The rise of biological psychiatry and the explosion of neuroscience knowledge and research that has marked the last four decades of the twentieth century has led many to question the relationship between psychoanalysis and psychiatry as it is now and as it will be in the future. I find this ironic since Freud himself asserted that psychoanalytic theories of mental functioning represented an intermediate phase in understanding of mental processes and clinical intervention, that would undoubtedly be transformed as new knowledge of brain function was discovered. … What I will do is focus my remarks on issues for the future in the areas of education, research, and clinical practice.
The economic forces transforming the clinical practice of psychiatry over the last several decades have seriously affected academic medical centers as well. Shifts in delivery systems, decreases in public funds available to support academic medical centers, and a disproportionately severe effect within psychiatry of managed care have all put increasing pressure on psychiatry faculty to generate funds necessary to support their positions. This has meant less time available for teaching from even committed clinician educators. Further, the explosion in neuroscience research and available grant funds to support such work have led to an emphasis on faculty who have the potential for garnering research funds, and a relative de-emphasis on those who rely primarily on clinical service to provide salary support. These forces led to a mass exodus of psychoanalysts from departments of psychiatry in the 70s and '80s. Feeling devalued and underappreciated, psychoanalysts reacted with anger and hurt, leading to a situation in which many departments of psychiatry today have little access to those psychiatrists most expert in teaching psychodynamic principles and techniques. …
[I]t is essential for psychiatrists to still have the knowledge and skills base necessary for psychological understanding and intervention. This is true even when the primary treatment modality is phychopharmacologic. This is the case not only in the outpatient clinic, where research is beginning to show the superiority of combined medication and psychotherapy treatment (especially in seriously ill patients) but in every clinical setting. … However, at present, teaching the knowledge and skills necessary to conduct psychodynamic psychotherapy occupies little curriculum time. Further, there exists little data regarding adequacy of psychotherapy training, which is necessary to plan appropriate training experiences. It is known, however, that residents feel increasingly unskilled when it comes to psychoanalytic psychotherapy. In discussions with residents around the country, the one issue I hear more than any other is a wish for a more adequate psychodynamic psychotherapy training program. …
The intersection of the economic state of affairs with pressures from residents for more psychotherapy training, especially psychoanalytic or psychodynamic psychotherapy training, provides an opportunity unparalleled in recent years for psychoanalysts and others able to teach psychodynamic knowledge and practice to re-engage in psychiarty teaching programs from the first year medical student level on up.
Even in the heyday of academic psychoanalysis, much of the teaching and clinical supervision provided to residents was made available by volunteer faculty in private practice. The severe financial pressures under which most analysts practice today are well known, but it is clear that this is a time when there must be a recommitment to re-engagement in psychiatry residency training lest the entire body of psychoanalytic knowledge and skills is lost to the discipline of psychiatry. Historically, analysts provided clinical supervision of outpatient work, often in their own offices. At present, though, there are opportunities to teach within the academic medical center on any clinical service and at every level. This is especially true with the rise of pre-clinical introduction to clinical medicine courses which are often coordinated by psychiatry and which have a major emphasis on teaching students about the doctor-patient relationship. …
To ensure that the psychiatrists of the future have the requisite psychodynamic knowledge and skills base, psychoanalysts must take advantage of the unparalleled set of opportunities available within psychiatry teaching programs.
There is little question that there is a rich potential in research in psychoanalysis, and that insights gained from such research can contribute much to our understanding the etiology and treatment of psychiatric illness. Unfortunately, historical forces within psychoanalysis have played a role in limiting the contributions that the field of psychoanalysis has made to modern psychiatric treatments. One aspect involves the limitations of the traditional focus on the single case study to psychoanalytic research. This is not to dispute the tremendous advances in our psychological understanding that have resulted from such an approach, nor to criticize its use, but to acknowledge that the state of the art in psychiatric research has moved far beyond this approach, which was so critical to the establishment of modern psychoanalysis.
