The clinics set up by psychoanalytic institutes have two missions: to help candidates find patients suitable for training analyses and to provide a low-cost treatment service for the community. To gain insight into how different institutes solve the problems that arise in their attempts to fulfill both these missions, interviews were conducted with the directors of three institute clinics in Manhattan. This article is a distillation of the comments of these directors and those of a number of other faculty members from the Columbia, New York Psychoanalytic, and New York University Institutes.
The first task for the clinic director is to find applicants for clinic analyses. Throughout the county the competition for patients among therapists offering differing treatment modalities is intense, but in Manhattan, with its five or more psychoanalytic training institutes in addition to many other therapy schools and thousands of therapists in private practice, the competition is particularly fierce. Directors are constantly trying to figure out ways to increase the applicant pool. Graduate analysts are exhorted to refer patients, advertisements are inserted in university newspapers and posted on bulletin boards, courses are given for the public to increase awareness of the benefits of psychoanalysis, and other, more short-lived marketing efforts have all been attempted.
Steve Rittenberg, currently codirector of the clinic at the New York Psychoanalytic, candidly acknowledges the problems and states, “We're trying everything possible.” He expects that it will take time to overcome the antianalytic forces at work in our culture. Wayne Myers, director of Columbia's clinic, is more sanguine. He says, “I usually scour up referrals by writing to, or calling, all of my friends, former supervisees, and current colleagues in our institute. The secret to securing patients is this continuous, personalized follow-up of referral sources. Unless I make the phone calls myself, they won't get done.” His policy of persistence seems to yield results—Columbia has the highest number of applicants among the institutes.
At two of the three institutes, potential patients complete applications before any clinical interviews are arranged. The third institute (NYU) usually does the same, but at times applicants will not see an application blank until the conclusion of the first clinical interview. Apart from brief historical inquiry, the application includes the applicant's signature of consent to sharing clinical information within the institute. Typically the applicant is asked to list medical conditions and prior psychotherapeutic treatment and to provide a short description of the reasons for which treatment is being sought. Some analysts feel that such an application may deter people from pursuing treatment. After all, these analysts argue, do we ask our private patients to fill out a questionnaire before we see them?
In the 1950s, when the psychoanalytic clinics were deluged with requests for analysis, Leo Stone devised a longer application to help screen out unsuitable cases. Later, in the 1960s and 70s, as this seemingly eternal fountain of patients began to dry up, the institute decided to shorten the application form to encourage applicants. Columbia, at the urging of Otto Kernberg, even dispensed with applications entirely for a block of 100 patients to see whether this move would increase the pool of suitable clinic cases. This experiment, however, failed to reveal any detectable positive effects on the number or quality of applicants, and use of applications was resumed.
At all three institutes, the completed application is first reviewed by the director, who screens out obviously unsuitable patients and refers them for another form of therapy. The three institutes differ in the number of interviewers who evaluate the more plausible applicants. NYU has the most streamlined process, and the New York Psychoanalytic the lengthiest.
At NYU, the applicant is evaluated by one senior faculty member. If that interviewer recommends the patient for analysis, the patient is next seen by a candidate, who, if he or she agrees with the senior colleague's recommendation, becomes the treating analyst. The previously extended evaluation was abbreviated because of the strong impression that the lengthier evaluations did not lead to a higher incidence of suitable patients for candidate analysis and the conviction that applicants were much more candid when evaluated by the analyst whom they might be meeting daily for years. As is usual in analytic practice, the prospective analyst (in this case the candidate/analyst) conducts the most thorough evaluation.
At Columbia, the patient is seen by at least two graduate analysts. If they have questions about the suitability of the case, Wayne Myers, director of the clinic, asks a third analyst to evaluate the patient, or he interviews the patient himself, and a final decision is made. The patient is then assigned to a candidate who is waiting for a case.
At the New York Psychoanalytic, the applicant is seen by one or, if there are questions, two senior analysts, who write up detailed evaluations. The cases are then reviewed by the Intake Committee, composed of 10 analysts; if deemed suitable for candidate analysis, the patients are assigned to students by the clinic directors.
This procedure is greatly abbreviated from the system at the New York in former days, when there was greater confidence in the predictability of analyzability. Because very thorough assessments were thought to lead to a higher rate of successful analyses, patients were evaluated in depth by three senior analysts, who wrote lengthy psychoanalytic formulations of the case. If there was disagreement about the case, the head of the clinic would perform a fourth series of diagnostic and prognostic interviews. The case would then be reviewed by the Intake Committee.
As Henry Bachrach, a member of the Intake Committee at the New York Psychoanalytic and a researcher on outcome in psychoanalysis, explains, “These were very high-level academic discussions. Faculty members who had expertise in a particular clinical problem were often invited to discuss the case with the Intake Committee. If the Committee felt uneasy about the case, the patient might be referred for several weeks of once- or twice-a-week sessions with yet another analyst, who would then either refer the patient back for assignment to a candidate or recommend against a clinic analysis. Certainly the evaluation procedure was among the most rigorous in psychoanalytic clinics in the United States.
Outlooks on the success rate of clinics in furnishing good analytic cases vary. George Gross, director of the New York Psychoanalytic Treatment Center from 1975 to 1985, for instance, points to the radical increase in the acceptance rate at
his own institute. In his day, between 9% and 13% of applicants were accepted for analysis; at present, 50% are accepted. He concludes that the patients selected now are less suitable for analysis than were the patients of a decade ago.
