A Meditation on the Present Future of Analytic Practice

We are at this moment a few months short of the sixtieth anniversary of Freud's passing. “No more a person / now but a whole climate of opinion … he quietly surrounds all our habits of growth,” wrote W. H. Auden in “In Memory of Sigmund Freud” in 1939. The profound discoveries, the pervasive truths have become a commonplace; and yet, our own sleep is disturbed as to where we belong, what we shall be, what shall become of us. A patient of mine recently disclosed to a relative that he is in analysis “with a Freudian.” The serious reply to this statement allegedly was, “I didn't know there were any of those left.” Is this purely a public relations problem?

We naturally think of this kind of scenario and its many ramifications as a problem. Even though more patients are probably in analysis at this moment than at any previous time in history, there are serious problems for the practicing analyst. The data bear this out — if one believes statistics. There are, of course, the unofficial, anecdotal accountings, all too plentiful and for the most part similar around the country. Referrals for analysis are hard to come by; case loads have diminished; private practice, in general, is encumbered in a fashion heretofore unseen — and unforeseen — by forces of third-party regulation, the real potential for federally legislated infringement on confidentiality, and an increasing number of other therapeutic modalities and practitioners, among other factors. Do we need numbers to tell us what is happening?

Since 1976, the Committee on Psychoanalytic Practice has been charged with surveying the membership periodically in order to ascertain the state of our clinical enterprise. Statistics can be misleading: One needs to know what and how to do with them. Even then, it is easy to reify numbers; science is traditionally anchored in a quantitative base. Yet without some comparative measure, accomplished systematically and rigorously and at intervals frequent enough to be informative while not so frequent as to be intrusive, how can we know what actually is happening with our colleagues and ourselves?

One major problem here is that pride and prejudice enter into the picture, as they do all too often — even in our hallowed halls of self-understanding. The 1996 practice survey devolved into an uncommonly difficult instrument from which to get a response. After more than a year of soliciting and dunning by the Practice Committee up through the very leadership of the American, it finally became possible to begin analyzing the numbers and producing the initial, general report, which was written once again by Lee Brauer.

Even a quick reading of the document strongly suggests the lack of enthusiasm amongst the membership for returning it (a 61 percent return rate compared to nearly 75 percent in the past). If statistics are to be believed at all, most members of the American spend most of their professional time and energy in activities other than clinical analysis. The mean number of cases per analyst has continued to decline over a twenty-year period at a rate of 1 percent per year. The modal number (the most frequently reported number) of cases reported by graduate, non-training analysts is zero! Almost one-third of all cases in analysis reported in this survey are seen at a frequency of three times per week. Approximately one-half of the membership has at least one case in three-times-per-week analytic treatment. Almost 40 percent of the membership never returned the survey, in spite of all the intensive dunning. One wonders if many were simply too discouraged by or too removed from analytic work to follow through with this task.

Satisfaction and Size of Practice

One very consistent finding through the years has been the correlation between analysts' degree of satisfaction with their analytic careers with the size of their analytic practice. The numbers suggest that there may well be an increasing discrepancy between what appears to be an essential factor for satisfaction with one's analytic career and the probability of attaining it. What, then, of the career of the twenty-first-century analyst?

This question raises in turn a series of other complex and challenging questions. Do the data reflect anything at all about clinical talent, or only about external conditions? Should all or even most graduates of analytic institutes be primarily conducting analytic treatments? Do all or most graduates really desire this anyway? Or is there an implicit assumption, to say nothing of a pressure, in our analytic culture that they should desire this? The ideal of the group has traditionally been to become the analyst of other analysts-to-be. Is it in the best interest of the future of psychoanalysis as a discipline for us to continue to validate tacitly, if not explicitly, only one kind of career goal/path for the professional?

Can we contemplate in any fruitful manner what is yet to be? An old story tells of Einstein lost in thought on his way to relativity theory, wondering how the world would appear if he were riding on a photon. Perhaps that is a fiction more than Einstein's experience, but it serves well enough. The billboard advertisement advises us to “think differently.” In 1899, who could have imagined that within a decade and a half automobiles and flying machines would forever alter our relationships to distance and time, to the observation of the planet, to warfare, to travel, to each other?

Should we be troubled that we preserve so intensely the nostalgia for the “Golden Age” of analytic practice in the 1950s and '60s? It is natural enough, but troubling nonetheless. The good old days, when things were done right, built right, when we were in demand: Behind the manifest content, we might read a longing for the nurturant mother, for an omnipotent wish to have it all with which to inflate our collective self-esteem or an intense desire to be the oedipal winners over all other rivals — not to mention the need to pay the exorbitant rent. We, too, long for our special places in the long-lost limelight. The world, like a departed mother, denies us, prefers another. Moreover, whether or not we are paranoid, they may indeed be out to get us.

New Spaces

There are practical steps that can and should be taken on both individual and group levels. These have been more widely discussed in recent years and will continue to be. But there are other vectors beyond these that we shall likely encounter soon enough — the advent of now-unimaginable technologies in brain intervention, medications with steadily more refined modes and sites of action, and so on. Telephone treatment is old news, and e-mail treatment occurs already. Videoconferencing is everywhere and will become a part of everyone's individual communication device soon. Traveling to the consulting room may no longer be an issue within several years.

Psychoanalysis has continued to be the treatment paradigm steeped in the conviction about the dynamics of transference and resistance in an actual, live relationship. I personally cannot fathom an effective analytic treatment without the living, breathing, sweating person-presences of analyst and analysand in the same physical time and space. But I speak like an old-fashioned Euclidean. Space-time continua are shifting. Relatedness of the human kind already involves computerized, virtual dimensions that render Freud's 1899–1939 experience and our own current experience a world apart from the surreal reality that is just beginning to be discovered and exploited. Where and how will psychoanalysis and its clinical impact move in these new spaces?

This is all to say that we need as much honesty as we can muster to know what we really do, both in the consulting room and on the outside, what works and what does not, and how and why. At the same time, we must prepare ourselves to see the phenomena in a new light, within new frames and contexts never before seen, and accept the fact that we, too, shall be transformed.

Then, I think, psychoanalysis will expand its illumination into the twenty-first century and beyond. This is a fantasy, but as Eric Sevareid put it, “not too wild a dream.”

Okay now, beam me up, Scotty.

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