Candidates beginning their formal training in the United States this year can expect to commence their psychoanalytic careers with but five years or so remaining in the twentieth century. This should be an exciting moment for our field, marking its emergence from infancy and youth; it will be almost one hundred years since Freud delayed publication of The Interpretation of Dreams just long enough to ensure its appearance in the year 1900—a work of the then new century.
But a spectre of crisis, even of survival, haunts the scene and informs even the most sanguine of depictions of psychoanalysis—as a treatment, a theory, and a research instrument—as it enters its second centennium. This is not a new predicament. From its inception and by the very nature of its revelations, psychoanalysis and its promulgators have been criticized, reviled, and excluded: attempts have been made from without and within to modify its less palatable aspects.
Nonetheless, the psychoanalytic movement grew and became embraced as an intellectual force and as a treatment method. In recent decades, many have addressed the history of its rise to prominence, first in Europe, then in the Americas, and of its subsequent development and the evolution of its present dilemma. Examples include several influential essays in the sixties by Max Gitelson on the love affair gone awry between American psychiatry and psychoanalysis and a recent exposition on the dire challenges facing psychoanalytic research by Robert Wallerstein.
Although it still occupies a primary position in American psychiatry, psychoanalysis is increasingly vilified as arcane (at least in its unmodified form as a treatment modality), as inapplicable to the most pressing psychiatric-social problems, and as cost-ineffective. The therapeutic marketplace has become crowded, and analysts are by and large not given to public demonstrations. Where does this leave us, and what effect is this having on those who are accepting the charge of representing the field in the near future?
One can easily discern that all of this has a definite effect on psychoanalytic students and their perspectives on their individual and collective futures. That this is so has been driven home to me dramatically in a year-old discussion group held at the meetings of the Association entitled, “On Becoming a Psychoanalyst in the ′80s.” The group was formed to provide an open forum, but one aimed especially at the younger members, where a variety of issues facing the new analyst could be addressed. Given free rein and a wide range of possible topics, what emerged spontaneously (and not surprisingly) as the overriding concern of this group is the question of the viability of psychoanalytic practice. Many doubt whether the practicing analyst is a realistic model in socioeconomic terrain that demands such harsh compromises. It is not lost on this group that there once was a “Golden Era,” and that that day is past.
The problem is clearly not simply an economic one; the difficulty in finding suitable training cases even at greatly reduced fees for candidates persists in many areas of this country. This is a real problem and has an inevitable effect on training. Training is lengthened and the financial burden on the candidate is probably greater than in previous years. But beyond this is the lingering question that surfaces in a variety of ways in these discussions: What can one anticipate in one's future professional activities and personal life style?
It is clear that many of the potential patients that would benefit from analytic treatment cannot afford it at standard fees. Analysts in the United States, at least those who have come from medical backgrounds, do not easily shed aspirations to a life style commensurate with even the lower-end earnings on the scale of income for physicians. Along with the material concerns of income, comfort and the prestige that accompanies such, is the wish to be an analst and to practice analysis. But to be an analyst in many parts of the country, one must realize that for a significant
portion of one's career, if not for most of it, he or she will have to accept reduced fees, to modify the treatment by decreasing frequency of visits, and/or to do less analytic work overall than might be preferred. The young analysts who deliberate on these considerations of their professional lives in our group express anxiety, disillusionment, and not infrequently, pessimism. Much of this ground has also been covered in the literature and in informal dialogues in a variety of arenas, but it has special meaning to those just setting out in their careers.
Our youngest members frequently speak of what they perceive as an “ivory tower” attitude among analysts; analysts, they say, segregate themselves from other disciplines and affairs, awaiting the influx of patients that once upon a time filled the waiting lists of the analyst's case-load. Possibly the metaphor is overextended; senior consultants to the discussion groups have made assurances that they too were required, if only in starting out, to seek a variety of referral sources. Even so, it seems clear that, far more often than in the past, activity outside the consulting room is necessary for the young practitioner. Not infrequently involvement in other work-places is mandatory.
At the beginning of their psychoanalytic training, many have not yet completed psychiatric or psychological programs or may still be consolidating a new private practice. It may be impractical to leave a position that insures steady income. One may have developed productive involvement or significant status in another type of work situation, to which one's psychoanalytic background often has applications. This is not to mention those who are dedicated to teaching and research in an academic setting as a primary career. Psychoanalysis is not, as we once hoped, securely established in the majority of academic centers, nor does this appear to be a likely prospect—less so now than ever before. Wallerstein has recently described the variety of factors influencing this outcome and paints a rather foreboding picture for a future place for analysis in academia. The shift in emphasis in many psychiatric residencies over the past five or ten years away from interest in psychoanalytic principles complicates further an already complex and difficult terrain for psychoanalysis.
