During the early 1970's, the Boston Psychoanalytical Society and Institute was rife with internal conflict, primarily centering on the relationship between Society and Institute and the appointment of training analysts. By 1976, the Society was seriously divided. Criticism of both Society and Institute was strong. The Society openly and honestly addressed the grievances of its membership. Committees that formerly were only open to training analysts were now open to non-training analysts as well, and in both the Institute and Society the non-training analyst was given more authority. As another outcome of this process, a group of training analysts split from the Boston Psychoanalytic Society and Institute and formed a separate, independent Institute in Boston (PINE). There remained, however, only one Society.
At that time, in 1976, the American surveyed the practices of its membership and members of affiliate societies, although the results were not released until 1981. The Survey on Psychoanalytic Practice documented the widely held impression that individual training analysts were treating substantially more analytic patients than individual nontraining analysts. A less well-known fact was that there was a nine percent decrease nationally in psychoanalytic practice over the course of the previous decade. The current report of a study of psychoanalytic practice and satisfaction among members of the Boston Psychoanalytic Society documents a further decline in analytic practice, but paradoxically notes increased satisfaction among Society members.
The American's final report on Psychoanalytic Practice (1981) proposed several recommendations. One recommendation called for the Executive Council of the American to “create a standing committee on psychoanalytic practice and careers” (Jaffe and Shapiro, 1981). Further, it recommended “that each local analytic community should organize itself to receive and review its own survey data”. At the annual meeting of the Boston Psychoanalytic Society and Institute in April 1981, our society established its Ad Hoc Committee on Psychoanalytic Practice.
In order to obtain a current and accurate picture of the membership's practice and satisfaction in clinical psychoanalysis and psychotherapy, a questionnaire was developed and sent to the Society's membership in February 1984. There were 134 responses, although there is an active membership of 268.
Sixty-eight respondents were active members of the American, 23 were associate, one was affiliate, and 44 were non-members. One hundred seventeen were men, and 14 women. Twelve respondents completed child analytic training and two members were still in child analytic training. One hundred twenty-two respondents had some private practice and 10 had none. One hundred twenty-seven entered psychoanalytic training from psychiatry, four entered from psychology and one from another profession. Sixteen were training analysts. The Boston Society membership is similar to this sample regarding percentage of members in each of these categories.
As to professional identity, 59 percent of the group saw themselves primarily as analysts and 32 percent saw themselves primarily as psychiatrists. Regarding the distribution of members' time, 62 percent was spent in private practice with a remainder of time devoted to clinics, supervision, academia, consulting, etc.
The average number of patients in psychoanalysis was 3.0 and the average number of psychoanalytic sessions per week was 11.0. According to frequency of sessions, a further breakdown for the 3.0 patients is as follows: fewer than three times per week—0.3 patients; three times per week—0.2; four times per week—2.1; 5 times per week—0.4. If we exclude the 16 training analysts who responded, the mean number of patients decreases from 3.0 to 2.5, with the mean number of sessions per week deceasing from 11.0 to 9.4.
It is clear from both the written comments at the end of the survey and and the statistical questions on satisfaction that members are not satisfied with the numbers of patients in their analytic practice. In response to satisfaction regarding referrals, 53 percent were not at all satisfied with the number of patients referred to them.
In our 1984 survey, respondents reported on their practices five years earlier. The mean was 3.4 patients; in 1984, the mean practice was 3.0 patients. The decrease is totally at the expense of non-training analysts since the number of analytic patients treated by the training analysts was 6.13, in both 1979 and 1984, while the number of analytic patients treated by non-training analysts decreased from 3.0 in 1979 to 2.5 in 1984.
Also compared were the diagnoses of patients presently being analyzed with those analyzed five years ago. Given decreasing analytic patients, we wondered whether fewer neurotic patients were now being analyzed. However, there was no difference in this regard.
Regarding referring sources for analytic patients, over half of the respondents ranked analysts as their primary source for analytic patients. Non-psychiatric physicians were second and psychiatrists were third. The respondent's own practice and other patients ranked fourth and fifth. The average practice has two to three patients in therapy for whom analysis is thought to be the treatment of choice. The primary reasons that these patients were not in analysis appeared to be insufficient funds, by far the strongest factor, and patient resistance. Patient and analyst time constraints were also cited as reasons. As to analysis of children and adolescents, very few members had such practices.
