The American Psychoanalyst

Richard Almond, M.D., is a psychoanalyst practicing in Palo Alto. He is a training and supervising analyst at the San Francisco Center for Psychoanalysis, founder of its Palo Alto Psychoanalytic Psychotherapy Training Program, and written books on therapeutic community and literary characters.
rjalmond@stanford.edu

Richard Almond

The recent APSA pre-election online chat stimulated dozens of postings in response to the candidates’ position statements. Members wrote of deeply held views on how to define psychoanalysis, its organizational health and mission, its support of research, and its educational role. Reading these posts, I was struck by a paradoxical mix of anxiety about the future and strong member engagement. The thoughts that follow are those of a participant-observer. I will look backward and forward, and try to write from both my own experience as an analyst, and from outside, as I imagine an anthropologist might. In brief, I will say the opportunities for psychoanalysis are better than we think, our field has a uniquely important mission clinically and theoretically that we must find a way to carry forward effectively. I will also argue that organized psychoanalysis may require some dramatic changes in its form to survive organizationally.

Phillipe Pinel unchained the inmates of the Salpetriere in Paris in 1795, a moment that has come to epitomize “Moral Treatment,” the view that the mentally ill—the “mad”—should be regarded and treated as sufferers, not as oddities, threats, or outcasts. Moral treatment also stressed that, if treated humanely, with attention and conversation, many would recover. Numerous “asylums” from the stresses and abuses of home life were created, privately and then in new state hospitals; young, educated men were hired to talk with the sufferers and listen to their concerns.

Moral treatment prevailed for over fifty years. But in mid-19th century America, with rapidly growing urban populations whose sufferers often spoke little English, the new state hospitals could not keep up. The conceptual pendulum swung to diagnosis and classification. Neurology had new tissue stains offering mastery of mental illness via study of microscopic etiological agents in brain specimens. Warehousing of pathologies replaced the humanism of moral treatment.

Sound familiar? Since the emergence of psychoanalysis, we have been through a modern version of this cycle. Psychoanalysis was a leading force in the 20th century return to a humanistic view of mental suffering and psychic function. The decades 1920-1970 are often considered the heyday of psychoanalysis. Since then it has been under fire. Critiques abound—from the outside and within. Our numbers are down, our theories debunked, and our treatment disdained. Psychiatry offers medication; psychology offers “evidence-based” behavioral treatments. The pendulum has swung away.

Internally, our professional organizations have been slow to respond, and have been preoccupied with protecting the purity of our models, our specific technique, and existing power structures. Energy has gone into excluding rather than including. Like the decimated Native American tribes of the West who developed a “Ghost Dance” that claimed to protect them from bullets, we have focused on ever-newer models of mind rather than squarely addressing our professional and organizational challenges.

Most of us work in the cottage industry format of private practice; we spend our workdays in isolated, emotionally intense dyads. We are concerned about our standing in the professional and lay communities around us; our self-esteem and livelihoods are involved. We look to our psychoanalytic organizations for guidance and support—from the local study group to APsaA and IPA. For the most part analysts are not embedded in an organizational structure in the same way as academics or employees of other large organizations. There is no “boss” we report to, nor can we dictate to our peers how to work.

This difference has consequences for the sociology and politics of our relation to our professional organizations for a discussion like this of “Where are we going?” While we have organizational infrastructures—locally, nationally, internationally—participation is optional, and authority over members is minimal. The result is that statements we or others make, like “Psychoanalysis is defined by ———,” or “Psychoanalysis should be ———” are often shouts into the wind. A more sophisticated way of saying this is that as a field of treatment and study psychoanalysis maintains itself, and changes, through persuasion and charisma. We also yearn for a mythic idealized past time when Freud’s ideas were breakthroughs in broad ways and were culturally popular—The Triumph of the Therapeutic, as the sociologist Phillip Rieff titled his 1966 book. This nostalgia includes the societal prestige of analysis in academic and educated circles, as well as being the new cure in town, when the pendulum of neurology had reached its limit. Things have been going downhill for half a century from this golden time.

Despite all these difficulties, and the pessimism often expressed about psychoanalysis’ future, I believe there are indications of change:

In looking forward it may be useful to consider why our field should continue. Suppose there are 10,000 analysts of all stripes practicing nationally. We know from surveys that the mean number of analytic cases an APsaA member treats in psychoanalysis is one or two, but let’s say it’s two. Then there would be 20,000 people receiving psychoanalysis. If an average analysis takes five years, there are 4000 patients finishing treatment each year. That’s 0.0013 percent of the population. With such a small number we cannot make a public health claim for psychoanalytic treatment. Many hours of teaching time go into the training of each psychoanalyst. How do we justify our field? I suggest several answers to this provocative question:

Analysis is a wellspring of ideas. Innovations in psychotherapeutic technique and training ripple outward from analytic treatment and its clinical scholarship to a wider circle of analytically inspired therapies and therapists. Not only does that circle then affect far more patients, but those patients in turn are often themselves in a position to help and teach, so the sphere of influence widens. I think the widening circle accounts for the fact our tiny minority field is still on people’s minds a lot—think of New Yorker cartoons. And why is there a continuing market for debunkers of psychoanalysis if the field is dead?

