The Future of Psychotherapy, Part 1
There is both great pleasure and a real sadness in writing this chapter on the suggested topic, ‘The Future of Psychotherapy’. The pleasure is simple and deep in that it provides an opportunity and a forum to address my colleagues with my convictions about the central passion—as well as central intellectual interest—that has guided and motivated my career as a psychiatrist and psychoanalyst over more than four decades and my views on the possibilities for preserving that central position for the like-minded colleagues who I hope will continue to seek out and pursue similar careers within psychiatry. The sadness is linked to the felt need to have to address this topic under the title ‘The Challenge for Psychoanalysis and Psychotherapy’ that we must also consider the negative possibility of a diminished and/or problematic future—perhaps, in extreme, the question of how best or even whether to try to preserve an endangered species (a soon to be anachronistic enterprise which once had its then appropriate day in the sun).
In fact, it is the very fact that we are having to address this topic with the range of manifest as well as tacit questions that I have just alluded to that bespeaks the enormity of the sea-change in the psychiatric enterprise over the years of my formal involvement
in the field, since 1949—in the immediate aftermath of the Second World War—to be exact. At the time I entered formal psychiatric training, on 1 January 1949, a paper on my topic today would have been either totally gratuitous—that is, unnecessary—or, if given, be the occasion for an utopian vision of ever-expanding human melioration and betterment as more therapists were trained and became available and more individuals became sophisticated to the role that therapy could play in resolving their emotional and behavioral distress and enhancing their lives.
In effect, psychotherapy was then—in 1949—taken for granted as a human good, in the sense of being the road to the treatment of mental disorder and disturbed behavior and, therefore, the overwhelmingly dominant learning goal of those who sought speciality training in psychiatry. There was, of course, a nation-wide network of state hospitals housing the chronically and severely mentally ill, the openly psychotic, often for years and even lifetimes, but it was not uncharacteristic for four physicians to be employed in such mental hospitals for up to 4000 patients—a ratio of 1000 to 1—and they were not regularly psychiatrically trained. In fact, they often were older pre-retirement general practitioners or physicians, sometimes foreign educated, who had difficulties in obtaining state licensure for private practice. These state hospitals were usually, and by design, removed from the major population centers and they attracted very few of the yearly quota of psychiatric residency graduates. Psychiatric units in general hospitals (and in major urban centers), of which that at Michael Reese Hospital in Chicago was an early exemplar, were just beginning to be established in the immediate post-war years. And the same was true of the academic departments of psychiatry in the country’s medical schools and their associated teaching hospitals. This was the period that consolidated the establishment of separate departments of psychiatry as major departments in our medical schools, with the usual progression being from combined departments of neuropsychiatry, with the last such combined department existing even into the 1950s or 1960s at the University of Wisconsin, or the less frequent separation—off into a separate department of the division of psychiatry from among the other speciality divisions of the department of internal medicine, the last such separation taking place at the University of Chicago in the 1950s. All these still fledgling departments of psychiatry had very small full-time academic cores to begin with and the formal psychiatric research enterprise was, essentially, still unborn.
Rather, the expectation of the beginning psychiatric resident of that early post-war era was to learn dynamic psychiatry, meaning psychoanalytic theory—that is, a psychoanalytic conception of human growth and development and its varying deformations into psychopathology and then the psychoanalytic psychotherapy fashioned to address that range of psychopathology, all euphemistically under the banner of ‘psychodynamics’. This was all given its official psychiatric imprimatur in the very influential 1952 NIMH-supported American Psychiatric Association Conference on Psychiatric Education held at Cornell University under the leadership of John Whitehorn, himself not at all a psychoanalyst but one of that outstanding generation of Adolf Meyer-trained psychobiologist chairmen, psychobiologist in the then Meyerian sense and not at all in the current sense of grounding in neuroscience and biological psychiatry. In the book of proceedings of that conference edited by a committee under Whitehorn’s chairmanship, the chapter on ‘The Role of Psychoanalysis in Residency Training’ stated in the very first paragraph that ‘it is now almost universally agreed that a necessary part of the preparation of a competent psychiatrist is the development of an understanding of principles of psychodynamics’ and that ‘it seems obvious that an understanding of psychodynamics presupposes—indeed, necessitates . . . knowledge of Freudian concepts and of psychoanalytic theory and practice’.
