Psychoanalysis 1980: An Interview with the Director of NIMH

Newsletter: Your article “Future Needs for Psychiatrists and Other Mental Health Professionals” (Archives of General Psychiatry, December, 1979) contains a wealth of information. What is the message in it for psychoanalysts?

Pardes: The article in the Archives focuses on a broad set of issues regarding projection of personal needs for all mental health professionals. Because it is written to address general systems of mental health services, we have not attempted to project any specific needs for psychoanalysts, behavior therapists, group therapists, etc. However, it would seem to me that needs for general mental health professionals have relevance to the question of the potential pool of psychoanalysts and psychoanalytic candidates. In other words, the larger number of psychiatrists, for example, who are in training, the larger number of potential applicants for psychoanalytic training. I think that psychoanalysts consequently would be concerned with these personnel issues, but that they also would be concerned as a result of their interest in the vitality of the mental health field per se.

Newsletter: You participated in a two-day conference in early March in San Antonio on the career choice of psychiatry. What evolved during the conference that psychoanalysts should know?

Pardes: The conference on choice of psychiatric career held in San Antonio came about as a result of concerns regarding the declining number of medical students entering the field of psychiatry. It is my feeling that that problem had developed over a period of time but was marked by the fact that those service settings which might have had trouble recruiting psychiatrists were able to compensate by the use of foreign medical graduates. Legislation passed in the mid-70's, which dramatically constrained the possibility of foreign medical graduates entering this country, had the result of calling to people's attention the fact that there had been an increasing erosion of the number of medical students going into psychiatry.

The conference focused on an analysis of the problem and a review of possible remedies. The conference dealt with diverse aspects of the problem such as the attractiveness of the psychiatric field for students generally, the nature of medical education and particularly the teaching of psychiatry, the models in the form of academicians and teachers with whom the students interact, the financial reimbursement of people going into psychiatry, the admission committees that screen applicants coming into medical school and related issues. It is premature to comment on specific suggestions that will come out of that conference. We are awaiting a report.

However, there was extensive attention given to the areas where academicians and psychiatrists might be able to have some impact. These included a focus on a well-balanced and inviting series of educational programs on the behavioral sciences and psychiatry in medical school. It would seem to me that psychoanalysts have been involved in the teaching of such programs for some time and they might want to scrutinize very actively what they do and what means they can identify to improve that teaching where appropriate.

Second, there was a concern about the visibility, the stature of psychiatrists within an academic center. Again, since a number of psychoanalysts are also on clinical and academic faculties, they might want to reflect on their visibility within academic centers, their availability to medical students, and their participation in the development of policies regarding everything from admissions, to nature of educational programs, to nature of clinical clerkships, etc. One of the key issues, for example, is that students who have the opportunity to involve themselves in direct clinical work and experience a developing capacity to help patients and see patients improve seem more likely to become interested in psychiatry as a career. So I would say that psychoanalysts, to the extent that they are concerned about the vigor of the psychiatric field and the related consequences for psychoanalysis, might be concerned about their participation in educational, clinical and administrative programs within an academic health center.

Newsletter: Many psychoanalysts have stated that positive experience with psychoanalytically trained psychiatrists during their psychiatric residency training led to a career choice decision to seek psychoanalytic training. Are there trends or developments that will change this influential experience?

Pardes: The phenomenon of psychoanalysts having contact with

residents and being seen as ideal mentors, supervisors, educators, models, is still widespread. As additional psychiatric career choices become identified and seem attractive, they may present competition for the given psychiatric resident. However, it is my feeling that there is a large number of psychiatric residents who are very psychologically oriented, and that psychoanalysts working with them and interesting them in the fascination of an understanding of individual psychology will continue to have a very substantial opportunity to influence the career choice of those residents.

Newsletter: Funds for psychoanalytic training are no longer available from the National Institute of Mental Health. Is it likely that the situation will change back to receiving funding for psychoanalytic training?

Pardes: I do not see in the near future any likelihood of training support specifically focused on psychoanalytic training. Insofar as we support a number of educational programs which include various kinds of educational efforts there is teaching of psychoanalytic principles, psychoanalytic theory, psychoanalytic treatment, as an important part of those general training programs; still, there is not specific funding of psychoanalytic candidates. The recent redirection of NIMH training programs requires that all of them address priorities identified by the Presidential Commission on Mental Health. These include the elderly, children, minorities, the relationship between general health and mental health care and some others. To the extent that psychoanalytic teaching has relevance to these priorities, it may be presented either as part of a broader training program or, if it has potential specific application to an NIMH priority, it may be put forward competitively with other training programs to the appropriate NIMH component.

Newsletter: Do you think that independent psychoanalytic institutes or psychoanalytic institutes associated with medical schools and universities are in a better position to adapt to the changes of the 1980's and 1990's?

Pardes: My preference is for analytic institutes associated with medical schools and universities. It seems to me that the vitality of the analytic field is dependent, to a considerable extent, on its interaction with other academic and clinical disciplines; given the enormous change in our society, the more immediate contact would put the analytic institutes in a far better position to adapt and even be a participant in shaping some of the changes of the 80's and the 90's. I am concerned, at times, that some segments of the analytic community seem to want to sequester themselves, and I think that is not in anyone's best interests. If psychoanalysts want the society, the academic establishment, etc., to be supportive and understanding of psychoanalytic theories, principles, and therapy, psychoanalysts have to interact with them. Given the potential seen in other theories and therapeutic approaches, it becomes even more pressing to do so. I see no alternative but for analysts to involve themselves actively in the medical schools and in universities.

