Like their colleagues in some Eastern-seaboard cities, many Bay Area analysts have experienced a decline in their analytic practice in the past decade.
In April 1978, determined to address this apparent local and national decline of interest in therapeutic psychoanalysis and a concomitant decrease in the number of cases for supervised analysis, the Board of Directors of the San Francisco Psychoanalytic Institute and Society appointed an ad hoc committee to study the local status and climate of psychoanalytic practice and to recommend ways and means by which the Institute and Society could assist their Psychoanalytic Clinic in generating renewed public interest in therapeutic psychoanalysis. After a year's study this committee, composed of members from the San Francisco Society at large and the Institute's Education Committee, recommended structural changes within the Clinic, which might increase the numbers of applicants and simplify the screening and referral process—specifically the appointment of an overall Director of Psychoanalytic Clinics to administer three separate, but related committees: A Clinic Committee on Undergraduate Analysis, a Clinic Committee on Graduate Analysis, and a Clinic Committee on Child and Adolescent Analysis. The Clinic Committee on Graduate Analysis, already informally organized, would refer cases not suitable for supervised analysis to graduate analysts willing to undertake low-cost analysis presumably because of their continued commitment to psychoanalytic therapy and research. The reports voiced the sanguine view that “there is confidence that as the pendulum swings, the public will increasingly perceive the value of rational modes of psychotherapy. Our ultimate aim would be that no suitable patient—child, adolescent, or adult—would be denied analysis because of lack of funds.” The report was endorsed by the San Francisco Society.
In April 1980, the Institute faculty discussed again the decline in numbers of analytic patients. Several ostensible causes were cited: the proliferation of competitive non-analytic therapies, the escalation of analytic fees in an inflationary economy, inadequate public information programs, and the failure of psychoanalysts when teaching to lay and professional audiences to sufficiently delineate and differentiate psychoanalysis from psychotherapy. The Faculty recommended that a survey committee be convened to further study the problem.
In its first meeting in July 1980, this newly appointed Survey Committee reviewed information about the increasing numbers of licensed psychotherapists in California, and found that there are fourteen paths to the practice of psychotherapy. All of these practitioners are fully licensed to conduct psychotherapy according to their own methods. As of May 1980, almost 40% (2,470 out of a total of 6,200) of the licensed psychotherapists in the six Bay Area counties were marriage and family counselors. The marriage and family counselor credential was obtained by completing one year of graduate training in psychology, or two years in marriage and family counseling programs.
Next, the Survey Committee attempted to review referral patterns. It theorized that one traditional referral source, nonpsychiatric physicians, may be making fewer referrals to psychiatrists and psychoanalysts. Anecdotal reports suggested that because the pool of medical and surgical patients in San Francisco was shrinking, non-psychiatric physicians were beginning to include psychotherapy as an aspect of their medical practice.
But what about psychoanalysts' resistance to psychoanalysis as a therapeutic modality? How many psychoanalysts settle on twice-a-week psychotherapy instead of analysis, presumably for justifiable considerations? If there is a dedication to the principle of psychoanalysis, will psychoanalysts settle for reduced fees? Is unresolved resistance to the analytic process a factor in the choice of twice-weekly psychotherapy over psychoanalysis? Currently, there is not enough information to answer such difficult questions. There have been few takers for referrals from our low-fee Graduate Clinic. Most have been recent graduates still consolidating a psychoanalytic practice and a psychoanalytic identity. The reasons for declining low-fee referrals are persuasive. Time and money constraints are most often cited. Yet it may well be that graduate analysts are simply skeptical of the clinic's ability to refer analyzable patients. San Francisco's statistics are congruent with established clinics at other institutes. In one San Francisco study, only 37% of clinic patients were in analysis after two years, and only 17% of the original group reached an analytic termination. But if graduate analysts are declining low-fee referrals from the Psychoanalytic Clinic, could they be selecting patients from their own practice for low-fee analysis? Perhaps, but not to any significant degree. One report indicates that Bay Area analysts (with the exception of Training Analysts) have fewer patients per capita in analysis than the national figure.
Our newly appointed Survey Committee continues its work. As one of it central tasks, it has included studying ways which will insure the preservation of a psychoanalytic identity for non-training analysts. The public information effort has moved rapidly. In a recent meeting with one San Francisco science editor, the assurance was given that newsworthy psychoanalytic research and education programs would receive good press coverage. Recent profiles in The New yorker and The New York Times Sunday Magazine offer vivid reminders that intellectual interest in psychoanalysis continues. The San Francisco Institute and Society is hard at work attempting to translate this intellectual interest into therapeutic and educational reality.
Morris L. Peltz, M.D.
San Francisco