This agenda was very congenial to the large numbers who flocked to psychiatric training in the wake of their wartime experience. Many were an older group, medical graduates of the 1930s who were swept into wartime military service after but a few years of general medical practice, who, because of the army’s voracious needs for an insufficiently existent psychiatric manpower, were converted via three-month-long indoctrinations into army psychiatrists sent to cope with the vast numbers of wartime psychiatric casualties, the so-called traumatic war neuroses, the heirs to the shell-shocked psychiatric victims of the earlier First World War and the predecessors of the newly christened post-traumatic stress disorders (PTSD) of the Vietnam conflict. It was these wartime psychiatric practitioners with only minimal formal psychiatric training who emerged from the army, so many of them in pursuit of the then model of psychiatric training grounded in the theory of psychoanalysis and its derived technical interventions, including the hypno- and narco-analytic techniques and brief crisis-oriented interventions that had worked so stunningly on the battlefield. They sought a more comprehensive grounding in psychodynamics in preparation for the private practice of dynamic psychiatry in the nation’s large urban centers where the most motivated and ambitious would, in addition, swell the ranks of candidates in the then rapidly expanding and proliferating psychoanalytic institutes. In the country’s largest psychiatric training center, the Menninger School of Psychiatry, where, in the late 1940s, 100 of the country’s then 800 psychiatric residents were being trained—one in eight in the country in that one small town—40 of the 100 applied simultaneously to the Topeka Institute for Psychoanalysis which strained to accept 8 to 10 when it had been thinking to take only 4 to 5. Most of those turned down scattered to apply elsewhere over the country, some bearing letters of rejection that gravely informed them that they ‘had talents in other fields’. Incidentally, that was the period when, in response to this overwhelming demand, the modal frequency of psychoanalysis in the United States switched from five to four times weekly on the basis that in each 20 hours of psychoanalytic work five rather than only four patients could be seen.
But, to stick to my main theme: the nature, the context and the conditions of psychiatric training when I turned up in Topeka in 1949 as one of its residents among the 100. Though this may be in some sense too categorical and sweeping a statement, I think it by and large true that the theory of psychoanalysis and its application in psychoanalytically informed and guided psychotherapy represented almost the totality of what was taught and learned. At the time, psychoanalysis was the prevailing psychology of psychiatry. The competing behavior modification paradigm based on academic learning theory psychology was in its earliest therapeutic beginnings mainly in academic psychology settings. And the client-centered Rogerian approach, which has never made a real inroad into psychiatric thought and practice, existed likewise mainly in clinics attached to clinical psychology programs in graduate psychology departments.
Contemporary neuroscience and the current explosive growth of molecular biology and molecular genetics were still part of an unknown future and the array of somatic therapies available in psychiatry at the time comprised only electroshock for psychotic depressions, insulin coma and subcoma—primarily for chronic severe schizophrenic illness—with the ill-starred lobotomy operation available for the even more intractable psychotically disabled, malaria therapy for neurosyphilis and a variety of sedating and soporific medications—primarily chloral hydrate, bromides and barbiturates, with all the potential for barbiturate abuse and addiction and for bromide poisoning from prolonged administration—plus such nursing measures as warm sedative tubs and cold sheet packs as general aids in the management of the overexcited and unruly. The contemporary era of psychopharmacology with its panoply of psychoactive drugs neuroleptics, anxiolytics and antidepressants—did not begin until 1954 with the introduction of the Swiss drug Largactil to the United States by way of Canada marketed by Smith, Kline and French under the trade name ‘Thorazine’. And to complete this catalogue of the then available psychiatric services and armamentarium, though there was an emergency room to be covered and a range of psychiatric consultations on the general hospital medical and surgical wards, there was no established Psychiatric Emergency Service or Consultation-Liaison Service in anything like the contemporary sense, nor were there specialized geriatric or substance abuse or forensic services with their specific clinical populations and their own bodies of theory and focused interventions.