There may be circumstances that would make a freestanding institute the preferred or only choice. I would hope that would be the exception, not the rule.

Newsletter: Around 25 years ago, there was considerable interest and activity intended to form a certification board for psychoanalysis as part of the American Board of Psychiatry but such a subspecialty board was not created. At the present time the American Psychoanalytic Association has it own procedures for certification in psychoanalysis. Do you think it makes a difference,

as far as Federal legislation and regulation is concerned, whether certification is done by the Association, or by an American medical specialty board?

Pardes: With regard to the question of certification, I'm not sure if I can comment on the use of the American Board of Psychiatry as the certifying board. Perhaps if they wanted to set up some special procedure, that might be considered. I would note, however, that the American Psychoanalytic Association should be giving considerable thought to a splitting of the issues of certification and membership. I know that there has been some consideration of this. I think that there is a danger of a loss of a considerable and vital part of the membership if the Association persists in the intention of making certification at some point a sine qua non for membership. A number of psychoanalysts enter a variety of professional careers and settings. It may never be either likely or possible that they will take the steps to secure the certification, yet they may be vital and vigorous members of the mental health and psychoanalytic community. To have a set of procedures which might conceivably exclude their participation in the Association's activities is, to my way of thinking, self-defeating for the Association.

Newsletter: There are reports that congressional staff research in preparation for health legislation is leading to the position that expenses for psychotherapy and psychoanalysis should not be reimbursed unless proven effective in the types of cases being treated. Can you enlighten us on this development?

Pardes: The issue of cost for psychotherapy and psychoanalysis, and the question of efficacy and safety of such treatment techniques is being scrutinized currently by staff in the Senate Finance Committee. I would recommend to the people in the Association or in the psychoanalytic community a reading of that Committee's hearings in 1978 on this issue. Subsequent to those hearings, one key staff member of the Senate Finance Committee has recommended that some process be established to look at the array of psychosocial treatments with the intention of identifying which are effective, safe, and worthy of reimbursement, and which are not. The problem from the vantage point of the Senate Finance Committee is that there are a rather large number of treatments identified as psychotherapy, and the staff contends that they have difficulty distinguishing what might be considered legitimate treatment. They also have questions about which treatments have been proven to be effective and safe.

I would add that interest in this area is apparent in that there is an Office of Technology Assessment in Congress and a National Center for Health Care Technology within the Executive Branch at this time. It might be interesting for the mental health community to be aware that an Office of Technology Assessment study has suggested that only 15-20 percent of all technology in general health has ever been proven to be effective through the use of controlled clinical trials. So this is not a question that is or should be restricted to the psychiatric, or psychotherapy area. My understanding is that the Senate Finance Committee staff is consulting with people in the field in initiating the process with a focus on psychosocial therapies.

The National Institute of Mental Health is concerned about getting more research-based information regarding psychotherapy and its effectiveness. Several major reviews have indicated that psychotherapy is generally effective. And this Fall, Smith, Glass, and Miller will publish a comprehensive review of 475 studies that clearly demonstrate psychotherapy to be effective. Beyond that general question there remain many questions of what psychotherapy is effective for what patient, with what problem. It is not that we don't have any data. There are, however, more sophisticated questions being raised. It is in the interest of the analytic community to consider ways by which it can demonstrate the effectiveness of the therapies about which it has concern.

Newsletter: What can private practice psychoanalysts do that can influence health legislation developments in Washington which will protect the continued use of psychotherapy and psychoanalysis in the 1980's

Pardes: They should consider a number of things. First, an active involvement in the public sector, and an active contribution to public and to political activities certainly is important in terms of the shaping of health legislation and health policy in Washington. The Association might consider an executive director to represent its interests and have that person located in Washington with the necessary staff support, perhaps modeled after some of the other major mental health constituencies. I would also suggest that the Association should work with such groups as the American Psychiatric Association and the American Psychological Association on issues of common concern.

Further, analysts have to be supportive of the academic and research activities in analysis. I believe a vigorous academic base is important in exploring therapeutic value among other things, and there is not as vigorous and lively a scholarly ferment in psychoanalytic settings as there should be. I think the effort of the Association to have a fund for psychoanalytic research is commendable. I think that it should be enlarged dramatically with active soliciting of private funds. The goal might be an independent research institute to work on the array of questions that have a bearing on psychoanalysis as a treatment as well as a theory and an investigative approach. These questions are linked to use of psychotherapy.

Newsletter: Are you satisfied with what the American Psychoanalytic Association is doing with regard to Federal health legislation and regulation?

Pardes: I think the Association has been a bit more active recently, but it still has a good ways to go. The analytic Association is not seen at this point as a vigorous enough factor in the Washington setting. I think that many people such as Herb Gaskill, Arnold Cooper, and Gerald Freiman have been trying to address that. They have secured a most knowledgeable consultant in Allan Fox. There are many others that are trying to help. I know that there is a reluctance on the part of many people in the analytic community to become too active politically. On the other hand, the reality is that there are numerous ongoing developments, ranging from questions of certification, to confidentiality, to reimbursement, to support for training, to professional personnel, which have important impact for the analytic community. If the community decides not to be involved in the shaping of those issues, the nature of their resolution will be far less to the liking of analysts.