It is easy in today's “marketplace” to become discouraged about our future as a profession. Journalists frequently speak of psychoanalysis as a theory that has been relegated to the past. Our treatment is spoken about as if it is an anachronism. Those who fund treatment argue that brief and superficial approaches are good and depth is “bad,” or at least too costly. An unexpected correspondence helped me to consider the impact this atmosphere of gloom and doom can have on those who are in the process of choosing a life's vocation.
A few months ago a consortium colleague sent a copy of a letter from a medical student he had taught in one of his undergraduate classes. My colleague thought the student would appreciate a reply from an analyst who had a psychiatric background. I was both moved and disturbed by the letter and sent a reply with my opinions. I received the permission of the letter's author to include it in this column. He wrote (and I have slightly edited) the following:
“Dear Dr. — — —,
I was a student of yours at — — — in 1996 and I very much enjoyed your class on psychoanalysis. I am writing to you because I am coming to the end of my third year of medical school and am deciding what branch of medicine to go into. I initially went to medical school with the plan of becoming a psychiatrist and a psychoanalyst. I still want to do that, although I have heard very mixed and conflicting ideas about the future of psychoanalysis. I know that with the advent of different therapies and the pressure from HMOs, things have changed for the worse for the practice of psychoanalysis. It seems that enrollment of psychology graduate students in psychoanalytic programs is decreasing as well. I wonder how this bodes for one who is planning to pursue a career in psychoanalysis.
I wanted to know your opinion on the future of psychoanalysis. My decision to pursue a career in psychiatry (versus another field of medicine) rests upon the belief that psychoanalysis and psychodynamic therapy will continue to thrive. Otherwise, I will probably go into another field of medicine. I was wondering if you could shed some light on this complicated subject.
Sincerely,“
I sent the following reply:
“Dear Mr. — — —:
Dr. — — — sent your letter to me and asked if I would reply to your inquiry about the future of psychoanalysis. It is my pleasure to do so. I understand your concerns about the viability of psychotherapy and psychoanalysis within the framework of modern mental health care and particularly in psychiatry. It is certainly true that psychotherapeutic treatments are not very favorably supported by third party payers. However, there is a need and it is being met on a daily basis by many different payment arrangements including insurance and private payment. While I can only offer my personal view, I believe that both psychotherapy and psychoanalysis are alive and well and will have an important role to play for the foreseeable future.
It is certainly true that the major viewpoint within psychiatry today is biological. Brain research has been very exciting and productive in the past decade. Newer drugs such as SSRI's have been very widely promoted and prescribed. Although many patients have been helped by the medications and the biologic approach, it is considerably over-hyped. The brain research has not yet produced great results in the clinic. The medications are a relatively crude approach to emotional problems and studies continue to say that a combined form of treatment, using medications and therapy, is superior to either approach alone. This is true even in those conditions most amenable to medication as a successful intervention.
Many patients, perhaps most, have their lives constrained by emotional problems and conflicts that are not very successfully helped by medications. These conditions, classified as neurotic or character problems, are much more successfully helped by “talking therapies.” Empirical studies are too few and somewhat limited, but the evidence that we do have, clinical and empirical, seem to confirm this.
Furthermore, it is quite possible to have a successful practice composed of mainly psychotherapy and psychoanalytic patients. Most younger psychiatrists start their practices with a combination of medication and therapy patients. However, in many areas of the United States, it is possible to develop a practice that is exclusively therapy based if that is the practitioner's desire.
Most psychiatric residencies are woefully deficient in therapy training. However, the accrediting board has recently mandated a greater emphasis on therapy in training programs. Those programs known to have a balanced approach do better at recruiting residents than those which are too one sided.
It is very exciting time to be a psychoanalyst and psychotherapist. The theoretic environment is pluralistic and innovative in a manner that contrasts to an earlier time of greater orthodoxy. Psychoanalysts from varied backgrounds and differing kinds of training and from all over the world are interacting in a mutually enriching way that contrasts with the more sectarian style of the past. Psychoanalytic training organizations are self-evaluative as never before to the benefit of their students and faculty.
I received a grateful reply from the student saying he was looking forward to starting a psychiatry elective soon.
I think this interchange alerts us again that excellent teaching of psychoanalytic concepts by psychoanalysts in the undergraduate programs of universities may be one of our best methods for inspiring future analysts. Similarly, our participation in graduate programs as analysts, not only as psychologists, psychiatrists and social workers, may be our best advertisement of the fascinating world that is the study and practice of psychoanalysis. As long as we continue to reach out as teachers to enquiring younger people and to offer ourselves as positive role models and mentors, I believe we can expect a continuous flow of applicants eager to become the next generation of practitioners, teachers and scholars in our discipline.
I teach in a residency program and I see the eagerness that some residents have for more training in psychodynamic psychotherapy. It makes their work more interesting and they have a wider armamentarium of means to aid their patients and to conceptualize all of their approaches. I am most familiar with the Institutes of the American Psychoanalytic Association and they continue to attract sophisticated students for psychoanalytic training and in their psychotherapy training programs.
Ronald M. Benson, M.D. chairs the Board on Professional Standards.
In summary, if psychoanalysis and psychotherapy is your interest, I believe you can have a satisfying and productive career in clinical work, teaching, administration and research.
Warm regards,“