There was a much higher degree of satisfaction regarding psychotherapy practice. For adults, the mean practice was 11.3 patients per week and the mean number of sessions per week was 15.6. Each practice had an average of two patients on medication. Only a few individuals had practices with children, adolescents or hospitalized patients. A further breakdown of the 11.8 patients, according to frequency of sessions per week, is as follows: less than one time per week—2.1 patients; one time—6.5 patients; 2 times—2.6 patients; 3 times—1.4; more than three times per week—0.1. Only 13 percent of respondents were dissatisfied with the number of psychotherapy referrals received.
The survey also addressed the members' satisfaction and involvement. Satisfaction with psychoanalytic career, overall professional career and identification with psychoanalysis were extraordinarily high. Only eight percent expressed little or no identification with psychoanalysis. Twenty percent reflected varying degrees of dissatisfaction with their psychoanalytic career, and only
four percent reflected varying degrees of dissatisfaction with their overall professional career. Only nine percent expressed varying degrees of dissatisfaction with their income.
Satisfaction with analytic training, the scientific quality of our Society and Institute, as well as satisfaction with other aspects of our Society/Institute were all very high. Only 20 to 31 percent reported varying degrees of dissatisfaction in these areas. Dissatisfaction with the scientific quality of the American was expressed by 41 percent, and dissatisfaction with other aspects of the American was expressed by 46 percent.
Degree of involvement in our Society/Institute was relatively high, with only 32 percent having little or no involvement. Fifty-four percent reported little or no involvement in the American.
Despite the significant and disturbing decrease in ability to sustain analytic practices, an impressive 91 percent continued to encourage psychiatric residents to enter analytic training.
Two interesting findings are noted in our survey. First, over 18 years, there has been a significant and deteriorating trend in the numbers of the analytic patients seen by non-training analysts. Second, satisfaction with varying aspects of our local Society has considerably improved since the last survey of the American in 1976. These two discrepant findings need further elaboration.
In 1976, the American survey reported the average Boston Society member was treating 4.0 analytic patients per week. That survey also noted that there was a nine percent decrease nationally in the numbers of analytic patients treated since the last survey in 1966. If we assume Boston's decrease paralleled the decrease nationally, it would indicate that 4.40 patients were being treated by all members in 1966. In 1979, all members were treating 3.4 patients, with training analysts treating 6.13 patients and non-training analysts treating 3.0 patients. In 1984, all members were treating an average of 3.0 analytic patients, with training analysts treating an average of 6.13 patients and non-training analysts treating 2.50 patients. (See Table 1)
Note again that the decrease in analytic patients is totally in the practice of non-training analysts. According to the 1976 American Survey, the difference between training analysts and nontraining analysts in Boston was 2.4 patients per week. In 1979, the difference was 3.13 patients per week. In 1984, the difference was 3.63 analytic patients per week. Therefore, between 1966 and 1984, there has been a 36 percent decline in the number of patients being analyzed per responding member. The percentage decline for non-training analysts is actually greater than 36 percent since training analysts have not experienced a reduction in analytic practice, but are included within total Society respondents. However, we do know that non-training analysts experienced a 17 percent reduction in their analytic practice just between 1979 and 1984. (Data for only non-training analysts was unavailable prior to 1979.)
| NUMBER OF ANALYTIC PATIENTS SEEN PER WEEK | |||
|---|---|---|---|
| All Members | Training Analysts Only | Non-Training Analysts Only | |
| *1966 | |||
Our data also indicates that total numbers of analysands treated by the membership of the Society decreased between 1979 and 1984. Respondents treated a total of 404 analytic patients in 1984, contrasted with 455 analytic patients in 1979, a decrease of 11 percent.
The question can be posed as to whether the decrease in analytic practice per responding analyst is a function of many more total patients in analysis dispersed among larger numbers of analysts. The data does not support such a conclusion. An extrapolation of the total number of analysands treated by Society members was performed all the survey years. The total number of patients analyzed by Boston Society members increased 29 percent between 1966 and 1976, but has decreased 18 percent since 1976. The Boston Society thus faces a situation in which there is a decreasing trend in the total numbers of patients being analyzed, though the practices of training analysts are seemingly unaffected by this trend.
