In the late 1980s and early 1990s, several phenomena converged to put considerable pressure on the prominent psychoanalytic long-term treatment centers. These included the increasing popularity of evidence-based, symptom oriented treatments, such as new psychotropic drugs or cognitive-behavioral and other brief therapies, the loss of prestige of psychoanalysis in academic centers and among private practitioners who had previously provided patient referrals, and the dramatic erosion of financial support for extended treatments by insurance providers. These factors impacted the great analytically oriented hospitals in ways that caused them to close, move, downsize, or alter or redefine their missions. In an effort to discover what remains of psychoanalytically oriented treatment at these historic centers and to learn which factors were considered most important in adapting their institutional priorities, I interviewed administrators or former administrators from McLean Hospital, the Menninger Clinic, Sheppard and Enoch Pratt, Austen Riggs Center, and Chestnut Lodge.
Chestnut Lodge, in Rockville, Maryland, is the only major long-term treatment hospital to have closed. Anne-Louise Silver, former director of education, describes this as a result of several factors. After Dexter Bullard, Jr. retired as medical director, his family, which owned the institution and now had no representative directing it, decided to sell the hospital. Alarmed, several members of the staff attempted to organize an employee buy-out, predicated on selling some of the land on which the Lodge was sited while retaining the parcel containing the original hospital buildings. Bank financing was obtained for the buy-out, but the staff group fell apart. Silver speculates that, in addition to concerns about the buyer for the land, this may have been due partly to the aftermath of tensions among staff members about the use of psychotropic medications, with one group holding that their abrogation presented a malpractice risk, and others feeling that medications were overused and undermined a genuine psychoanalytic orientation. With increasing pressures to discharge patients to outpatient care after a month or two, the sense of community at Chestnut Lodge also, to some, seemed to be eroding. Silver wonders additionally whether “the staff's natural ambivalence about the work” played a role: “This work is so very difficult that staff members both longed to continue their mission but at the same time also desired, perhaps, to be rid of it.”
The institution and its land were sold to Community Psychiatric Clinics (CPC), a group that, according to Silver, had no experience running an inpatient hospital. Silver notes that the new director was repeatedly invited to speak with the staff, but never came to meet with them as a group, and board meetings were closed. The hospital went from “running in the black” to incurring millions of dollars of debt and was eventually closed by CPC.
Austen Riggs Center has retained an exclusively psychodynamic focus. Edward Shapiro, CEO and medical director, described Riggs's advantages of having a cohesive staff and longstanding tradition, a relatively small size, and an advantageous location in Stockbridge, Massachusetts, where costs tend to be relatively low and rates can thus be somewhat less than in urban areas. When he was appointed, Shapiro asked staff, board, and patients to identify what each thought was essential about the hospital. He helped them to “negotiate the difference” in defining the center's central mission, while at the same time “taking seriously what the outside world is saying about us” and trying to address it. The guiding concept of treatment at Austen Riggs was refined and became articulated for the public as “the treatment and study of the individual in context” in order to “help treatment-resistant patients become people who can take charge of their lives.”
The idea that resources to fund treatment are limited, articulated increasingly by the insurance industry in the 1990s, became incorporated into Riggs's approach to working with patients and families. As M. Gerard Fromm, director of the center's Erik H. Erikson Institute for Education and Research, states, “Managed care took the management of fiscal resources away from the patient and placed it between the insurance company and physician. We try to enable patients to take back some control of their insurance through negotiation.” Shapiro adds, “We also help our patients negotiate support from their families, working with them to think through the conflicts, guilt, and anxieties that interfere with realistic assessment of family resources and needs.”
To help treatment become more affordable, less costly step-down programs were initiated, with patients followed at every step by the same team of mental health professionals so that care was not disrupted. At present, “one-third of patients stay at Riggs for a month or two, a middle third for eight months, and a final third for one-and-a-half to two years in the various step-down programs.”
For Richard Munich, the challenge, when he was appointed medical director and chief of staff at the Menninger Clinic in 1997, was also to discern how to maintain institutional values while saving the institution fiscally. Changes came somewhat later to Menninger than to the other institutions because it had begun this period with a substantial endowment.
Munich reported that the leadership team and the board decided the best way to preserve Menninger's fiscal viability and clinical, educational, and research missions was to affiliate with a major medical center. A formal affiliation with Baylor University Department of Psychiatry and the Texas Medical Center in Houston
Marie G. Rudden, M.D., is an assistant clinical professor at Weill Medical College of Cornell University and on the faculties of the New York Psychoanalytic Institute and Society and of the Berkshire Psychoanalytic Institute, a new APsaA training facility, where she is also a training and supervising analyst.
was eventually negotiated and Menninger moved there from Topeka, Kansas. An informal relationship has also been created with the Houston-Galveston Psychoanalytic Institute.
