The profession of psychoanalysis has a strange relationship with the theory and practice of psychotherapy, Officially, the American Psychoanalytic Association has looked with suspicion on those institutes which have embarked or are embarking on psychotherapy training programs.
Unofficially, however, most psychoanalysts are up to their necks in practicing and teaching psychotherapy. How did this strange contradiction come to pass? What should be done about it?
Most likely, today's paradoxes echo Freud's warning against diluting the pure gold of analysis with the copper of psychotherapy. Freud's injunction came at a point when psychoanalysis was attempting to define itself, and the difficulties of operationalizing and documenting the complexities of the psychoanalytic situation still make it hard to define what psychoanalysis is or is not. I believe this difficulty is the major reason for our national organization's reluctance to encourage or support the teaching of the theory and practice of psychotherapy as an integral part of institute curriculum.
Psychoanalytically oriented psychotherapy is the most common form of psychotherapy practiced in the United States both in outpatient psychiatric clinics and in private practice, It is the individual psychoanalyst, supervising mental health students and teaching psychiatric residents, who is responsible for this integration of psychoanalytic theory into the practice of psychotherapy, These activities contribute importantly as well to the high status in which psychoanalysis is held by most mental health practitioners. Many students of such psychoanalytic teachers, such as myself, became interested in psychoanalytic training as a result.
All but a small handful of psychoanalysts today practice psychotherapy as well as psychoanalysis. Certainly the practice of the young psychiatrist consists predominantly of psychotherapy well into the second decade after beginning training, A major motivation to enter psychoanalytic training for today's psychiatrists is to increase psychotherapeutic skills as well as to practice psychoanalysis, Official psychoanalysis has neither addressed these facts nor met these needs.
Psychoanalysis as a treatment modality is on the defensive. Insurance carriers and individuals ask, how do psychoanalysis and psychotherapy differ? What are their advantages and disadvantages? Which treatment is indicated for and which treatment cost effective for which problems? These are reasonable but perplexing questions for which we have no clear answers.
Several psychoanalysts have attempted to respond, however. John Gedo suggests that psychotherapy is the treatment of choice for many neurotic difficulties, while psychoanalysis is best suited for severe characterological problems of the narcissistic type, Merton Gill argues that properly conducted psychotherapy and psychoanalysis are closely related, if not identical, enterprises, More psychoanalysts might investigate these questions were psychotherapy routinely taught in psychoanalytic curricula and psychotherapy training programs conducted in institutes.
Two recent developments also argue for psychoanalytic institutes instituting psychotherapy training programs. First, today's general psychiatry training programs are more biologically oriented. Residents are graduated without being exposed to either psychoanalytic theory or psychoanalytic teachers. Such untrained, neophyte psychiatrists could enter institute programs and become eminently more qualified clinicians, There is also the probability that, then, some might become interested in psychoanalysis
and in training as psychoanalysts.
Second, within the past decade many professional schools have appeared which produce every year literally thousands of mental health clinicians— psychologists, social workers, marriage and family counselors, and others. Often the quality of their professional training is suspect. By offering psychotherapy training to the best and the brightest graduates of these schools, psychoanalytic institutes could become the educational and intellectual leaders of their communities, and psychoanalysis as a science and profession could gain preeminence in the mental health field.
In my opinion, institutes should have specific basic resources before mounting a psychotherapy training program. There must be available an appropriate number of interested and qualified teachers. The program must be efficiently administered, the curriculum well-planned, and the space for teaching identified. This must take place in a manner that does not affect adversely, either educationally or financially, an institute's psychoanalytic training program.
I suspect the more established and larger institutes, such as San Francisco, would not have a problem. The primary reason for the reluctance of institutes to teach psychotherapy, or to present psychotherapy programs, I believe, is not resources, but rather the policy question of whether or not it is appropriate, or in the best interest of psychoanalysis, to do so.
In summary, I feel it is important for official psychoanalysis to reverse its current position of reluctance to teach psychotherapy in the psychoanalytic curriculum and of discouraging institutes from developing training programs in psychotherapy, for the following reasons: first, by bringing psychotherapy into the psychoanalytic curricula, the parameters and indications for both psychoanalysis and psychotherapy would become more clearly identified; second, psychoanalytic candidates would be educated in psychoanalytically informed psychotherapy—an education they desire and need; third, institute psychotherapy training programs would involve the untrained, neophyte psychiatrist and the mental health worker, thereby improving their clinical skills and exposing them to psychoanalysis; finally, through these educational activities, psychoanalytic institutes would build a preeminence within the mental health community.