Psychoanalytic societies and psychoanalytic institutes are adapting in many of the same ways, since both face the same challenges, often fall within the same organizational structure, and most often work in synergy to resolve problems that affect education as well as practice. While enlightened and generous self-interest could take us in certain directions, it may not be possible to formulate the most useful response to a challenge in a particular locale, and we need to respect differences.
Driven by changes in the psychoanalytic climate, psychoanalytic societies are evolving in ways not contemplated a decade ago. These changes include increased competition from other practitioners and methods, favor given by third-party payers to short-term treatments, emphasis by third-party payers and in many psychiatric residency programs on purely psychopharmacological interventions, a diminished — even disparaged — image of psychoanalysis, and unprecedented challenges to privacy and confidentiality. These evolutionary pressures have been manifested in declining referrals and practices. In response, societies have become increasingly activist.
Activist responses, however, have occurred so rapidly as to scarcely allow time to consider their meaning and implications. Whom does the society represent, and what is its mission? Only last May, the Executive Council discussed these questions, and a recent issue of the Committee on Societies Newsletter voiced concerns about preserving the essence of the society as its mission expanded.
As mandated in the by-laws, the core of a psychoanalytic society is the graduate analyst. Many societies also make special provisions for candidates. In addition to the foundation of graduate analysts and candidates, some societies have a rich and diverse mix of individuals who, while not analysts, are committed to dynamic understanding and to dynamic applications in psychotherapy, literature, the social sciences and humanities, administration, and other human endeavors. Most societies have special, affiliate, corresponding, student, psychotherapist, honorary, or other affiliations or memberships. This tradition of non-analyst affiliation has a long history but has not always been thoughtfully employed to further psychoanalysis, even though the talents, relationships, and positions of such individuals could expand our capabilities.
Conceptually, the society has two basic functions. It functions as a guild, to expand and enhance psychoanalysis and psychoanalytic treatment; it also functions as a learned society, to enrich intellectual discourse and advance psychoanalytic science. These two functions turn on somewhat different skills and orientations, but both are essential.
In attempting to enhance psychoanalytic opportunity, the society is concerned with impinging social, political, and economic influences. Although situations vary, there are three basic elements of societies' efforts:
Outreach, the process of forming relationships with natural political and clinical allies.
Inreach, the sometimes overlooked process of motivating and activating our members.
Public education, the process of keeping psychoanalytic ideas before the public to counteract the denigration or dismissal of intensive, patient-oriented therapy.
With their broad bases and significant reach into the communities, societies are in a unique position to take effective action, but the question has often been how to do it. One way to begin is to take advantage of the experience of colleagues in The American who have explored, collated, and adapted successful models. Some examples follow.
The problem of inadequate referrals is due only partly to the inroads of managed care and the loss of indemnity insurance plans. Before there was widespread insurance coverage, analysts had healthy referrals and good practices. A significant part of the problem is inadequate contact between analysts and their natural communities. The new Ad Hoc Committee on Community Clinics is seeking out, highlighting, and developing models that will allow societies and institutes to provide psychotherapy to under-served populations, keep in contact with potential patient and candidate bases, contribute to the training of future colleagues, and help educate the public. Psychoanalysts can best demonstrate the value of psychoanalysis and the benefits of their training by demonstrating knowledge and skills in the potential consumers' environment.
It is so fundamental in health care as to be almost a truism that one cannot build a referral base by limiting oneself only to high-end specialty service. Psychotherapy is a broader service, which we do extremely well; if we can become identified with that service, it will generate the specialty psychoanalytic cases. To take a working example from a successful effort, a psychotherapy clinic has been established in collaboration with a university's department of psychiatry. Residents, who need psychotherapy experience, are supervised by analysts. The patients — including a number of undergraduate, graduate, and medical students — receive high-quality dynamic psychotherapy. In the process of offering a community and educational service, analysts fulfill an important teaching function and come into contact with professionals in training, a traditional patient population. A liaison is established with a psychiatry department that, despite different emphases, is an ally in the concern over the control of health-care expenditures and the issues of privacy and confidentiality.
Finally, the public, in this case the therapy-consuming public, is educated to the benefits of psychotherapy focused on patients' humanity rather than their symptoms. It is hard to overemphasize how important it is for the public to have a visible, practical, affordable
Jon Meyer, M.D., is Secretary of The American and a member of the Wisconsin Psychoanalytic Society and the Wisconsin New Training Facility. He has been an executive councilor and was chair of the Ad Hoc Committee on Executive Council Structure and Function. He is currently chair of the Ad Hoc Committee on Community Clinics and a member of the Joint Ad Hoc Committee on Governance.
alternative to the restrictions of managed care. The public cannot support dynamic understanding and treatment or the unique capabilities of psychoanalysis unless it has some experience with it, and those experiences are progressively less available. The fact that this clinic has a bottom line that is in the black is, of course, an important consideration for its sponsors.