What there was then at that time in psychiatric residency training, and as I have said, as almost the totality of it, was seminar instruction in psychodynamics and psychopathology with their applications in psychoanalytic psychotherapy—and almost all of that individual psychotherapy with some adjuvant teaching of hypnotherapy (still in use)—and group therapy—mostly faute de mieux—to help deal with the suddenly rapidly swelling mental hospital population especially in the newly opened network of VA Hospitals taken over from wartime army general hospitals to accommodate the influx from the continuing psychiatrically disabled among the 10,000,000 demobilizing service personnel. What this meant for the average psychiatric resident in the then three-year residency programs—after a separate rotating internship year—was a 40-hour scheduled work week with the expectation of 20 hours minimum for individual psychotherapeutic work with patients. The other 20 hours per week was consumed, probably more than consumed, by individual supervision for 3 or 4 hours, paperwork, general ward duties, the processing of admissions and discharges, meeting with relatives, perhaps some work with groups, one or two, and anywhere, depending on the program, from 5 to 10 seminar and lecture hours—the concept, pioneered by The Menninger Foundation—of the psychiatric residency as a School of Psychiatry making up what the medical school had failed to teach of psychiatric theory and practice. A minimum of 20 hours of individual psychotherapeutic work for up to 50 weeks a year was close to 1000 hours of individual psychotherapy experience, which, multiplied by the three years of residency, meant that the psychiatric resident of my vintage logged around 3000 hours of psychotherapy during the residency training period. The only significant difference among the three residency years was that in the first year of primarily inpatient service the psychotherapeutic work was with the hospitalized psychotics—who in those days were hospitalized for months if not years and available for efforts at intensive psychotherapy along with the ECT or insulin coma that some received (and here the writings of Frieda Fromm-Reichmann and Harry Stack Sullivan and John Rosen in America and, in Europe, of Gertrud Schwing and M. A. Sechehaye and, among the British Kleinians, Herbert Rosenfeld served as inspiring and inspirational guideposts)—and in the next two years of primarily outpatient service the work was with ambulatory neurotics in the classical mold of the psychoanalytic psychotherapy identified in the writings of that time with the names of Knight and Gill and Bibring and Rangell and Stone. And for that minority that went on into child psychiatry fellowship training there was a gradual shift to include an increasing number of children and adolescents into the treatment mix.
Given an ‘average expectable’ diligence, intelligence and talent on the part of the resident, the psychiatric residency program of that day could graduate its trainees reasonably confident that they were equipped to practice a reasonably competent brand of primarily outpatient psychotherapy in the private practice market. And many, of course, used their residency training as prep schools for the psychoanalytic institutes in which they sought candidacy while pursuing their careers as dynamic psychiatrists practising analytic psychotherapy. And in those days, of course, there was a widely receptive market of available and waiting patients eager for their services. There were few other mental health practitioners in the private sector. Clinical psychology as a professional discipline was in its infancy with the very recent proliferation of clinical psychology training programs under combined university and V A Hospital auspices, with the VA eager to offer internship and postdoctoral fellowship experiences to psychologists who could then be enticed into the VA jobs dealing with the large numbers of hospitalized neuropsychiatrically impaired veterans—jobs with psychiatrists, intent on the private market, were more reluctant to take, at least not in anywhere near the numbers needed. Some few clinical psychologists were starting in private practice, but, often, with a heavy emphasis on diagnostic psychological testing then a more cultivated and honored activity than today. And though psychiatric social work, both in individual case work and in group work, was a well-established profession, almost all of its practitioners worked at that time in social agencies, family service agencies, child guidance clinics, etc, supported on some combination of public and private philanthropic dollars and dealing with the social and psychological problems of the poor and other groups of the socially disadvantaged. Almost no psychiatric social workers were in private practice at that time and psychiatric nurses, the few that there were, were to be seen exclusively on the inpatient services in psychiatric hospitals and in the newly being created psychiatric units in general hospitals. Other than intensive individual psychotherapy, the private practice market included some hypnotherapy, the flamboyance and showmanship of Moreno’s psychodrama in New York, the beginnings of family therapy at the Ackerman Institute also in New York and, among social workers in social agencies, the psychoanalytically-oriented group therapy pioneered by Slavson. The real proliferation of bowdlerized psychoanalytic offspring, Gestalt, transactional analysis, primal scream, etc, had, of course, not yet occurred, nor the many fringe and cult therapies—in which California has always had a leadership role—nor the real growth of the various self-help movements, of which only the original prototype, Alcoholics Anonymous, then existed on any scale. In effect, the psychiatrists practising psychotherapy had the private practice market pretty much to themselves; they had plenty of patients and by and large they were competent at what they did with them and confident that their training had equipped them to do it well enough.