Our 1984 findings of relatively high satisfaction towards Society and Institute are most interesting. In the American's survey of 1976, our Society profile revealed a lower identification with psychoanalysis compared to the national norm, as well as “serious criticisms of the scientific programs of the affiliate society, greater than the norm nationally of the affiliate society, and the Society is seen as being ‘too divided’ to a larger extent than is true in many other societies”. It should be noted that the 1976 survey occurred during a period of great internal strife that culminated in the Society and the Institute becoming more responsive to non-training analysts' needs. A salutary outcome of the process was the clear improvement in member satisfaction with both Society and Institute between 1976 and 1984. The increased satisfaction paralled the increasing open-mindedness of Society and Institute to the concerns of its members, particularly those of the non-training analysts.
Although this addresses the practices and satisfactions of one very large Society, our findings support both specific recommendations for Boston and general recommendations for other societies of the American. We are in broad agreement with the recommendations proposed by the Committee on Psychoanalytic Practice of the American reported in CAPE, March 1981, and summarized by Arnold M. Cooper, M.D., President of the American, in 1981. In fact, some of the recommendations have already been implemented at the national level, most notable being the establishment of a Standing Committee on Psychoanalytic Practice, chaired by Theodore Jacobs, M.D. Many other thoughtful recommendations were noted in the Summary of the Final Report. I would like to elaborate on some of these recommendations as well as advance some other recommendation which might be of some import to many societies and their members:
As already noted, this recommendation from the Final Report has been implemented nationally and at most local societies.
Thus, many local societies have already established their own equivalent of Boston's Ad Hoc Committee on Psychoanalytic Practice, which identifies and addresses concern organic to its membership. The local societies also send representatives to the workshops sponsored by the American. These workshops serve, in part, as forums for exchange of information, collection of data, identification and study of problem areas, recommending possible avenues of approach to these shared concerns.
Each society should direct its Committee on Psychoanalytic Practice to repeat a survey on analytic practice and satisfaction every five years. The results should be integrated into each society's equivalent of Boston's Long Range Planning Committee. Further, areas of dissatisfaction need to be directly addressed. Boston was a society in conflict, as noted in the survey results of 1976. Those painful areas of dispute were openly addressed, even eventuating in a split of some training analysts who formed a second institute. However, the 1984 survey now indicates a high level of satisfaction with our society. Obviously it is healthier to learn of society strife and openly address the problems.
The final report of the 1976 survey recommended that the Board on Professional Standards study the “potential place of advanced training in analytic psychotherapy at a post-candidacy level under the aegis of the institutes”. The Boston survey noted for all members that the mean number of psychotherapy sessions per week was 15.6, while the mean number of analytic sessions
per week was 11.0. For non-training analysts the gap between psychotherapy sessions per week and analytic sessions per week widened. These findings supported the notion of our Institute offering coursework, not previously offered, in psychoanalytic psychotherapy. In the academic year 1984-85, an elective course on psychoanalytic psychotherapy was introduced at our Institute for advanced candidates and recent graduates.
Bernstein (1983) addressed the subject of psychotherapy, prior to psychoanalysis, conducted by the same analyst. In his paper, Bernstein presented a psychotherapy patient who was converted to psychoanalysis without observable limitations on the analytic process. His paper clearly supported this practice, when thoughtfully undertaken. Seminars addressing such conversions should be provided for both candidates and members. It is clear from the Boston study that members wished to do more analysis. Furthermore, over half of the members ranked other analysts as their primary source of referrals, although overall only 22 percent of respondents are very satisfied with analytic referrals. Depending on other analysts, who are generally in the same straits, is clearly not the best way to increase one's analytic practice. Interestingly, members' own practices ranked only fourth as a source of analytic patients. There are undoubtedly many reasons why analysts have not converted potentially appropriate patients to analysis. Those reasons can be best explored in a seminar context, which would, hopefully, result in increasing conversion amongst some therapy patients.
The notion of converting therapy patients to psychoanalysis is also an important one for candidates. In fact, at the 1984 Fall meeting of the American, the Workshop on Psychoanalytic Clinics addressed this question. At most institutes, candidates struggle to find appropriate controls. Most institutes now encourage candidates to convert at least one patient from therapy to a control analysis. Yet, such conversion may take place without benefit of a thoughtful, organized approach. The establishment of such coursework in the basic curriculum is, therefore, also advocated.