It appears that analyzing may have to be relegated to a secondary or at best part-time pursuit, that most will be forced to do analysis and something else as well. Much time was spent at our discussion groups exchanging strategies about what the “something else” could be that might augment the chances of being able to do more analysis by, for example, helping to promote referrals. Such things as active participation in other settings, teaching, consulting in medical centers and programs for other disciplines have been stressed.
Going even beyond this is the idea of gaining exposure for the field in the public media, such as in print, on television, to educate the medical and other referring public. Clearly the notion implied is that analysts must enter the fray of competitive public relations, to establish contact with potential referral sources. Common sense dictates that
others will have to “get to know” us and what we can offer if there is to be any interest in seeking us out. This has been emphasized in a number of committees of the American and in much of the recent writing on similar topics. (Apart from the issue of stimulating more referrals for analysis, is that of creating analytic patients from those referred for general evaluation and taken initially into psychotherapy. Many of us are convinced that most analytic cases these days are derived in this fashion—i.e., the conversion from psychotherapy. However, it is the younger analyst especially who, while depending more upon such techniques, lacks the experience, competence, and conviction necessary to accomplish the conversion successfully.)
There is much to be said in favor of analysts' going out into the community at large to show their wares. If nothing else, correcting some of the misperceptions about our treatment and theories and addressing some of the unserviceable shibboleths head-on is a duty that befalls us all. That analytic principles may be applied to a variety of settings is a factor which can be capitalized on to stimulate interest in our perspectives and expertise. Our discussions indicate that student analysts and recent graduates are directly affected and therefore acutely aware of these problems and very much involved in attempting to confront them appropriately and effectively. Again, activity is the by-word and the means to an end.
There is a paradox, however, inherent in this vision that is inevitable, perhaps insurmountable. Some may consider this a false issue, although I do not. The issue is whether a price of some significance must be paid for such refocussing of the analyst's activities. What might the effects be of a shift from the analyst analyzing to the analyst as extracurricular consultant or to the analyst turned businessman?
This sounds naive at first blush to our realists of the ′80s. The analyst cannot treat without analysands, of course. In addition, in an era when analyzing is often an economic compromise between the desire to analyze and the external realities that confront our potential patients and ourselves, one must make difficult choices. There is no room for counselling insularity. This is neither productive nor feasible. But the question remains: is there something valuable to be sacrificed as we run out the consulting-room door to a variety of public relations engagements?
Becoming a psychoanalyst in the ′80s is an arduous and unusually long process. The complex and subtle skills involved demand not only native talent, certain emotional capacities and one's own reasonably successful struggle with personal neurotic conflicts and narcissistic strivings, but a great deal of experience, which in this endeavor requires lengthier periods of involvement than in most other disciplines. Will analysts analyze as well if time and financial concerns require their attention to be diverted elsewhere?
Not only may clinical analytic acumen become compromised, but the very identity of the analyst may be altered by such circumstances. Perhaps this is intrinsic to a professional adaptation that cannot be avoided given the present environment. But, if that is the case, psychoanalytic science could be jeopardized incalculably. The point is moot only if one maintains that the principal avenues of progress will be derived from extra-analytic sources anyway.
“I do not begrudge the social good that conceivably may result from the many activities which now separate the analyst from his study and his couch and which join his special technique to those of other sciences and disciplines. But I am greatly concerned about the consequence of all this to psychoanalysis as the most refined instrument for research on the structure and operation of the individual human mind. … The American psychoanalyst … I believe, must ponder deeply the proposition that unless psychoanalysis as a clinical method is practiced by him in its most developed form we will lose it as a research tool. … To preserve the one I see the complete necessity of continuing the other.”
Max Gitelson wrote these words exactly thirty years ago. The statement could be said to be even more relevant today. To have lived in Western culture in the twentieth century is to have grown up within the influence of Freud's monumental vision as it has permeated the fabric of life from its most quotidien aspects to the most abstract of intellectual deliberations and to the burgeoning of mental health science itself. It rests upon the shoulders of the new generation of analysts and those to follow to carry this young science, in whatever manner one views that term, into the future. This can only be accomplished if its embodiment in its praxis is secured. The solution to this dilemma will come neither easily, nor without conflict, nor without sacrifice and compromise, and will require a careful balancing of choices of commitment of one's time and energies.