Psychoanalysts practice more psychotherapy than psychoanalysis and many of our societies and institutes now sponsor psychotherapy training programs. Yet our stance toward psychoanalytic psychotherapy remains highly ambivalent. Our neglected stepchild is still considered “what is not psychoanalysis.” How did such a situation develop, is it a major obstacle to the future of our discipline, and what can we do about it?
Following World War II, a crucial debate between William Menninger, on one side, and Ives Hendricks and Bertram Lewin, on the other, established the status of psychotherapy in APsaA. Menninger suggested that because many physicians returning from the war would be seeking training in psychotherapy, an opportunity was presented for organized psychoanalysis. Hendricks and Lewin countered that addressing this need would dilute psychoanalysis and argued that a firm line should be drawn between the two types of therapy. The Hendricks-Lewin position prevailed; Freud's metaphor of the “pure gold” of psychoanalysis and the “lesser alloy” of psychotherapy became institutionalized within APsaA.
Henceforth psychoanalysis and psychoanalytic psychotherapy followed separate pathways. “Dr. Will” returned to the Menninger Clinic, one of the first of many first-rate departments of psychiatry. In the 1960s, as psychoanalysts faced further competition from newer psychotherapies and psychotherapists, the differential “branding” of analysis and psychotherapy was felt to be not only scientifically, but also economically and politically, essential for the future of the profession. However, because psychoanalysts occupied key positions in educational and training institutions, the connection between the two disciplines remained close, albeit ambivalent.
Since then the shift in emphasis to psychopharmacology and to briefer and more behaviorally oriented psychotherapies has undermined this affiliation. Our relations with other disciplines have been weakened, depriving young professionals and students exposure to psychoanalytic understanding. This in spite of the fact that psychotherapy, rooted in an analytic understanding of character and treatment, remains an important if not critical treatment modality for a wide range of patients.
Our relations with other disciplines have been weakened, depriving young professionals and students exposure to psychoanalytic understanding. This in spite of the fact that psychotherapy, rooted in an analytic understanding of character and treatment, remains an important if not critical treatment modality for a wide range of patients.
More recently some of the old divisions have come to be challenged. Many of our psychoanalytic societies and institutes have initiated psychotherapy training programs and APsaA instituted a category of affiliation for psychotherapists. The Menninger-Lewin/Hendricks debate of 50 years ago is being quietly reconvened but the “upstairs-downstairs” hierarchy endures. Psychotherapy faculty, graduates, and students still face second-class status compared with their institute colleagues with whom they share a psychoanalytic orientation.
APsaA launched a “psychotherapy initiative” and appointed a Task Force on Psychotherapy to reconsider the place of psychoanalytic psychotherapy within our discipline and institutions. At a panel in Seattle on this topic, sharp divisions of opinion were voiced between those who drew precise boundaries and those who conceptualized a continuum. One panelist said that analysis is the treatment of choice for most patients and anything less is preliminary to full analysis. Another panelist suggested any divisions were purely arbitrary and basically politically motivated. A third compared the difference to that between a pencil or charcoal sketch and a textured oil painting. Each involves related but different media and techniques, but both are worthy of detailed study in their own right.
The question remains as to how to integrate as well as differentiate between these two forms of treatment flowing from the same scientific source. Can the two therapeutic modalities be integrated without compromising the uniqueness of traditional psychoanalysis? What do analysts actually do when they conduct psychotherapy? Are there real differences between psychotherapies conducted by analysts versus therapists not analytically trained or between individual analysts? These kinds of studies about technique are possible without the addition of value judgments. It is past time for this work to be done if we are to reclaim one of our most successful achievements.
Currently the task force is working at an operational level to break down old barriers and to develop new opportunities. We have focused on four related areas to promote the profile of psychotherapy in APsaA and to re-establish communication with clinicians and students from neighboring disciplines.
Richard P. Fox, M.D., is chair of the Task Force on Psychotherapy and former APsaA president.
With the assistance of the Program Committee, we aim to promote psychotherapy as a topic for scientific study and discussion. At the scientific meetings we sponsor workshops on training, regular two-day clinical workshops, and several ongoing discussion groups on psychotherapy and supervision. We hope to encourage the submission of more papers devoted to these topics. In addition the task force publishes a bimonthly e-newsletter that highlights the scientific program and other items of interest to those who conduct psychotherapy.
Within the organization the Psychotherapist Associates that numbered 139 when the group was formalized in 1999 has grown to about 350 active and involved members. This group forms the core of our evolving initiative. The task force also promotes the development and growth of similar affiliations in local societies thereby providing a home for many practitioners who seek greater involvement with psychoanalysis. The Committee on Societies (COS) is helping us acquire further information on the status of psychotherapists in local societies.
The psychotherapy training programs sponsored by our societies and institutes vary widely in their duration, intensity, and requirements. The task force conducts an ongoing psychotherapy training workshop where faculty members can meet and discuss shared problems and solutions. New programs can turn for assistance to those who have built established programs. An ongoing topic at these workshops is the ambivalence encountered by psychotherapy programs. It is reassuring to learn from well-established programs that with sufficient time and longevity these prejudices tend to melt. In the meantime, however, we are concerned about what happens to psychotherapy students and graduates.
One of our biggest challenges has been confronting the breaches between analysts and non-analytic groups and practitioners. Institutional resistance has become entrenched and attempts to develop liaisons with departments of psychiatry, psychology, and social work have proven difficult and of limited value. On the other hand, working on an individual basis, we find eager partners, practitioners, and leaders interested in promoting the cause of psychotherapy and who share our interest in restoring its connection to psychoanalysis. By including “outsiders” in our workshops, discussion groups, and task force, collaborative relationships are developed and our goals find meaningful expression. This “big tent” approach, which is reopening doors closed for many years, is fostering fluid relationships with individuals and groups that, in the past, were beyond the analytic pale. This direction has been greeted with new enthusiasm and excitement. Our challenge is to make distinctions between these therapies while continuing to integrate the therapists!