More widely, the same is true for the world of ideas. Analysis remains an important body of thought, concepts, models of mind, developmental thinking. These ideas have relevance for the social sciences; for medicine, especially neuroscience; and for the humanities and performing arts, for business and organization theory. Freud modelled such interdisciplinary applications; the creativity of analytic thinkers continues to provide insights deepening these fields. In fact, it could be argued that analysis as an intellectual discipline is unique in its continued breadth in an era of specialization of knowledge and remoteness of clinicians from sufferers. Like medieval monks copying Greek and Roman texts, we are a living preservation of humanistic experience in a time of technology and short attention spans. And here is the value of including those who work in many adjacent disciplines, research and applied, in our organizations.

…. we are a living preservation of humanistic experience in a time of technology and short attention spans. And here is the value of including those who work in many adjacent disciplines, research and applied, in our organizations.

Analysts often refer to theory as though it embodies all aspects of our field. Unfortunately, we get into struggles over which theory model is the “correct” one, the true psychoanalysis. The anthropologist in me asks, “Why these sectarian differences when the subject is so complex?” Freud himself developed new models several times, so that what we think of as Freudian theory is an unintegrated mix of six or more concept systems. But we also know that from the earliest days, membership in the psychoanalytic group required staying close to Freud’s thinking. In other words, there is an illogic around our favored theories—we hew to them, while knowing others have the same loyalty to other theories. Battles have been fought; careers destroyed; major intellects banished. The bird’s eye view would say different theories privilege different aspects of mental function, that it’s the proverbial elephant. Or a religion/cult, where affiliation depends on doctrinal correctness.

Why this preoccupation with theory? In academia theories are debated as forays toward greater understanding of complex subject matters. I think our devotion to theory stems from the unique clinical/subjective/intellectual nature of our work situation. We analysts are human; working in isolated dyads in a fraught emotional atmosphere, we want the comfort of feeling we know what we are doing, and that what we are doing is right. We need to believe in what we do, a point that was made in 1961 by Jerome Frank in Persuasion and Healing. In a 2003 paper I argued that theory and the associated groups gathered around each theory provide a hold for this stress. I am struck at how often supervisees new to analytic work choose one technical idea, and then apply it to everything they hear from a patient. Yuval Harari in Sapiens writes that humans evolved the unique capacity for internalizing belief systems, and that this facilitated the development of civilizations. The effective function of groups too big for face-to-face coordination was enabled by this individual ability to hold a set of abstract beliefs. Such a system builds on the need for attachment; we abide by the group’s rules to feel accepted, safe, and supported.

Recognizing this important psychological function of theory may help us understand part of the current malaise among analysts and help us speculate about the future. In the mid- and late 20th century most American institutes taught some version of Freud’s last model, ego psychology. When other models appeared, there was schism and division. More recently there have been increasing calls for tolerance, pluralism, and modesty about theory claims. An unexpected and unintended consequence of this shift has been a decline in analysts’ sense of absolute conviction about theory. If we accept multiple models, do we really have a solid base of ideas underlying our work in the subjective hot house of analytic process? I have watched as the dominant model in my home institute in San Francisco shifted from ego psychology—which, interestingly, was interpreted in widely differing ways—to the ideas of Neo-Kleinians, then Bion, Lacan, Winnicott, Barangers, Ferro, Civitarese, and so on. Each helped describe and elucidate particular clinical phenomena; each enabled particular clinical guidance for living out the analytic role. I wonder whether this sort of evolution reflects a wish for certainty through affiliation with Freud redux, a yearning for the time when psychoanalytic theory was the new and powerful kid on the block. We want to be in that kid’s gang, but we know too much.

Thomas Kuhn’s idea of theory cycles has been over-used, but something like that seems to apply. We are in a phase of multiple theories, of “theory crisis” in Kuhn’s language. We doubt that any of our models will suffice. Kuhn says such a situation then awaits a new sort of theory that seems to explain all present anomalies, but that such scientific revolutions are painful, with casualties.

Here is my guess about the future of theory. It comes from two directions. First, process research indicates the importance of a trusting attachment for good outcomes. Freud’s “unexceptional positive transference,” or the “therapeutic alliance” crucially enables the other processes that influence patients in a positive direction. In other words, the dyad’s capacity to create a secure process is a sine qua non of change. “Attachment; alliance; dyad”—all two-person terms. Second, all models of mind seem to move from the intrapsychic toward the issue of relatedness—whether Freud’s transference, John Bowlby’s attachment, Heinz Kohut’s selfobject, Thomas Ogden’s analytic third, or relational theory’s intersubjectivity. Freud himself said, “in the individual’s mental life someone else is invariably involved, as a model, as an object, as a helper, as an opponent; and so from the very first individual psychology … is at the same time social psychology as well” [italics added] (Civilization and its Discontents).

