Four days a week, Rachel H. takes the
subway uptown, waves to the doorman in the large prewar apartment building where
her psychoanalyst keeps his office, lies down on a burgundy leather couch and
begins to talk.
Ms. H., a 33-year-old graduate student,
has heard all the jokes. She has listened patiently to friends who tell her
she would be better off taking Prozac or trying yoga or leaving New York altogether
to escape her obvious "dependency" on her analyst. She has endured
teasing and incredulity.
"Don't you think that's so last
century?" asked one woman.
Yet Ms. H. is not bothered by this
lack of enthusiasm.
After spending six years and about
$60,000 on analysis, she says, she is less self-destructive, more responsible,
more productive and more successful in her work. She has more compassion for
others. She understands, in ways that have grown more layered and complex, her
own strengths and limits and those of the people close to her.
In the last quarter century, psychoanalysis
has been declared dead many times over. Psychoanalysts, once dominant in psychiatry,
now stand on the sidelines of a field where drug treatments and brief forms
of talk therapy are the rule. Thanks in large part to Woody Allen, Freud's talking
cure has become shorthand for costly self-indulgence with no obvious benefit.
And many psychiatrists barely hide their disdain for what they regard as an
outmoded approach to treating mental disorders.
Yet thousands of Americans - it
is not known exactly how many continue to seek out psychoanalysis. Like Ms.
H., they believe that the arduous, uncertain and often emotionally painful dissection
of mental life such treatment entails offers something they can find nowhere
else.
"Obviously I think it's an incredibly
valuable thing that I'm doing. Otherwise, why would I do it?" said Ms.
H., who spoke on the condition that her last name not be used out of concerns
for her privacy.
"You have to see things for
what they are, and I think that's essentially all that it's about," she
said. "It's about lifting the veil, seeing relationships and seeing yourself,
so that you can begin to make choices that will not lock you into an unhappy
future and an unhappy life."
In its heyday in the 1950's and
1960's, psychoanalysis attracted a wide swath of the intellectual elite, along
with many middle class patients who, backed by generous health insurance plans,
were referred to psychoanalytic treatment as the best psychiatry had to offer.
Experiences on the couch, good or
bad, provided routine fodder for dinner parties. And the language of classical
psychoanalytic theory - the unconscious, the Oedipus complex, the superego and
the id became firmly embedded in the culture.
Yet most psychoanalysts now acknowledge
that analysis was practiced far too broadly and that its effectiveness, particularly
as a treatment for severe mental illnesses like schizophrenia and manic depression,
was greatly oversold.
"Many analysts thought that
psychoanalysis was the treatment of choice for virtually every mental disorder,"
said Dr. Kerry J. Sulkowicz, the chairman of the public information committee
for the American Psychoanalytic Association, which held its winter meeting in
New York last week. "We've learned that that's not the case."
Today, pharmacology and focused,
short-term psychotherapies predominate in the treatment of mental illness. Psychoanalysts
are more cautious about whom they will treat on the couch. And those who seek
their help represent a far smaller and more select group.
According to a survey conducted in
2001 by the psychoanalytic association, analytic patients in the United States
are typically well educated, well-off financially, white and 30 to 50 years
old. Some are mental health professionals, trying to understand themselves better
in order to better help their patients. But business people, artists, writers,
academics and others also find their way into analysis.
Many have tried other forms of talk
therapy and have been dissatisfied with the results. Some have taken, or continue
to take, antidepressants or other psychiatric drugs and have found that while
helpful, the medications have not solved their problems in forming intimate
relationships or in avoiding destructive behavior patterns. Still others remain
stubbornly committed to the notion that their emotional difficulties are rooted
in the unconscious rather than in the ebb and flow of brain chemicals.
"I had this really strong conviction
that my problems were psychological, and I wanted to deal with them psychologically,"
said Patrick Cody, 40, a communications consultant in Washington who spent 10
years in analysis, which he sought out after experiencing depression and severe
panic attacks.
In an era of managed care, most patients
pay out of their own pockets for their treatment, which typically involves three
to five sessions a week, at fees varying from $10 a session at a psychoanalytic
training clinic to more than $200 a session at a Park Avenue practice.
But time is often a bigger issue
than money.
"I don't have a problem with
patients' affording fees," said Dr. Henry Bachrach, a researcher and analyst
at the New York Psychoanalytic Institute. "But I can't get to see them
four times a week, because I can't ask them to give up their livelihood."
Hollywood portrayals to the contrary,
studies suggest that few people enter analysis for casual reasons.
In a 2002 survey of 342 American
analysts conducted by Dr. Norman Doidge, an assistant professor of psychiatry
at the University of Toronto, most said that many of their patients in analysis
suffered from multiple longstanding psychiatric disorders like anxiety, depression,
sexual dysfunction and pervasive personality problems.
About 80 percent of the 940 patients
reported on in the survey had received other treatment before analysis. Eighteen
percent were taking psychiatric medication.
At the same time, three-quarters
of the analysts' patients were steadily employed at the start of analysis, Dr.
Doidge found. And they were mentally tough enough to survive the rigors of treatment
on the couch an experience that bears some similarity to immersion in a sensory
deprivation tank and that Dr. Bachrach described as "putting you on the
stove and turning up the heat."
Psychoanalysis itself has undergone
profound changes in the last decades. In Argentina, France, Germany, Finland,
Canada, especially in Quebec, and other countries, Freud's legacy continues
to thrive. Psychoanalysts are held in esteem and patients are plentiful. In
some cases, the cost of psychoanalytic treatment is underwritten by national
insurance.
