A New Initiative for Psychoanalysis

Marvin Hyman Ph.D.

Nothing that I have read or heard in recent months leads me to be optimistic about the near term or long term future of psychoanalysis as one of the health care professions, nor indeed, as a professional and academic endeavor of any kind, within or without existing professional groups. It seems to me that it is a relatively common occurrence for the analytic practitioner to hear psychoanalysis disparaged as a treatment, denigrated as a theory of human mental function, and devalued as a means of access to important information about the emotional lives of individuals. This disparagement of psychoanalysis is not limited to professional and academic discussion and debate; it has also been the subject of newspaper and magazine articles and reviews (not to mention cartoons), most of which are, at best ridiculing, and at worst, labeling of psychoanalysis as quackery.

Over the past century, psychoanalytic practitioners have survived such assaults on their practice and theory by both so-called colleagues and the popular media. Both practice and theory have survived these attacks by having ignored the critics and by letting psychoanalysis prove its worth in the consulting room and in the laboratory. In recent years, however, psychoanalysts' confidence in what they do has eroded significantly. In my view, this is a direct consequence of analysts trying to define their professional work as a "health care activity" and by trying to get other segments of the health care industry to accept that definition. Increasingly, these efforts to be included in the health care system have failed. Yet psychoanalysis continues to strive to have its theory and practice adopted by third party payers so as to be authorized to qualify for health care fee reimbursement.

I believe the cost to the integrity of the psychoanalytic enterprise because of this effort has been considerable and that the cost is escalating. Specifically, as psychoanalysis continues to offer itself for virtual enslavement to third party payers, and, as third party payers continue to reject the offer, psychoanalysts have increasingly begun to question both the value of their work and the enterprise in general.

Among the criticisms of psychoanalysis that are frequently heard by the analytic practitioner regarding analytic practice are the following:

Psychoanalysis takes too long. Psychoanalyses cannot be completed in six (or ten or twenty) sessions. Psychoanalysts want to meet too frequently with the patients. There is no outcome research to prove its effectiveness. It is not specific to the removal of the presenting complaint. Very importantly, with the current emphasis on cost containment, there is a lengthy series of criticisms to the effect that: Employers and other purchasers of health insurance do not want to include psychoanalysis as a benefit for which the insurance company will be the third party payer. Lastly, psycho-analysts are seen as those who resist managed care and utilization review procedures as unwarranted intrusions into the therapy situation, claiming them to be detrimental to the work and not in the best interest of the treatment. Analysts are thus accused of preventing the care manager from ascertaining whether or not the therapy is "appropriate" or "cost effective". Psychoanalysts tend to resist writing treatment reviews both because writing such reviews is extraordinarily time consuming, and, more importantly, because such reviews are believed to be irreparable violations of the confidentiality which is so necessary a part of the psychoanalytic situation. In sum, analysis is not brief, valid, or "cost effective", and psychoanalysts are not cooperative and sympathetic to and compliant with the profit making and technocratic concerns of insurance companies and other third party payers. For such reasons, third party payers are not willing to include psychoanalysis as a part of the health care delivery system as the system analysts have defined the criteria for inclusion.

To these and other such criticisms, psychoanalysts, individually, as members of psychoanalytic associations, and/or as part of other health care organizations, e.g., psychology, psychiatry, social work, seem to be pleading guilty; and not with pride but with contrition. Psychoanalysis is presenting itself as though the criticisms are valid and that, in return for third party reimbursement, it will mend its excessive and inefficient ways and conform to the requirements and demands imposed by the governmental and other developers of health care delivery systems. Further, psychoanalysis seems ready to invest enormous sums of money and other resources in continued efforts to persuade the powers-that-be to admit psychoanalysis into the reformed health care system. The cost to the theory and practice of psychoanalysis for admission to the system would be great: A conceptual diluting of the essential definitions of psychoanalysis. As entry into the system continues to be denied, many psychoanalysts seem to begin to question the worth of what they do based on the conviction that if third party payers won't pay for it, it can't be worth anything.

It may be that I am unduly pessimistic and that in the forseeable future psychoanalysis will be admitted into the health care system as a psychotherapeutic modality for which third party payment is justified. And, further, that compromises will not have to be made in the essential features of psychoanalytic therapy. Even if that extremely unlikely prospect comes to pass, it would not obviate the need for the initiative I would like to propose for our consideration.