While I have illustrated one exciting way in which an interested society can tap into the work of colleagues, there are many other examples. The Committee on Government Relations and Insurance is working to establish local political action subcommittees. The Public Information Committee is interested in the coordination of public information activities and the development of materials.
The Executive Council has about 40 committees, and there are approximately 20 joint committees of the Council and BOPS. These committees focus on practice, public information, governmental relations, confidentiality, peer review, practice guidelines, racial and ethnic diversity, and societies, among other topics. They are increasingly open to new membership, including members of societies, recent graduates, candidates, and others who are willing and interested in working nationally and will take home what they learn.
A society can achieve an even broader perspective by working with the Executive Council, to which each society is eligible to send a councilor and an alternate. These are important positions, with a broad range of responsibilities including fiduciary responsibility and trusteeship for The American. There are also important benefits to the society; involvement with the Council is one of the best ways to move ideas from the national arena to the society. One new alternate recently commented that though it seemed corny to say so, it was inspiring to see how dedicated people were and how much useful work was being done. If inreach in the society will stimulate analysts to become involved nationally, there will be a reciprocal feedback of useful ideas and experiences that, while not always inspiring, are often exciting and stimulating.
To take another example, a society's relationship with the Council may also serve as a reference point in outreach efforts. At the last Council meeting, a councilor became aware of the national committee considering the question of psychotherapy associates. This information helped that councilor, who was responsible for a psychotherapy training program under the auspices of his society, to find out about other experiences, pursue the possibility of local and national affiliation for his trainees and thus encourage local interest in psychotherapy. It is important to note that approximately 50 percent of that program's trainees are in personal analyses and/or are applying for formal psychoanalytic training.
Although psychoanalysis has developed a marvelous and unique corpus of technique and knowledge, it also has a long tradition of openness to ideas in related fields and the application of its ideas in academic areas. Building on this tradition, some societies have developed an active outreach program to students in their communities, similar to the student associates program of The American. These student associate programs often include medical students and graduate students in psychologically related or interested fields.
Other societies have approached the intellectual side of their mandate by developing academic associates programs to appeal to academics, thus bringing interest and talents from the universities to the societies. Still others have developed study or interest groups designed to appeal to academics. One society has a discussion group that considers psychoanalytic phenomena, such as dreams, in the context of poetry, the humanities, neurophysiology, and the classics. The discussion group is also open to residents and graduate students and other members of the departments of psychiatry and psychology. Although such programs are not always easy to implement, it is conceptually a natural development to take advantage of the overlapping areas of interest among psychoanalysts and academics who find their dynamic and humanistic interests unsatisfied in other venues.
Some have expressed concern that including such affiliates or associates will dilute the level of psychoanalytic discourse and pose problems of confidentiality. Experience has suggested that the non-analyst participants are very interested in hearing about and discussing psychoanalysis — rather than some watered-down derivative — and often elevate the level of the clinical and intellectual discourse by their contributions and by stimulating the membership.
Learned societies do not thrive when closed to new ideas. Psychoanalytic ideas, concepts, theory, and observation are able to withstand and benefit from the questions of inquiring minds. In fact, the overall trend is in the direction of a positive export balance in psychoanalytic ideas.
The impaired image of psychoanalysis in professional and public communities is due to lack of contact between psychoanalysis and those communities — a phenomenon far from entirely attributable to psychoanalysts. Nonetheless, it is incumbent upon psychoanalysts to correct the situation. It is in our interest to do so.
Challenge is also opportunity, and it seems likely that societies will evolve in the direction of representing psychoanalytic interest, broadly defined. A blueprint for this evolution would involve inreach, the mobilizing of members in terms of their experiences and talents; outreach, the forming of relationships with naturally related groups and professionals who share an interest in dynamics and the patients' humanity; and public information, the effort to keep psychoanalytic concepts in the public eye when the trends are to discredit or dismiss them. An important means to implement those efforts is to take advantage of the experience and models developed by others as collected, collated, and refined by our association.
Inreach, outreach, and public education do not compromise the society; they enhance it as a gathering of psychoanalytic scholars. The same individuals who help psychoanalysis with its practice problems bring new and stimulating ideas to our intellectual discourse. In the business language of todays marketplace, distasteful but descriptive, psychoanalysts have a marvelous product. There is no reason to be fearful of having it examined or making it accessible.