My guess then is that the next phase in psychoanalytic theory will be about the psychoanalytic social unit. Beatrice Beebe’s APSA presentations of infant-mother micro-interactions have overflow attendance; attachment theory has been readmitted. Despite the gap between such data and the adult clinical situation, many seem to recognize the power of the dyadic interplay—that it shows the impact of early relational experience but also models the clinical situation. The additional links with neuroscience via functional MRI studies may ground us further. Whether my hunch is right or not, we await consensus on a new paradigm, an umbrella under which most of us can gather.

Some will protest, “This isn’t psychoanalysis anymore!” That is the pain of scientific revolution. We will have to move beyond the idiosyncratic languages of the multiple schools of thought. We will always have a base in our ideas of mind, conscious and unconscious, driven and object-related. Perhaps colleagues from social psychology and anthropology will help us conceptually, which is more reason for outreach.

Parallel with theory angst is organizational angst. Appropriate in an organization where the average age is around 70, where numbers are dropping. Yet if I am right that the pendulum is swinging back to our side, the future should be bright. Before speculating on how psychoanalytic organizations may evolve, I will comment on some aspects of the whole project that Freud began. In the late 19th and early 20th centuries intellectuals were less specialized. Yes, there were scholars of arcane subjects, but people in any field had broad interests and knowledge. Freud was excluded from an academic professorship, but not from thinking widely, not from attracting a bright, off-beat group of followers. Treating patients was a way to earn a living, but writing about the mind, and about application of his ideas was Freud’s primary mission. This tradition is reflected still in our journals and APsaA meetings. Nevertheless, the power center of our professional organization has tended towards the values and practices of a guild, an evolution described by the sociologist, Max Weber, as “the bureaucratization of charisma.”

Freud complained about Americans’ preoccupation with money. While I don’t believe that many analysts are in it just for financial reward, priorities are different now. The analytic movement is no longer a radical, bohemian outpost. While the choice of an analytic career still involves massive personal sacrifice, most of us want a secure life. The result is, as many have pointed out, that our organizations have tended to be cautious about change, protective of the status quo. National meetings do include a wonderfully wide range of topics, but the organizational power structure has reflected abstract ideas of purity via “standards,” and practical control by a minority (BOPS, TA’s, etc.). Otto Kernberg, Kenneth Eisold, Robert Wallerstein, and others have made this critique, and proposed organizational and educational changes. Until recently such changes have been largely resisted, and adherence to largely untested theoretical and clinical beliefs has been a way to limit membership and exclude differentness.

…we may be at the brink of a major revision of the organizational style and mission. Suppose APsaA defined membership by interest in a range of ideas.

Exclusion has taken its toll. We all know the sad history. But the hopeful signs I listed above suggest we may be at the brink of a major revision of organizational style and mission. Suppose APsaA defined membership by interest in a range of ideas. Suppose we treated psychoanalytically informed activity like psychotherapy, other kinds of clinical work, and intellectual scholarship as equally legitimate for purposes of practice, education, and research? Suppose instead of 3,000 members paying $1000 annual dues we had 20,000 members paying $250? Suppose APsaA was able to value equally traditional 3-5 x per week treatment and less frequent treatment conducted with awareness of psychoanalytic processes? Suppose we were to welcome students, non-mental health professionals, law enforcement, scholars, and so on as equal members?

It would take time to overcome the enmity analysis has incurred by excluding, by its claims to specialness and superiority, but gradually our organizations would be revitalized with clinicians and many others who find the ideas and techniques useful. Several institutes and centers have begun such shifts in emphasis already. A major redefinition of membership and mission at the national level, already begun with limited steps, would enhance the regional vitality of organized psychoanalysis, while promulgating the wider project that Freud began. It will always be important to support the solitary work of individual practitioners and to recognize the contribution of those who are deeply devoted to traditional analysis. They have been our Levites and Kohans, our priesthood, carrying the educational mission and maintaining confidence in psychoanalysis’ importance. What I am talking about here is a shift in an enduring balance between two aspects of organized psychoanalysis that have always been there.

Finally, I must admit I cannot predict whether or how such a change could happen. It is possible that APsaA must burn so that something new can rise from the ashes. Or APsaA might adapt, as it often has, through a process of incremental re-formation. For the latter to work we have to consider important relationships both upward with the IPA and downward with local member organizations. And, again, the crucial organizational level is the individual, whether in practice or in some other setting, who will or will not become part of a changing future.