Munich added other evidence-based treatments such as cognitive-behavioral and dialectical-behavioral therapies to the core dynamic approach: “We want to do everything that works for our patients.” Psychoanalytic psychotherapy, formerly conducted at Menninger four times weekly with every patient, is now offered twice-weekly to about half of all inpatients, with the option of increasing the frequency to three or four times a week if this is judged helpful to the individual.
The hospital has divided into six central programs. The Professionals in Crisis Unit, with an attachment theory-based psychodynamic orientation, treats professionals with dual diagnoses, mental illness, or character pathology that has significantly disrupted their professional lives. The Compass Unit offers intensive psychotherapy for patients in the age group of 18 to 30, who are complexly ill and have been treatment-resistant, but are not so much acutely ill as in need of substantial rehabilitation to redirect their lives. The Hope Unit treats patients with severe character disorders or psychoses with an array of treatment methods, including psychodynamic treatment and dialectical behavior therapy for those with para-suicidal behavior. The Adolescent Inpatient Unit offers three to six months of intensive psychoanalytic treatments, while the Eating Disorder and Obsessive-Compulsive Disorder units are structured around more behavioral approaches. Average stays at Menninger are six to eight weeks, and aim at offering consultation to the original outpatient therapists and discharging back to those treatments when possible.
When Steven Sharfstein became CEO of Sheppard and Enoch Pratt in Baltimore, he felt that his choices, given increasing operating costs, bleak prospects for extended inpatient treatment due to managed care, and increasingly costly regulations, were to either radically downsize from 320 beds and offer intensive inpatient care to a very small patient population or to alter the institution to “serve a community need.” A community psychiatrist but “fellow traveler,” who trained with psychoanalysts and had his own personal analysis, Sharfstein opted to “survive as an institution and fulfill a mission of providing excellent mental health care” to a larger community. Beds were initially closed, but later brought back as the institution diversified and became the largest mental health care provider in Maryland, offering special education programs, supervised housing for the mentally ill, outpatient day programs, and 254 inpatient beds spread over several campuses, with another 150 beds in general hospitals managed by contract. Average inpatient stays are 10 days, but three specialty units offer stays of two to three weeks. A “self-pay, longer term unit” and The Retreat, an assisted living facility, retain a psychoanalytic orientation but also offer other treatment modalities.
The continued commitment to providing psychodynamic treatment or at least toward stressing the value of excellent training in outpatient psychoanalytic therapy seems to result from the enduring presence of analysts and analytically trained practitioners on the voluntary faculties and staff at these institutions.
According to Steven Washburn, former service chief for Partial Hospitalization, McLean Hospital in Belmont, Massachusetts, has changed a good deal in the last 25 years in response to the pressures of the insurance industry to cut psychiatric treatment costs. The brief lengths of stay that are the current norm, aimed at stabilizing the patient before discharge for outpatient treatment, have resulted in a dramatic downsizing in the number of inpatient beds. He maintains that inpatient units for major mental illnesses now emphasize evaluation, pharmacotherapy, and supportive activities, though a few specialized units, such as that for Dissociative Disorders/Trauma, retain the original “sensitivity to relationships and to psychological structure.” Leonard Glass, an associate clinical professor on the voluntary faculty, observes that two adult units preserve a psychodynamic focus: Appleton House, which is “a three-quarter way house,” and the Pavilion Unit, a dynamically attuned ward for private-paying patients. John Gunderson heads a well-funded psychosocial research program that includes research on psychodynamic therapies and offers fellowships that can provide a path for psychoanalytically oriented trainees to learn research techniques.
Of interest is the fact that, despite the sacrifice of a core psychodynamic orientation at Sheppard Pratt and at McLean, trainees at these institutions seem to have more exposure to psychodynamic supervision than is the case nationwide. At McLean, according to Glass, psychoanalyst supervisors are in high demand with “a competition for senior analysts or exciting young analysts or candidates from the Boston Psychoanalytic,” and a number of psychiatric residents each year pursue psychoanalytic training. The training director of the joint University of Maryland/Sheppard Pratt Psychiatry Residency Training Program, M. Philip Luber, is a psychoanalyst, and senior analysts from the Baltimore-Washington and Washington Institutes supervise residents and teach part of the didactic program in psychotherapy. Luber asserts that “residents who come here know that this is a program that embraces psychotherapy, and in which there is no polarization among biological, psychodynamic, or community approaches.”
The continued commitment to providing psychodynamic treatment or at least toward stressing the value of excellent training in outpatient psychoanalytic therapy seems to result from the enduring presence of analysts and analytically trained practitioners on the voluntary faculties and staff at these institutions. Administrators and boards that remain knowledgeable about psychoanalytic therapies are also crucial to this commitment.