Writing about politics and practice is an interesting assignment, since politics and psychoanalysis seem strange bedfellows. Politics in the best sense, however, is the art of accomplishing worthwhile goals: for us, the preservation and enhancement of psychoanalytic knowledge, spirit, and ecology. In that sense, there are four important political levels: governmental, inter-organizational, public, and internal.
Since the 1970s, analysts have watched the declining fortunes of psychoanalysis and dynamic psychotherapy. Although these ecological shifts require little documentation, the data are informative. Our first practice survey was conducted in 1967, with others in 1976, 1990, 1993, and 1996. From the 1967 base of 6.15 cases, there has been an approximately 1 percent annual decrease: to 4.79 cases in 1976, 4.22 cases in 1990, 4.06 cases in 1993, and 3.93 cases in 1996. The averages, however, are somewhat misleading because in 1990 the modal (most common) number of cases was two, whereas in 1996 it was zero. In other words, 13 percent of us have no analytic patients. While the number of psychotherapy cases remained relatively constant (the 1996 average being 13.47), more than half were seen once per week.
In the early 1990s, the Clinton Health Plan heralded national systematic problems. There was no quarrel with the need to extend coverage to the uninsured, but plan provisions would have de facto eliminated private practice by criminalizing private contracting. In other words, analyst and patient could no longer agree privately on frequency and fee. In leading the opposition to these consequences, we cut our teeth on high-level political action.
In this context, the Executive Council endorsed political action priorities: (1) the protection of private contracting, (2) the protection of confidentiality and privacy, and (3) parity for mental health coverage, including psychoanalysis. To speak with one voice, an alliance was forged between the American's Committee on Governmental Relations and Insurance and the Coalition for Patient Rights. Ultimately, we engaged a Washington firm specializing in health-care law and a legislative consultant.
Although our major effort is to educate, inform, and influence, we have contributed significant specific accomplishments. In addition to opposing the Clinton Plan, we supported the Kyle Amendment, allowing some Medicare private contracting; opposed the Bennett Bill, which would compromise confidentiality; built alliances with others for the broad protection of health-care confidentiality, including the special protection needed by psychoanalysis and psychotherapy; filed an amicus curiae brief in Jaffee v. Redmond, helping to establish judicial precedent for absolute psychoanalytic and psychotherapeutic privilege; and are working with the National Coalition of Healthcare Providers and Consumers, which will focus on managed care in its Rescue Health Care Day.
Where the Clinton plan failed, managed care was expected to deliver. Managed care, which I believe is more aptly considered an economic vehicle than a health system, seems driven solely by price. That guiding principle affects access, scope, and quality of care; managed care also relies upon utilization review and quality assurance procedures, which compromise confidentiality.
I have never thought it reasonable to view health care as an industry, since it depends upon the trustworthiness and intelligence of doctor and patient in one-to-one clinical relationships. In my view, an insidious aspect of the managed care industry is its impact on that trustworthiness through the confounding of economic and clinical responsibilities. For example, in capitated plans the clinician contracts within a fixed per capita payment; it seems easy to derive the formula that less care equals more profit. Other plans present similar but less blatant dilemmas; for example, if utilization increases, chances for contract renewal or reappointment to a panel of providers decreases.
Nevertheless, accountable health plans cannot simply be written off since participation, especially among younger analysts, has grown from 15.9 percent in 1990 to 32.5 percent in 1996. We must not ignore but rather try to reform managed care by turning its excesses to advantage. To mention a few examples, managed care has come under criticism for restrictions on access, curtailment of medical care in general, limitations on mental health particularly, and protection from liability for managed care policies under the 1974 Employee Retirement Income Security Act (ERISA). A recent challenge to ERISA in Texas is a promising development. Any lessening of managed care's liability privilege would help redress the balance between economic-administrative and clinical judgments.
While political action at the federal and state levels is important, no less important is the effort to forge psychoanalytic alliances. In the Psychoanalytic Consortium we have joined with Division 39 of the American Psychological Association, the American Academy of Psychoanalysis, and the National Membership Committee on Psychoanalysis in Social Work (and soon, hopefully, the Independent Psychoanalytic Societies). Together we are working on building a crucial political consensus on the standards of education, training, experience, and practice that define an analyst. Working toward consensus, when these organizations sometimes have less than happy histories together, requires statesmanship on all sides. Without such consensus, however, psychoanalysis might be defined by others whose standards we view as compromising the public interest.