My proposal is that psychoanalysts, individually and collectively, undertake to invest a substantial portion of their monetary and other resources in the implementation of a new, two-part, initiative for psychoanalysis. The first part of that initiative would consist of systematically informing ourselves and others of the worth of what we do as psychoanalysts. We have to make psychoanalysis once again the topic of informed discussion, debate, conversation, and excitement that it was in the 1920's and 1930's, before it got organized, bureaucratized, politicized, and medicalized. We could be writing articles for newspapers and magazines describing and extolling psychoanalysis in terms that can be understood by everyone. We could be offering our consultation to the film industry like Zilborg did when he consulted on the film "Spellbound". We could be helping television understand and portray psychoanalysis in terms that are accurate and even, when appropriate, help them make parody funny rather than destructive. The ways in which we can work to make psychoanalysis, as we define it, appreciated by our society are limited only by our ingenuity and the amount of effort and resources we invest.

The second, and perhaps more important, part of the initiative consists of organizing a systematic search for the ways and ideas to place psychoanalysis as a profession outside of the health care system and outside of the professions allied with that system. How long can we continue to perceive ourselves and act as if we are a sub-specialty, neglected and maligned, of psychology, psychiatry, social work, or nursing? Is this our only hope of survival? Perhaps we can begin to consider the heretical notion that there are other professions than the four just listed upon which we can model our profession: e.g., law, accountancy, architecture, art, even perhaps, religion. None of these, for the most part, rely on third party payers for its definition and legitimacy.

In effect, I am proposing that we initiate a search for a professional identity that defines psychoanalysis as an enterprise in which the parameters are constructed only by the participants in that enterprise and for which only those participants have responsibility. Psychoanalysis would be defined as an endeavor in which the participants do with each other instead of a situation in which one participant does to and/or for the other. One possible outcome of such a collaborative effort on the part of members of our Section would result in psychoanalysis being conceptualized as taking place within a consultation model, rather than within a treatment (medical) model.

To the degree we change sufficiently society's current automatic rejection of psychoanalysis and its value, and to the degree we can change our view of ourselves from health care providers to, say, consultants, to that degree can we introduce into the psychoanalytic enterprise respect for our consultees (not patients), respect for ourselves, and respect for our services. With such respect, useful and meaningful contracts for services, including payment therefore, can be arranged between provider and recipient, both of whom recognize the value of the work they are doing together.

I anticipate that what I have written will be condemned and or dismissed as playing into the hands of our enemies who will be only too glad to read it as affirmation of their criticisms of psychoanalysis and justification for drumming psychoanalysis out of the health care system. Also, there will be those who argue that this is no time to be diverting even a part of our resources, all of which, they claim, are needed to argue and promote psychoanalysis into the health care program. And finally, I think there will be the argument that psychoanalysis is expensive (which it is) and therefore will be available only to the rich, as though clinics of psychoanalytic institutes and other such training facilities have not been offering psychoanalysis at low cost for decades. Because of these and other objections, we are being urged to maintain the status quo and to petition for whatever form of corrupted psychoanalytic treatment we can be allowed. Looking back over the past months and years, however, leads me to believe that we better not place all of our eggs in this one basket, assuming that we so decide. We better have an alternate, perhaps preferable, position into which to move, whether in the form of this proposal or some other. That we have to do so is, I believe, self evident; we can do no less if we wish to preserve the integrity of psychoanalysis as a theory and practice.

This article was originally published in the Round Robin, the newsletter of  Section I of the Division of Psychoanalysis of the American Psychological Association.  It is reprinted here with permission.

Dr. Hyman has recently retired from his private practice in psychoanalysis and from his post as Associate Professor in the Department of Psychiatry and Behavioral Neuroscience at Wayne State University School of Medicine.  He has been president of the International Federation for Psychoanalytic Education, the Division of Psychoanalysis (39) of the American Psychological Association, the Michigan Psychological Association, and the Michigan Society for Psychoanalytic Psychology.  He is the co-author, with B.F. Auld, of Resolution of Inner Conflict:  An Introduction to Psychoanalytic Therapy, published by the American Psychological Association.  Dr. Hyman was a founding member of the Academy for the Study of the Psychoanalytic Arts and is current chair of its Lexicon Committee.

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