In 1993 The American again conducted a survey designed to monitor the state of analytic practice and the satisfaction of its members with their practices and organizations. The last such survey was made in 1990. Questionnaires sent out to members elicited a response rate of 71 %, an excellent figure yielding dependable results. A full report of the survey has been distributed to members of the Executive Council and to presidents of local societies. Following is a summary of salient findings.
The organization comprises predominantly older members. Two- thirds of the membership are 55 or older, and half of all training analysts are over 65; few are under 55. This prolonged developmental course in analytic careers is discouraging to many. In addition, the aging membership imposes a financial burden on the organization, as life members are not required to pay dues. In recent decades, the proportion of women in The American has seen a steady increase. Women now constitute over a third of the membership under 45 years of age.
Fewer psychologist analysts responded to the current survey than in 1990. Since it is unlikely that their proportion of the membership has decreased, it is possible that their lower response rate indicates some recent problem with this group's participation in the organization. Psychologists who responded, however, are not disaffected, as they scored higher on all indices of identification and satisfaction than did their psychiatrist counterparts.
At the present time, most members over the age of 45 are certified, and the number is increasing. In the past three years, the percentages of graduates who are training analysts or who are certified have increased, and the percentage of uncertified graduates has declined by 6%. It is possible, however, that members will seek certification in fewer numbers now that it is no longer a requirement for voting membership. There are 283 respondents under the age of 55 who are not certified, and probably another 140 uncertified analysts who did not respond. A relatively small percentage of active members apply for certification in any given year.
Uncertified members today are just as likely to serve on institute faculties as are certified members. Faculty appointments provide encouragement to members beginning their careers, but the lack of distinction between certified and uncertified analysts may indicate that the certification process is losing its significance.
Training analysts are more likely than others to have had some child training. Over one-third of training analysts have either completed or had at least some such training.
One of the surprising changes since the 1990 survey was taken is the dramatic increase in the number of analysts who have joined HMOs. The percentage of younger analysts who have joined them has doubled in the past three years to 51 %. As senior analysts do not affiliate with HMOs as frequently as do younger, less established analysts, it is difficult to ascertain which patterns of practice correlate with junior status and which can be attributed to the pressures of belonging to an HMO. Analysts who belong to HMOs have smaller analytic practices, are less identified as analysts, and are less satisfied with their analytic careers. However, a much more powerful determinant of practice size and satisfaction with the profession is status within the analytic organization. Training analyst status correlates with increase in size of practice, and in identification and satisfaction with the profession. In former years, membership in an HMO might have been taken as a sign of internal resistance to an analytic career. Now it is more likely to be simply the result of economic necessity. Today even senior people, well advanced and established, are joining these organizations. Those who are certified or have become training analysts, however, are much less likely to be affected by joining an HMO than are analysts who lack these achievements, which seem to reinforce analytic identity and morale.
Given the trend toward joining HMOs, and early evidence that membership in them is associated with declining practice and interest, it seems important that The American and its local institutes and societies organize programs and advisory groups to help members deal with the pressures encountered in these organizations, and to evaluate the impact of HMOs, both on the clinical outcome of analyses and on analytic careers and morale.
Over a third of certified members and active members draw some salary from some source, and slightly more than a quarter of training analysts also collect some salary. Being salaried is not antithetical to becoming a training analyst.
Analysts worked an average of 42.2 hours a week, 2.3 hours less than in 1990. There has also been an alarming drop in the average number of patients, independent of membership in an HMO. Analytic practice has declined roughly 1% a year since 1976, for all categories of membership. There has been a 3% decline in the level of analytic practice since 1990, except for certified analysts, whose analytic practice declined a dramatic 15%. (The practice of training analysts has declined 15% in the seventeen years since 1976.) Although the 3% drop in analytic practice is not statistically significant, it does constitute a disturbing trend, as the decline was felt by a large number of analysts, 45% of whom experienced a decrease in practice since 1990. This was three times the number of analysts who reported an increase. However, between 1990 and 1993, there has been no significant downward change in the frequency with which analytic cases are treated; 27% of cases are seen three times a week.
As evidenced by some members' rather pessimistic written comments, the decline in practice is not lost on analysts. Many report that prospective patients have chosen other forms of treatment instead, either for financial reasons or because psychoanalysis is held in low regard. Many respondents
Lee David Brauer, M.D., chairs The American's Committee on Psychoanalytic Practice.
expressed the opinion that psychoanalysis does not compete well with other forms of therapy.
In spite of the decline in the size of members' practices, there is a slight improvement in identification with psychoanalysis; mean levels of identification fell between high and most high. However, members continue to report less satisfaction with their analytic practice than with their professional career overall. Nonetheless, levels of satisfaction remain close to high. By contrast, there is only moderate satisfaction with the analytic organizations—the institute, the society, and The American. The least satisfaction registered, between mild and moderate, is with The American. These levels of satisfaction with analytic organizations apply to all three categories of membership.
Identification with psychoanalysis and satisfaction with the profession grow with an increase in the size of practice, and both are quite high when the member has four or more cases. Training analysts and certified members are less dependent on case load for satisfaction with the profession. Members who have joined HMOs tend to be less satisfied with the psychoanalytic profession than are analysts who have not, but the causal relationship is unclear. The dissatisfaction may precede and in fact influence the decision to join, or it may be consequent to it.
The survey reveals that in the three years since the last survey only minor changes have occurred in the composition of The American with regard to age and gender. Many changes overtaking the health care industry generally, however, have had an observable negative impact on the membership, most notably the dramatic rise in the number of those who have felt constrained to join HMOs. Many members are dissatisfied with their analytic practices, and see no improvement in the coming years. The changes seen in the past three years may be indications of more pronounced changes to come, as managed care and government control exert a rapidly increasing influence on health care nationwide. The downward trend in the size of practices, coupled with the increase in HMO participation among younger members, may presage a more profound decline in years to come.
Given the tenor of comments and the discouragement many members have expressed, the societies and The American are well advised to sponsor workshops and forums to keep members abreast of changes in the health care field and to discuss individual and collective responses. If the organizations of analysis remain aloof from this task, they may come to be regarded as peripheral to important concerns of the membership and may suffer an even more precipitous drop in the esteem in which they are held.