Presenting in this way the picture of the nature and conditions of psychiatric training and practice at the point at which I came into the field in 1949 highlights clearly, I think, the vast changes that have taken place when we compare all this—as I am sure you have been silently doing while listening to me—with the nature and conditions of training and practice today, especially as we hold the guiding thread of concern for the transformations undergone by the psychotherapy enterprise—its place in the overall psychiatric scheme of things—over this time. I won’t try to trace all these kaleidoscopic changes in the nature, scope and content of psychiatry over these four decades stepwise and sequentially over time. I have spelled those out at length elsewhere and will merely state them here in very condensed form.
First, of course, is the literal explosion of knowledge in neuroscience and neurobiology, especially in its molecular biological and molecular genetic dimension with the spectacular growth of intelligence of brain-behavior interrelations in the domain of mental and emotional disorder, with specific scientific focus on the elucidation of genetic markers of mental dysfunctions and on the multiplicity of interlocking and interacting neurotransmitters and cell receptors. Biological psychiatry has rapidly become a most significant and exciting scientific arena and is now the research and clinical focus of many academic psychiatric careers and major psychiatric space and money resources.
The second, and related, major development, also in the biological realm, is the modern era of psychoactive drugs as a central therapeutic modality in the management and treatment of the psychiatrically ill, especially the sicker, psychotic patients whom we psychodynamically-trained psychiatrists have tended anyway to avoid and who have been historically such a heavy, collective, undischarged social responsibility of our profession—for long warehoused in large public mental hospitals, often neglected at best and badly abused at worst. I do not need to recount the great proliferation of psychoactive drugs and of classes of such drugs since the inauguration of the modern psychoactive drug era in 1954—the major tranquilizers or neuroleptics, the antipsychotic drugs, the minor tranquilizers, the so-called antianxiety drugs, the several classes of antidepressants, or the very special drug lithium with its so poorly-understood effects in relation to manic and depressive disorders. Suffice it to say that the existence of all these drugs has vitally changed the practice characteristics of psychiatrists (not to speak of the ministrations to emotionally and behaviorally troubled individuals by non-psychiatric physicians) and has forced accommodations in the psychotherapeutic arena where adjuvant or concomitant use of psychoactive drugs has become commonplace—especially with the less well-integrated patients, for the most part those outside the normal-neurotic range—and where understanding of drug-behavior interactions and of the psychological meanings of such chemically-induced mood and behavior changes has become part of what we must know and teach in our psychotherapeutic working.
The third major dimension of change in the field of psychiatry is in the psychological arena. Here I need only point out that psychoanalysis is no longer the unquestioned prevailing psychological theory guiding and illuminating our understanding of the human mind and its aberrations. It has now been challenged by the astonishing growth of two fundamentally different and competing psychological paradigms: the one the learning-theory and stimulus-response conditioning model (partly classical, partly operant) with the behavior modification technology derived from it and the other attacking both psychoanalysis and behavior modification as being mechanistic and stripped of essential subjectivism and humanism (the so-called existentialist-phenomenological tradition of European philosophy and letters brought to America as humanistic psychology and leading to the whole encounter and human growth and potential movement, to some extent, within our profession and, to a far larger extent, outside it). Of more practical consequence to those of us practising and teaching dynamic psychotherapy is the encroachment of the behavioral technologies into our clinics and training programs—for example in the sex therapies or the eating disorder clinics, both now popular arenas of subspecialization.
The fourth major dimension of change is in the social science (and social policy) arena. Here I want to mention another influence, as potent as the psychoactive drug revolution in transforming the character of modern American psychiatric and mental health practice, and that is the community mental health center movement inaugurated by the Kennedy legislation of 1963. This community mental health movement is clearly a new center of gravity in political power and in access to funding in the whole field of mental health and illness. It is also a succession of linked conceptualizations and ideologies, not necessarily all politically inspired, and many of them developed both before and outside the official community mental health movement. I refer to the concepts of the open hospital and the therapeutic community pioneered by Maxwell Jones in England and of milieu therapy as designed by D. Ewen Cameron in Canada and further developed with psychoanalytic sophistication by Will Menninger and his colleagues at the Menninger Clinic in Topeka, Kansas as well as the current and dominant concept of deinstitutionalization that has already carried us from the era when most of our sicker patients were kept, or rather incarcerated, in our large public mental hospitals for very long periods of time, even for their whole lifetimes, to the current time when hospitalization is by and large very short and mainly for acute and unmanageable life crises and psychological decompensations and when most of even the very sick, chronically psychotic patients are managing (or not managing) in outpatient lives in the outside world—and where we now see the new untoward consequences of the deinstitutionalized life, the patients once neglected and abused in the state hospitals now often neglected and abused in board and care homes and cheap inner-city hotels or, worse yet, swelling the ranks of the homeless living on our streets. In any case, a host of major problems and issues that stamp the whole face of current mental health practice and that are necessarily a major concern of academic psychiatry in preparing its students for their professional life ahead.
