Illustrations by Jason Novak
IN THE LAST five years, the American Psychoanalytic Association (APsA) leadership has taken dramatic steps to halt a long and steady decline in membership. At the beginning of 2023, a supermajority voted to loosen membership requirements while pushing for more inclusivity, for example, by opening up APsA committees to self-nomination. A serious obstacle to the organization's growth, however, remains the number and status of social workers in the organization.
The number of social workers in APsA remains astonishingly small at 8 percent, when social workers comprise more than half of mental health providers nationwide, according to the Bureau of Labor Statistics. Physicians still account for a majority of the membership at 62 percent as of 2019, the latest year for which figures are available.
I wish to protect analysis from the doctors and … from the priests. I should like to hand it over to a profession which does not yet exist, a profession of lay curers of souls.
Not all nonmedical clinicians have fared as poorly as social workers. The percentage of clinical psychologists, for example, has more than quadrupled since the late 1980s, when a lawsuit aimed at opening the APsA-certified institutes to clinicians outside the medical profession. Psychologists now account for over a quarter of members, which is triple the number of social workers. The number of social workers at most institutes remains minuscule compared to the number of psychologists and MDs.
Marginalized by APsA, many social workers have opted for non-APsA institutes, such as the Contemporary Freudian Society, and some formed their own association, the American Association for Psychoanalysis in Clinical Social Work, with its own conference and journal. Even though some participate in APsA's activities and publish in its journal, relatively few social workers have made the migration to APsA or its institutes now that they are officially welcome there. No masters-level social worker has ever held the presidency of APsA.
Given the sharp decline in the number of physicians who go into psychiatry—a 36 percent decline since 2011—and APsA's hunger to grow, the organization might want to tap social workers to bolster its ranks. The failure to attract a greater number of social workers up to now represents a significant missed opportunity for APsA and its network of institutes, as well as for the social workers whose practice could be enriched and supported by a greater connection to psychoanalytic ideas and institutions.
A BIT OF HISTORY It wasn't always this way. Social work actually represented one of the driving forces behind the growth of prewar psychoanalysis. A full two decades before the opening of the first training institutes in the US and the agreement that they would be limited to medical doctors, social workers were actively exploring the application of psychoanalytic ideas in work with juvenile offenders and “delinquent girls.” While American psychiatrists were routinely traveling to Europe
to learn how to apply the ideas of Freud and his followers to clinical work, as early as 1909 leading social workers were incorporating psychoanalytic ideas into their work and recruiting medical professionals, as needed, to advance their social welfare mission.
Psychoanalysis was also central to social science academics. Indeed, the very social scientists then considered the apostles of the new empiricism often embraced psychoanalysis, though that embrace is often forgotten or minimized. Prominent among them were sociologists like Ernest W. Burgess, an ardent exponent of the case history method of sociological research, and his colleague William Fielding Ogburn, who chaired the American Sociological Society and the University of Chicago's sociology department before chairing the board of the Chicago Institute for Psychoanalysis.
The most promising effort to integrate psychoanalysis with behavioral science, social work, and social science played out first and most prominently in Chicago, which was both the seat of Progressive Era reform and home to the University of Chicago, the leading social science research university of the time. People sometimes talk about psychoanalysis as though it's incompatible with progressive reform because the latter focuses on structural social problems while the former focuses on individuals' internal psychological conflicts. Some of the most pivotal social reforms and scientific advances of the Progressive Era, however, have a clear debt to psychoanalysis.
No institution did more to spread the ideas of psychoanalysis in social work than Chicago's Juvenile Court. Social workers eager to remake the system of juvenile justice devoured the works of Freud's criminological interpreters such as Austrian analyst and educator August Aichhorn and Berlin analyst Franz Alexander, who would eventually lead the Chicago Psychoanalytic Institute. Indeed, historian Nathan Hale called the Juvenile Court's Psychopathic Institute a leading center for the early recruitment of psychoanalysts in the US.
Influential Chicago social worker and philanthropist Ethel Sturges Dummer exemplified this integration of social work and psychoanalysis as a veteran of the both the YWCA movement and the Juvenile Court movement. From the earliest reports of Freud's visit to Clark University, Dummer took an expansive view of the relevance of psychoanalysis to social work, underscoring the value of Freud's theories for understanding and helping rehabilitate young women who engaged in prostitution—an issue that preoccupied the social work profession and social reformers in the post–World War I period. In her 1923 foreword to The Unadjusted Girl, the first major academic study of prostitution, Dummer displayed a nuanced understanding of Freud, arguing that “Freud's teaching of the danger of sex repression to mental health … would seem to explain much of the modern success in the rehabilitation of the young prostitute.” By the time the first psychoanalytic institutes in the United States opened in the early 1930s, alumnae of the Chicago efforts had spread to Philadelphia, New York, and New Haven, producing a flowering of interest in the application of psychoanalysis to social work.
Tensions existed between organizations focused on locating mental illness in individual sources and those sociologists and social workers like Dummer who focused on societal explanations. Nevertheless, the potential for collaboration was evident in the May 1930 National Conference on Mental Hygiene, a Rockefeller-backed effort that drew a who's who of social workers, scholars, philanthropists, and analysts. By many estimates, Franz Alexander was the toast of the group's DC event, from which he returned to find an invitation to join the faculty of the University of Chicago—where he would become the world's first university-based professor of psychoanalysis.