Governmental and inter-organizational work are fundamental to the psychoanalytic ecosystem but receive relatively little public attention. The utility and uniqueness of psychoanalysis in relieving suffering and freeing creativity must be brought before the public by other means. It will be an uphill road. Where psychoanalysis once enjoyed unparalleled public currency, a number of sources have declared us dead. Managed care, and most psychiatric and psychology training programs, deride intensive treatment as expensive and ineffective; advocates of empirically validated
Jon Meyer is secretary of the American and a member of its Executive Committee. He is chair of the Ad Hoc Committee on Community Clinics. He directs a Milwaukee psychotherapy clinic offering low-cost psychodynamic treatment to the community and training residents in psychotherapy. He is medical director of an insurance plan that fully covers psychoanalysis and psychodynamic psychotherapy.
treatments or manualized therapies consider psychoanalysis unscientific; the biologically oriented routinely explain neurosis as biochemical; and many refer to clinicians as providers, undermining all professionalism.
We have been hurt by our critics, and we may have failed to respond effectively, but to paraphrase Mark Twain, the reports of our death have been greatly exaggerated. Under the American's Public Information Committee, and through the efforts of individual analysts, scarcely a day goes by without letters to editors of prominent print media, interviews on electronic media, both proactive and reactive responses to those who are uninformed or misinformed, and efforts to help journalists interested in balanced reporting. Our success was represented at the December 1998 meeting by our first award for Distinguished Contributions to Psychoanalysis in Journalism.
Part of our effort to repair public perception and enhance our presence is represented by community outreach. To cite all the important committees and individuals would be impossible in this brief article, but we are trying to reach all levels of education, from preschool through graduate school and specialty training; provide information to the media, from print to electronic; forge alliances with psychiatry, psychology, social work, and others; embrace social issues representing the tolerance and understanding central to psychoanalysis; and encourage and welcome psychotherapists, students, and academicians. Such programs can be described as a balanced mosaic of efforts to shift from reclusiveness to activism while retaining the integrity of the analytic position.
Outreach is of little meaning without inreach. If our efforts do not reach, support, interest, and even inspire the individual analyst, they cannot succeed. Although there has been an average national decrease in practice, that decrease is not uniform. In certain areas practice is increasing. What these areas have in common is not just programs, but programs that engender a feeling that involvement is not ancillary but complementary to analytic pride and identity.
The programs themselves are easy enough to identify. Societies and institutes have opened doors to psychotherapy, student, and academic associates; developed psychotherapy training programs to fill gaps left by virtually all graduate education programs; developed sliding-fee community clinics, thus bringing psychodynamic psychotherapy and psychoanalysis to our traditional patients, who are now casualties of insufficiently humanistic education or managed care; formed foundations and foundation boards to raise funds and give psychoanalysis access to decisionmakers; and elaborated career tracks to cultivate not only training analysts but also psychotherapy teaching and public service.
Where these programs work, a synergy develops between the programmatic effort and the analysts who feel engaged in contributing to their field. The most important product is the pride in being an analyst and willingness to speak out for psychoanalysis.
There is no more effective ambassador than an informed, committed analyst with a core psychoanalytic identity. Communications by such analysts may be subtle, but they are powerful. Fortunately, the American, as both a membership and an educational organization, is in a strong position to encourage and motivate an analytic identity. Although this article is not focused on our educational and standard-enhancing functions, the efforts of the Board are crucial. The credibility of the American in all our efforts and, ultimately, with ourselves in our analytic identities derives from the fact that we stand for quality in education and practice.
What does analytic identity have to do with the politics of practice? I believe the answer is rather direct. FDR said, in mobilizing the nation after Pearl Harbor, “We have nothing to fear but fear itself.” In psychoanalysis, to paraphrase Roosevelt, we have nothing to worry about quite so much as our own identity as analysts. The most profound effect of the activities of engagement, which are political in the best sense, is the change in the demeanor and behavior of analysts when they speak out. Their pride means that colleagues listen, the press is receptive, the public is respectful, and patients are able to hope for health.
When the analyst is committed and conveys that conviction, it reaffirms the fact that psychoanalysis works and is a testimony to the reason we went into psychoanalysis to begin with. Pogo, the nonpareil possum, once said, “We have met the enemy and he is us.” We have no lack of opponents, but we are able to deal with them because we have met the basic enemy and he is, in truth, no longer us.