Fifth, and last in this cataloguing of the major dimensions of impact upon psychiatry over the past five decades, are the correlated developments of theory that relate to the changes in emphasis from the therapeutic to the preventive ameliorative models and from the idiosyncratically individual to the socially controlled family and group and social system concerns that characterize the philosophic thrust of the community mental health movement. Some of this theory was developed within psychoanalysis, such as crisis theory as innovated originally by Lindemann, but most of it has been developed outside psychoanalysis in academic sociology and social psychology, such as role theory, theories of deviance, theories of social group behavior and social systems theory. Again, the main point is that there are other bodies of knowledge, social science knowledge, which are being brought to bear as explanatory frameworks upon many of the phenomena that are within the purview of psychiatry and that in terms of the issues surfaced by the emphases of our crisis clinics and community mental health centers, are presumably better, in the sense of being more broadly encompassing or more directly relevant, or perhaps just more easily understandable or commonsensical as explanatory frameworks.
So much for the tabulation of some of the major developments within and around psychiatry in these last five very fast-moving decades. All of them found their way into the seminar sequences and the clinical rotations of the psychiatric residency training program. Though the typical residency is now a four-year sequence, at least six months and up to a year in many of the programs is given back to what used to be in the separate internship year, rotations in general medicine, in neurology and, or for those who look to futures as child psychiatrists, in pediatrics. In the three to three-and-a-half years of specifically psychiatric training experience, major rotations exist through inpatient services which are no longer psychotherapy focused but rather are drug-management focused since lengths of stay are rarely, except in some very specialized clinical centers, longer than 30 days; through outpatient emergency rooms and crisis clinics and acute inpatient emergency units with their lengths of stay usually a week, or less if forced by the pressure of new admissions; through substance abuse wards and outpatient detoxification and methadone maintenance units; through consultation-liaison services; through specialized inpatient and/ or outpatient geriatric units. Significant amounts of the so-called outpatient years are devoted to community mental health centers with their brief therapy and group therapy focus and, often, to speciality clinics like affective disorder clinics, chronic drug maintenance clinics, sleep disorder and eating disorder and sexual disorder clinics, all with their drug treatment and/or behavior treatment focus. All of these significant time allocations and major teaching and learning foci, it goes without saying, have been carved from the time once given to the teaching and learning of psychopathology, psychodynamics and psychotherapy since these were the activities that once consumed almost the entire residency training and since they are anyway presumably more flexible in the more-or-less time that needs to be devoted to them.
And, of course, I should add to the many pressures that conduce to the diminution of the time and effort devoted to the teaching and the practice of psychotherapy the pressures of the insurance carriers and the various governmental sources of third-party reimbursement whose concerns for cost-benefit balances and for demonstrated therapeutic efficacy of the reimbursed services have led inexorably to the progressive shortening of the coverage afforded to long-term individual psychotherapy in favor of brief therapy models, group therapy and psychoactive drug management. This, of course, has had an inevitably chilling effect upon the readiness of mental health care providers, whether institutional or individual, to offer intensive psychotherapy to the extent that it is truly indicated and clearly socially and individually useful.
It would be a digression here to elaborate on the conceptual and technical complexities of the process and outcome research that would be necessary to establish the comparative efficacy of intensive psychotherapy vis-a-vis briefer or drug-centered approaches to the array of disorders in the psychopathological spectrum, but suffice it to say that in terms of the criteria central to governmental and insurance carriers and concern for the relief and amelioration of presenting symptoms and disturbed or disturbing manifest behaviors, it is unlikely that intensive psychotherapy will be (or can be) established to be indubitably superior. Its putative benefits lie rather in the subtler and less measurable realms of enhanced life satisfaction and more effective and adaptive life functioning consequent to inner character and personality shifts and alterations.