Mark Kanzer, who was active at the time of the founding of the institute at Downstate (now NYU), feels, on the other hand, that the patients of yesteryear, rather than being more suitable for analysis, were actually less suitable than patients being selected for candidates today.
“The patients were plenty sick in the good old days. Some of our analytic cases might be called schizophrenic today,” he says. “We weren't that far advanced in our differentiation skills at that time. Patients on the couch would begin to reveal delusional formations and even hallucinations. We didn't think it was that shocking. I guess I had a much more welcoming attitude toward schizophrenics. Many people think that a lot of Freud's cases were much sicker than cases a lot of people would feel comfortable treating with analysis today. It wasn't so easy for us to find analysands for the candidates in those early days of our Institute. We took whatever patients we could find, and helped the trainees work with them.”
Herb Wyman, codirector at the New York Psychoanalytic, feels that clinic analysands today are no sicker than those who presented themselves for treatment 30 or 40 years ago. He says, “As the popularity of analysis among the general public has waned, there is a self selection process among prospective patients, and those individuals who do apply now are generally more informed and more motivated for treatment. And, of course, these days we are more prone to accept patients from the ‘wider scope,’ patients for whom we feel a somewhat higher risk of failure in an analysis is justified by the potentially high gain if the outcome is favorable.”
Stephen Firestein, whose NYU clinic currently accepts only about one out of every eight or nine applicants, feels that if they took, instead, one of every two applicants (a ratio closer to that accepted at present by both Columbia and the New York Psychoanalytic), “it would be bad from every point of view; bad for the patients and for the student analysts.” In his experience, approximately a third of applicants considered likely to be suitable analytic subjects are, in fact, ignorant of the distinction between regular psychoanalysis and psychotherapy and of the special advantages of analysis for approaching their difficulties. Some of these applicants are able to proceed to an analysis with but brief preparation; others must be deferred while their initial resistances are explored in lengthier psychotherapy.
Austin Silber, describing the ambiance at the Downstate Institute during his candidacy years in the 1950s, recalls, “Our institute was much more autocratic in the early days. Our supervisors were from a patriarchal European tradition, and we went along with it. We were like lambs, much more passive than candidates are these days. Our faculty today is much more responsive to the opinions of the candidates than it was in the early years. We take their evaluations of instructors seriously; we let our candidates know that they are free to talk about any discontent they may feel about supervisors, their training analysts, or their clinic patients.”
Wayne Myers has a somewhat different perspective on the subject of candidates' refusing to accept patients approved for clinic analyses. He feels that the rejection of prospective clinic patients by candidates is often due to anxiety about beginning a first or second case, and he tries to curb enactments of this resistance by limiting to three the number of cases that a candidate can turn down.
Another issue that the three institutes handle in different ways is fee collection. Patients at Columbia write their checks to Columbia University, whereas those at NYU pay their fees directly to their candidate analyst. Firestein explains the rationale for this procedure: “We want the candidate situation to be as much like real life as possible. Since the patient pays the candidate directly, all the affects are brought directly into the treatment.” The New York Psychoanalytic Institute “privatized” the clinic patients in the latter part of 1989 because they felt that distortions introduced into the treatment by patients paying the clinic were simply too great. To offset the loss of income derived from patient fees, the institute will now collect a yearly supervision fee from all candidates past the first year of training. The faculty at Columbia is currently studying the feasibility of having patients pay the candidates rather than the institute, and it is struggling to devise solutions for the economic problem that loss of the patient income could cause the institute.
Clinical research projects have been part of the tradition at the treatment clinics of both Columbia and New York Psychoanalytic. It was during his tenure as clinic director that Leo Stone (1954) wrote his widely read paper on the “Widening Scope.” He feels that his exposure to a far broader spectrum and much greater volume of patients in the clinic than can be seen in individual practice was a stimulus to his thoughts on the applicability of analysis. Joan Earle's (1979) paper on analyzability utilized data from the clinic at the New York Psychoanalytic.
John Weber, a former director of Columbia, received a grant in the 1950s from the City of New York to do outcome studies on the clinic analyses, for psychoanalytic treatment was actually considered to be a public health issue at the time. Wayne Myers mentions a number of research studies that are currently being conducted by faculty members using data from the clinic. Early results from a study by John Oldham (personal communication) have been suggestive, for instance, of a better prognosis for patients who present for analysis with a depressive symptomatology, as opposed to those with anxiety syndromes.
Rittenberg and Wyman are continuing this tradition with the announcement of a
new journal, The Journal of Clinical Psychoanalysis: Proceedings of the Treatment Center of the New York Psychoanalytic Institute. This quarterly journal, whose first issue is to be published by IUP in 1992, will draw on the vast clinical archives of the institute, in addition to publishing new clinical contributions.
Issues that the clinics face in the 1990s reflect those of society and the psychoanalytic community at large. The economic downturn has pressured all our social institutions to cut costs and search for additional sources of revenue. Candidates are being urged to pay careful attention to the matter of fee setting and to avoid the very frequent pattern of undercharging clinic patients. Currently, candidate analyses at the New York University and at New York Psychoanalytic are conducted five times a week; most candidates at Columbia see their patients four times weekly.
Competition among therapists from different backgrounds for the available patients has led to a gradual expansion of the criteria for analyzability and to a much higher rate of recruitment of analysands from the analyst's psychotherapy practice. Candidates at many institutes are now permitted to convert patients from psychotherapy to analysis.