For example, further psychoanalytic research is crucial for better understanding of the role of psychological processes in anxiety disorders. Such an effort will have tremendous impact on future directions in caring for this group of patients. As many of you know, the 1998 approval by the American Psychiatric Association of practice guidelines for panic disorder was cause for great concern among psychoanalysts, and highlights the need for the kind of research that uses the modern techniques. …
What accounts for the relatively meager body of psychoanalytic research using modern techniques? Obviously, many factors, which include the lack of funding and, until recently, a lack of clearly defined methodologies for conducting psychotherapy research. But such tools are today used consistently to study other forms of psychotherapy, most notably cognitive-behaviorial and behavior therapies, resulting in a large and growing body of literature. The comparative paucity of reports on psychoanalysis and psychoanalytic psychotherapy has already resulted in a minimization of the role of these approaches in patient care, as is most clearly highlighted in the controversy surrounding the APA panic disorder guidelines. Further, there are tremendous opportunities to study combined psychoanalytic and psychopharmacologic treatment….
Thus, a major task lies before us as psychoanalysts, as significant time, resources, and energy must be devoted to a number of major research questions. Success, though, will require a shift in the traditional approach of psychoanalysts….
For psychoanalysis to thrive as a part of modern psychiatry, we must undergo this shift of culture and apply the methodologies that our most senior colleagues have developed over the last several decades. As an active researcher myself, I know firsthand that this is not always a comfortable or easy process. But it is an essential process if we are to take our appropriate role within modern psychiatry. …
In recent years many articles, within both the scientific literature and the popular media, have predicted the death of psychoanalysis as a clinical enterprise. My own view is that the future of the clinical practice of psychoanalysis in this country is very difficult to predict. While we are well aware of the economic forces at work that drive choices of treatment and of the advances in other aspects of psychiatric knowledge and practice, involving both psychopharmacologic interventions as well as other psychotherapeutic interventions, we clearly don't have enough data to accurately predict the future. …
There are several factors, though, that I believe will be important in predicting the future of psychoanalysis as a clinical enterprise both within and outside psychiatry. One issue has to do with not only political trends and economic forces, but career pathways and the choices that graduating psychiatric residents are making. Over the last two decades there has been a steady decline in the number of psychiatric practioners entering training in psychoanalysis. This is not surprising to me since, as I mentioned earlier, many residents no longer have early educational imprinting experiences with psychoanalysts and many do not even receive any teaching by psychoanalysts throughout residency. To be blunt, we shouldn't expect someone will choose a career pathway that they know little about or have no role models after whom to pattern their careers. Whether this trend will shift depends in large part on psychoanalysts' willingness to reengage in psychiatric residency teaching programs, as I discussed earlier….
My best judgment is that in the clinical arena there are major contributions psychoanalysis has to make to psychiatric practice regardless of the economic enviornment. To me, the major determinant regarding the clinical relationship between psychiatry and psychoanalysis in the future has more to do with how many psychiatrists choose psychoanalysis as a career path rather than any other issue. Unfortunately, unless some of the major shifts that I have discussed in the educational and research arenas take place, I think we may be forced to conclude that fewer and fewer psychiatrists in the United States will choose to become psychoanalysts. In spite of all other factors, this in itself would lead to a distancing of psychoanalysis from psychiatry.
To summarize, I have no doubt there are tremendous opportunities for interaction between psychiatry and psychoanalysis in the areas of education, research, and clinical practice. Many uncertainties lie before us, however, and the maintenance of a close clinical collaboration between psychoanalysis and mainstream psychiatry relies, I believe, on major shifts in education and research in psychoanalysis. Without such shifts, I fear an ongoing divergence between psychoanalysis and psychiatry which would impoverish both disciplines. While much work needs to be done to ensure that this does not become the path we take, I am optimistic that we have the resources, knowledge, and skills to succeed. What remains to be seen is whether we also have the will.