If training analysts not only analyze and supervise candidates but also are the primary course instructors and essentially “administer” a society and institute, then satisfaction is too often predicated on whether one becomes a training analyst. The development of three professional tracks, therefore, is advocated along the format of the St. Louis Society. First, criteria for selection of training analysts should be well promulgated. Second, teaching and administrative tracks should be equally valued. In our 1984 survey, 38 percent of members' time was spent in professional activity other than treating patients. Although some of that talent is presently tapped by societies and institutes for teaching and administrative functions, it is clear that more can be done. Society extension divisions should actively and regularly update lists of its members who wish to teach. Members should be familiarized with the mechanism for introducing new, relevant courses. Any member should be able to attend Extension Division meetings which might stimulate evolution of some course. The instructor should be appropiately remunerated; token payment may diminish the value of teaching. Clearly, minimum enrollments would be required to avoid financial loss. A mechanism for evaluating the course and instructor should exist. Proliferation of relevant courses can only have salutary effects. Satisfaction of members would be enhanced and the Society would derive the bonus of increasing its revenues. Finally, outstanding teachers should be invited to teach at the institute.
A well-publicized administrative track should be operational. Members should be polled annually for interest in serving on committees. Where committee membership is elected, the Nominating Committee should be privy to the interests of the members. Where committee membership is appointed by the society president or a committee chairman, that person should have access to the administrative interests of the members. Furthermore, institute committees should be open to non-training analysts in appropriate ways and numbers. Satisfaction of membership can be enhanced by establishing these three highly valued tracks—training analyst, teacher and administrator.
Increasing the numbers of appropriate analytic patients must be a multidimensional approach. Certainly, the previously mentioned course of analytic conversion would be helpful. Increased Extension Division coursework would familiarize mental health professionals with indications for analysis, perhaps increasing referral of appropriate patients for analysis or control analysis, including self-referral by the course participant. Society sponsored meetings could focus on how members build analytic practice. Publicity efforts should include sponsorship of symposia, direct advertising, selected scientific meetings open to the mental health community, etc. The society should also poll members as to their willingness to accept low-fee analytic patients. In our 1984 survey, members were willing to accept a fee of $45 per hour for analysis. Such a list should be maintained and updated at the society, with the community made aware of such opportunities.
Outreach efforts need to be generated and sustained. One approach is to create a team of clinicians available for meetings at mental health facilities for open discussion with staff in regard to analysis and its indications, or patient-centered clinical conferences. During the 1983-84 academic year, Boston's Committee on Institute Analysis established such an outreach group to increase the numbers of referrals for control analysis. Twenty-six of our 210 inquiries were generated through efforts of that committee and a major public relations function was served.
Although our membership is most encouraging of psychiatric residents entering analytic training, we need to worry about the deteriorating patient trend. Not only is the gross number of patients in analysis down, but there is also competition with a multitude of therapists of various persuasions, as well as the phenomenon of a new, less comprehensive training program in psychoanalysis, administered by psychologists. Numbers of graduating analysts continue to increase. The Boston Institute had 106 candidates in full training at the time of the 1984 survey; candidates being trained by our colleagues at PINE add to that already swelled number. Can we justify training that number of candidates when the overwhelming majority of our membership is not satisfied with its psychoanalytic practice? Is it fair to our members or members-to-be? There is no easy answer. Yet, our survey results implore us to raise and address that question.
In sum, our data strongly advocates a re-evaluation of affiliate societies at regular intervals. The results should be circulated to the membership and be utilized for planning purposes. No attempt should be made to dodge the hard question or avoid the noted conflicts. Satisfaction can be enhanced only by a process of openly responding to the concerns of its membership.
| **1976 | 4 |
| ***1979 | 3.4 | 6.13 | 3 |
| ****1984 | 3 | 6.13 | 2.5 |
| *American Psychoanalytic Association Survey | |||
| **Impressionistic data from Boston Society and Institute 1984 Survey | |||
| ***Boston Psychoanalytic Society and Institute 1984 Survey |