Psychoanalysis and Psychiatry: are they friends? family? rivalrous siblings? fickle ex-lovers? enemies? Do they overlap? Should they overlap? How much? And does anyone care?
I had a professor of English History once who suggested that we Americans would do well to assume that the Americans and the English use separate languages; instead of being baffled by our many differences, we might then often be very pleased at how many words we share and how well we understand one another.
I think a major split has developed between American psychoanalysis and American psychiatry over the past 25 years, and not just as a reasonable or proportionate response to previous over-enthusiasms, or to good new knowledge in brain biology on one hand or social and environmental factors on the other. I think the split has gone too far and has not been good for science or for the mental health of patients and of society as a whole.
Along with welcome advances in neurobiology, psychopharmacology, genetics, and so on (advances that, I suppose, would have pleased and interested Freud), I think we must retain much of the very large amounts we have learned in psychology and psychodynamics. We also need further advances in psychology and psychodynamics, including better measurements of what we mean and what we do; and we need continued integration of bio-, psycho-, and social knowledge. Who is going to do this integration? Who is well enough educated in the several realms at once? Can we expect our trainees to do it if some of us do not do it well ourselves?
It is a relatively widespread human pastime to denigrate those who think differently, or who know different things. It is usually relatively easy to stick to what we learned in the past, and to be good at one difficult field rather than two or three. And it is usually easier to simplify than to integrate. Some simplification, for a while, for a purpose, is often essential and productive, to break large complexity down, to look at and measure component parts with relative clarity. But in a really complex field, like the brain plus the mind, with many simultaneously active significant variables, and very different levels of research access, continual back and forth motion between analysis and synthesis seems to me essential.
That brings me to cooperation, and respect for colleagues and for variety. It seems to me that many of us do not understand, or even much like, many of our colleagues. This is not entirely new, but it may be worth some rethinking. Some psychiatrists, and others, now think of psychoanalysis as irrelevant, distracting, and passé. Some psychoanalysts, and others, think of 1990 psychiatry as hopelessly biologically reductionist. Some psychiatric residencies now hardly take psychodynamic psychotherapy seriously. One resident in psychiatry was quoted nationally in print this year as saying something like, “Now that psychoanalysis and psychoanalytic psychotherapy have been shown to be useless. …” There are also interesting value judgments and pressures from the public at large, from government, from media, from pharmaceutical houses, from insurance and managed-care people, from large numbers of less or differently trained semi-colleagues. Many of these represent or buttress powerful economic forces, and tend impatiently to push us to simplify, speed up, and make cheaper. (“Can't you listen faster?” an insurance executive asked.) All this, I think, means trouble, premature closures, danger of major losses, danger of major oversimplifications.
The pressures are unlikely to change fast, or be fixed fast, or go away; but we can probably influence them, both as individuals and through our organizations. I have not always been an American Psychiatric Association activist—in fact, as many of you know, my roots in psychoanalysis are far older than my roots in the APA—but I have found the APA repeatedly decent, and useful. Much as I respect variety, private choices, private practitioners of psychoanalysis and psychiatry, academics, researchers, and cultivating one's own garden, I also want to suggest to everyone reading this that it would probably be both useful and rewarding to devote some of your time, for 10 or 20 or more years of your professional life, to public psychiatry or psychoanalysis, e.g., to psychiatric and/or psychoanalytic organizations. I have for years urged psychoanalysts to take part in organized psychiatry, to influence it and help run it. Not enough do. Such participation takes time and energy and cumulative effort, but it is possible. DSM-IV (with its long preparations) is only one among many APA issues that would probably go better for psychiatry and for psychoanalysis if more psychoanalysts took an active part in the APA.
I urge you to help the American Psychoanalytic Association and the APA to be active and work well, separately and together. Please consider what you yourself can do, and please tell or write me and/or anyone else active in the APA whom we should consult or appoint, and what you want APA to do more, less, or differently.
I hope, and expect, that psychoanalysts, the American Psychoanalytic Association, and the APA can work together actively and well.