WHERE WE ARE NOW The collaboration between psychoanalysis and sociology would last only so long, however. A century later, the strong ties that leading academics and social
workers had forged were all but gone. Indeed, psychoanalysis has disappeared from the curriculum of many of the leading schools of social work in the United States, which prompted social work professor Jerrold Brandell to ask about the fate of psychoanalysis in social work academe, “Can this patient be saved?” Outside of schools explicitly focused on psychoanalytic social work, such as Smith College, graduate training in social work generally offers only a cursory exposure to psychoanalytic ideas. Some schools, such as the Jane Addams School of Social Work at the University of Illinois, explicitly exclude psychoanalysis as not “evidence-based.” Others relegate the courses to non-tenure-track faculty. For example, the two-course sequence on psychoanalytic therapy at the University of Chicago's social work school is currently taught by an adjunct faculty member. Continuing education programs rarely include developments in psychoanalytic thought and focus instead on interventions like dialectical behavior therapy (DBT) and motivational interviewing that have been successfully marketed as evidence-based.
As social work training has wandered away from psychoanalysis, APsA has done nothing to stem the tide, leaving a dearth of social workers in APsA membership and leadership and at APsA institutes. Outright exclusion, degree privilege, and differential pay scales contribute. Some leading training programs on the East Coast, such as Columbia's and NYU's postgraduate program, still do not even accept social work applicants for candidacy. Can the lack of a clinical doctorate continue to provide a compelling rationale for exclusion from university-based institutes?
Likely, the low levels of social work participation in APsA and leadership in its institutes also derive from economic barriers. The cost of training and foregone earnings associated with training fall disproportionately on social workers, whose pay is generally far lower than psychologists' or psychiatrists'. To attract more social workers into APsA, it may not be enough simply to open the doors to non-MDs as APsA did, because degree privilege has erected and maintained structural barriers to the inclusion of social workers in all areas of the community, as the findings of the recently published report of the Holmes Commission on Racial Equality suggest.
In a period of diminished interest in psychoanalysis among clinical mental health service providers, the marginalization of the single largest profession providing clinical services has left a significant resource untapped by APsA. If APsA intends to make good on its claims about inclusion, it will need to undertake a top-to-bottom review of the pipeline from candidacy to APsA participation with an eye to closing the gap between the potential and the actual engagement of social workers.
The most profound obstacle to attracting social workers to psychoanalysis may be the field's resistance to fully theorizing individual experience in the social environment—long considered social work's distinctive contribution. This resistance stifles serious exploration of the social surround—through more robust psychoanalytic study of topics such as race, class, and gender—across all aspects of institutional and intellectual life in psychoanalysis. Absent such an exploration, the long shadow of the Ferenczi controversy—the failure of psychoanalysis to account adequately for the real-life traumas experienced by patients—will continue to leave psychoanalysis and many of its institutes open to the criticisms that it is a treatment of and for the elite.
There seems to be some dawning recognition of the underrepresentation of social work in APsA and related institute leadership. APsA's affiliated institutes in particular have taken small steps to address the limited place of social workers in the community and the exclusion of the social surround in the psychoanalytic understanding of behavior. Programs and tracks in community psychoanalysis have surfaced in several institutes. Among the oldest American institutes, which opened in the 1930s, Boston and Chicago appear to have made the
most progress in the inclusion of social workers in leadership. Until recently, the Chicago Institute was led by social worker Erika Schmidt, and several social workers currently occupy leadership positions on the Boston Institute's board of directors, including the board chair. The Washington Baltimore Center, another member of the old guard, has a sprinkling of social workers in its executive leadership and on key committees. It even has a disproportionate number, roughly 50 percent, on its Admissions and Ethics Committees. Nevertheless, even there, social workers remain largely absent from committees related to the traditional concerns of psychoanalysis—supervision, training, faculty development, and curriculum.
Within APsA as a whole, the perceived need to address the marginalization of social workers has been faint but real. The organization has revived its Graduate Education in Social Work Committee, which promotes psychoanalytic education among social work students and licensed social workers in the community. This year, the committee announced its first-ever tuition support program for social workers interested in advanced training in psychoanalysis. It plans to award $750 to defray the cost of tuition for two early-career social workers enrolled in programs offered by APsA-approved institutes or APsA affiliate societies.
But social workers still remain largely invisible in APsA. So it is no surprise that their signature emphasis on the importance of the social surround in individual experience has been muted in recent decades. Although the Holmes Commission challenged the field to rethink the importance of the social surround in theorizing about individual emotional life and behavior, the Commission itself included only one social worker. APsA's June 2023 conference program, designed in part to stimulate conversation related to “the social,” included only one social worker in a program of some two dozen participants. Social work is the only clinical profession explicitly required by its code of ethics and its education to address the social dimension of emotional life. To rebuild the alliance between social work and psychoanalysis, more progress is needed.
“Within APsA as a whole, the perceived need to address the marginalization of social workers has been faint but real.”
Flora E. Lazar is a historian and psychotherapist who has spent her career at the intersection of research, public policy, and clinical practice. She has served on several APsA task forces related to psychoanalytic advocacy. She lives in Salisbury, Connecticut.