, and the treatment centers have generally availed themselves of the opportunity. All of the larger centers report research programs which utilize the available clinical material.
Yet another function which has developed in the treatment centers is their use for post-graduate education. In a variety of formats — seminars, workshops, study groups and staff conferences — graduate analysts find in the clinics a ready opportunity for interchange with colleagues and for continued study.
In one respect the treatment centers have apparently not exploited their potential. Although they offer a community service, for the most part they have not used this service as a means of establishing close community bonds. In general this has meant the loss of an opportunity to educate the lay public about psychoanalysis; at the same time potential support from the community is not realized. Only two of the clinics in the survey reported activities in relation to community education and work with community agencies.
The varied functions which have been described are most fully developed in the larger and older centers. In the evolution of a given center, the first step is the creation by an Institute of an organization which can provide analyzable patients for candidates in training. At the start it is administered by an analyst appointed by the Institute, and staffed by the Candidates. As the Institute and its treatment center grow, graduate analysts join the staff, and the service, research and post-graduate aspects of the center gradually evolve. With increasing size and complexity, the clinic in time finds it necessary to retain one or more analysts on a salaried basis as chief administrators, and to add social workers and psychologists to the professional staff.
One of the largest treatment centers is staffed by 66 candidates, each contributing some 327 hours a year; in addition there are 57 graduate analysts, contributing about 136 hours per year. The teaching faculty consists of 32 supervising analysts. Candidates are expected, as a requirement of training, to conduct analyses of 2 clinic patients.
This clinic will in the course of a year answer close to 1,500 inquiries about availability of treatment. Of these inquiries, some 15% will eventuate in formal applications, and about half of those who apply will be accepted for analysis. The chief criteria for acceptance are financial eligibility and suitability for analysis. From among those who cannot be accepted for analysis, some are accepted for psychotherapy, and the others are aided in finding help elsewhere. The census of this typical center will be over 250 patients at any given time. In a year it will conduct about 30,000 sessions of analysis or psychotherapy. Its case load includes children.
The outlook is for a slow growth in both the number and size of low-cost treatment centers. The limiting factor in the growth of any analytic clinic is the availability of candidates and graduates to conduct analyses. The pace at which the clinics can grow must therefore parallel the growth of organized psychoanalysis. In the nature of things this will never be rapid.