But in the United States, the scientific
and economic events that have transformed psychiatry have squeezed psychoanalysts
to the margins. Most analysts' caseloads include only a few full-fledged psychoanalytic
patients, the rest arriving once or twice a week for less intensive psychotherapy.
The American association, the largest
of the psychoanalytic organizations, counts roughly 3,500 members, 700 of them
in New York. The average age of the association's membership is 62.
Once rulers, analysts now more often
find themselves supplicants, mounting public relations campaigns to improve
their image and reaching out to attract more candidates for psychoanalytic training
and to forge better relationships with other psychiatric disciplines.
This is not always an easy battle,
as was evident in the focus groups assembled as part of a "strategic marketing
initiative" undertaken by the association in 2000. Asked to describe their
psychoanalyst colleagues, the mental health professionals who participated in
the groups used adjectives like "arrogant," "elitist," "uninvolved," "cultish"
and "insular."
The public was no more helpful. Freud's
name still rang a bell. But the marketing effort found that the only thing most
Americans knew about psychoanalysis was that it took a long time and that it
involved a couch. Asked what kind of mental health professional they might look
to for treatment, no one mentioned an analyst.
Still, much of the tarnish that clings
to psychoanalysis derives from an earlier time, when rigid neo-Freudian orthodoxy
was the rule.
"I think there's been a shift in
the last 15 years," said Dr. Robert Galatzer-Levy, an analyst in Chicago. "There
was a time that if people deviated from whatever was at that point standard,
they risked being thrown out of the analytic community."
Now, Dr. Galatzer-Levy said, "the
ideas get heard, they get discussed, they get debated, they are often integrated
with one another."
In fact, few analysts these days
adhere to a strict Freudian model, though most subscribe to the basic tenets
of psychoanalytic theory, including the importance of unconscious fantasies
and conflicts, the influence of childhood experiences, the centrality of the
relationship with the analyst as a replaying of other important relationships
in the patient's life.
Most talk to their patients, rather
than sitting silently. Many are willing to divulge information about their personal
lives: whether they are married, for example. Many exercise eclecticism in treating
patients, drawing upon different theoretical perspectives. And many endorse
the use of medication, in some cases prescribing it themselves.
At one time, analysts were required
to have medical degrees. But social workers, psychologists, art therapists and
other mental health professionals have now joined the ranks of those who pursue
the four years of training or more that becoming a psychoanalyst requires.
At its best, Dr. Galatzer-Levy said,
what analysis has to offer is change that is far deeper than what may be achieved
in the 6 to 20 sessions of therapy covered by most insurance plans, change affecting
"the way people think and feel about things, the way they act in the world."
Some of that change may take place
after the last psychoanalytic session has ended.
In one of the first tightly controlled
studies of the effectiveness of psychoanalytic treatment, Dr. Peter Fonagy,
a professor of psychoanalysis at University College London, found that adult
patients with borderline personality disorder, given psychoanalytic treatment
in a partial hospital setting, showed significantly more improvement than a
control group that received no formal psychotherapy.
But Dr. Fonagy also found that the
patients receiving psychoanalysis continued to improve in the 18 months after
the treatment, progress he believes occurs "when you face new problems and you
are then able to deal with them in a superior way."
Patients who have had good experiences
in psychoanalysis also describe substantial personal growth.
For Mr. Cody of Washington, the fruit
of his treatment has been emotional maturity, he said, a lessening of fear,
a greater ability to control his emotions, an ability to laugh off criticism
where he once would have rankled.
In his analysis, Mr. Cody said, there
were "periods of great stagnation but also periods of great benefits."
"There would suddenly be one session
where things popped open," he said.
"Every time that happened, I'd say,
`That's worth $3,000.' "
Ms. H. said that in the course of
her sessions on the couch she had examined every aspect of her life, from her
fears of abandonment to her perfectionism to her repetitive dreams of running
through city streets to save her brother from an attack by urban guerrillas.
She has learned, she said, that "the
truth is mutable, the story changes."
"You might hold your parents responsible
for some of your unhappiness and then later on that becomes incredibly unimportant,"
she said.
Yet Mr. Cody and Ms. H., like many
others in analysis, have moments of doubt and disillusionment, and lingering
questions that may never be fully answered: How much growth would have taken
place anyway, with time and life experience? How much of what has been accomplished
in 10 years could have been accomplished in 4 or even 2?
Dr. Doidge, in his survey, found
that the average length of analysis was
5.7 years.
In an address to the psychoanalytic
association last week, Dr. Owen Renik, a training analyst at the San Francisco
Psychoanalytic Institute and Society, said that keeping patients in analysis
"for years or even decades" when no improvement was taking place represented
an egregious - and common - ethical violation by psychoanalysts.
"Too many analysts keep too many
patients too long in treatment in the absence of any evidence that it's helping,"
Dr. Renik said later in a telephone interview.
Analysts, he added, often rationalize
why they are keeping a patient in treatment, but actually may be delaying the
end of the analysis out of a desire for financial gain, an unwillingness to
admit defeat or other unconscious motives.
Those whose time on the couch has
been less than positive could add other breaches to the list: Analysts so psychologically
damaged themselves that they make their patients worse, not better. Analysts
who allow the transference to become a pseudo love affair that replaces relationships
in the real world.
Analysts who are unable to admit
their mistakes
Dr. Bachrach of the New York institute said it was no surprise that analysis
could cause damage. "If it can do a lot of good, it can also do a lot of harm,"
he said.
Yet in a world of quick fixes and
glib explanations for human behavior, analysis still symbolizes a commitment
to complexity and deeper understanding.
"It is a question of values," Dr.
Bachrach said, "what you want and what you expect out of life."
Copyright 2003 The New York Times
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