Most psychoanalysts (it would be more precise to say most graduate members of the American Psychoanalytic Association who respond to practice surveys) spend most of their professional time engaged in work other than clinical psychoanalysis. This is the inevitable — and to many, the most important — conclusion derived from the APsaA's surveys on psychoanalytic practice over the past decade, or the past quarter-century if the 1976 survey is included.
Is this important? Does it have any bearing on the organization? On any individual analyst? On the future of North American psychoanalysis?
The mean number of analytic cases per graduate-analyst member has dropped from 4.78 in 1976, to 4.22 in 1990, to 3.67 in 2001. This has been interpreted as demonstrating an average decrease in the size of practice of about 1 percent per year (a 13 percent drop from 1990 to 2001). These data and other findings from the surveys have been cited to call attention to the difficult times we face as analytic clinicians and our need to do something about our standing in the current mental health treatment marketplace. Indirectly, it could be argued, the statistics have been utilized to show the membership just how bad things are — or conversely to encourage us by showing that our individual misery entertains lots of collective company.
The surveys have been conducted and analyzed in a systematic manner over many years by Lee Brauer and others with a high degree of sophistication. They were reviewed in 2001 for methodology and reliability to reinforce our confidence in the results. They yield a longitudinal picture that can provide important comparisons and a reliable graphing of the gross changes over time in psychoanalytic practice levels. However, as Paul Mosher (who consults to the Committee on Practice) noted recently, one can come to different interpretations of the data or use them for divergent purposes, depending upon one's agenda. But there is even more here than meets the traditional eye, and it influences what data we collect and what those data suggest, support, and omit.
The complete report of the 2001 Brief Survey on Practice can be read in the closed section of the APsaA Web site. Among its findings:
The response rate was slightly more than half that of previous surveys (36 percent vs. 60–70 percent), due to the absence of the customary dunning effort. A 70 percent response rate is considered very high for survey studies in general, but it still means that one-third of the population is not responding. With only 36 percent of members responding, it can only be tentatively surmised that the general trends reported in the past continue.
The average analyst member has fewer cases. Training analysts, in general, have always had and continue to have larger analytic caseloads on average than non-TAs. However, during the past four years, the training analyst cohort experienced the most significant decline in mean number of cases — from 5.27 in 1996 to 4.87 in 2001. Most of the reported cases in analysis are seen four times weekly. However, 25 percent of all cases are seen three times weekly, and 50 percent of the respondents are treating at least one case at this lesser frequency, which thus remains a legitimate treatment modality for a significant percentage of our members. In addition, the numbers demonstrate quite clearly the rapidly changing demographics of the organization toward a much higher representation of women and those from nonmedical training backgrounds. We are rapidly becoming more diverse.
In the end, what can one understand from this kind of study, both individually and as part of a larger group that should be grappling with psychoanalytic-life issues? Over the years of surveys, certain correlations appear to hold. A relatively “healthy” psychoanalytic practice is correlated, somewhat, with geography. There are apparent group differences between different local societies and cities, and these shift over time. Higher analytic caseloads correlate fairly strongly with lack of participation in HMO or other salaried work; inversely with large psychotherapy practices; and very significantly with training analyst status, child analytic training, and identifying professionally and personally most strongly as an analyst.
To some extent, such correlations must seem obvious. In other respects, it is not clear which factors are influential and which ones are causal. The most consistent statistical correlation of all, however, has been that of “satisfaction” in one's psychoanalytic career with size of analytic practice, i.e., the number of analytic cases. Again, this finding may appear obvious. Or is it not so simple?
One analyst who spent his entire career in the academic arena and was the director of a major psychiatry residency was fond of saying that he loved beginning his day seeing an analytic patient and ending it similarly. This member, if he had responded to our practice surveys, would have fallen far beneath any national mean that has been reported. Was this an “unhealthy” or unsuccessful analytic career? This individual enjoyed and contributed more to the future of our field than many.
I do not wish to diminish the importance of immersion in clinical work for anyone's developing competence. I wonder, however, if we have been asking the wrong questions or not enough questions or, at the very least, if we have slanted our questions toward a misleading impression of our collective “health.” Our questions themselves may be creating distress. The belief that the size of one's analytic caseload validates one's identity as a psychoanalyst may be having a more deleterious impact on our field than even the alleged decline in practice.
I say “the alleged decline,” because I am not at all sure that there are fewer patients in analysis than previously. The opposite seems more probable, because there are more analysts now than at any time in history, though not all are trained by and members of the APsaA. It is likely that there are more analysands than at any time as well. This may not be reflected in our surveys.
But there is an even more important question: Is the “decline” necessarily the most important issue for the field of psychoanalysis or for those of us who are involved in this field in many different ways?
The ego ideal, so to speak, of our professional lives has remained steadfastly monolithic. It is tacitly reinforced by our organization and, I
Erik Gann, M.D., chairs the Committee on Psychoanalytic Practice. He is a training and supervising analyst and past president of the San Francisco Psychoanalytic Institute and Society. He is also an associate clinical professor of psychiatry at the University of California, San Francisco.
fear, even by our practice surveys. The successful analyst is one whose time is devoted to seeing a dayful of analysands. The future of the field is guaranteed by the promulgation of this ambition and its reward, the highest prestige in our ranks — the training analyst appointment.
Although this has its political ramifications, and the resulting hierarchical fall-out periodically obtains some degree of controversy, it is not the democratic urge that is at issue here. Rather, it is the very future of psychoanalysis in the social and intellectual ethos of this new century that is endangered. We have different talents, various dispositions, and multifold interests. Many individuals may be perfectly happy at home raising their young children and seeing only three analytic cases a day. This could qualify as a very healthy practice. Others of us may be more interested in seeing a mix of therapy and analytic cases, or in doing research or teaching English, or in consulting to businesses or preschools. This is arguably how the field will flourish — or it will risk increasing marginalization.
We must reconsider in a genuinely creative way what a psychoanalyst is and does. In the process we will redefine our own internal ethos, ambitions, and consensus about what is valuable and what should be valued most in our field. This would require revised editions of the kind of survey that should be performed, one that will reflect the many kinds of psychoanalytic careers that exist. Such careers embed our invaluable, psychoanalytic ideas in the heart of the wider culture within which we live and breathe, where they can and should continue to disturb the sleep of mankind.