The Challenge to Psychoanalysis and Psychotherapy

Psychoanalysis and Psychiatry

A Changing Relationship

The changes occurring in the relationship between psychoanalysis and psychiatry in the 1990s are, and will not be, the changes we have always hoped for. It is appropriate to start with the antecedents and background of the two principals in the affairs: psychoanalysis and psychiatry. I can start by assuring you that their relationship is by no means incestuous, although they are distantly related. Psychoanalysis, the younger partner, did not grow out of nineteenth-century psychiatry—indeed, it could not have. Psychoanalysis stems from the outpatient practice of clinical medicine—specifically, clinical neurology, while nineteenth-century psychiatry focused on the care of the institutionalized mentally ill. The earlier psychoanalytic patients, like so many since, were members of their doctor’s social communities—young, educated, intelligent, affluent and not socially labeled deviant.

They were worth listening to and, of course, it was by listening to them that Breuer and then Freud discovered the psychoanalytic method. In contrast, the psychiatry of the time was practised across a huge social gap. The mentally ill had been excluded from the doctor’s world. The physician was charged with their humane care and, if scientifically inclined, he was interested in classifying them and studying them objectively. But he could hardly be expected to develop an emotional relationship with them, especially not to attend to their obviously meaningless communications. Psychiatry and psychoanalysis were not even to meet until their adolescence.

However, once that adolescence occurred, their relationship expanded quite rapidly. Psychoanalysis broadened its interest from hysteric and other neurotic patients to embrace the traditional patients of psychiatry. Although at first it did not pretend to have an effective treatment for them, Freud discussed Schreber’s case history and formulated an explanation of paranoid symptomatology; Bleuler and Jung were early converts to the psychoanalytic approach and Freud’s theories were instrumental in the development of Bleuler’s new concept of schizophrenia; Brill, Meyer and others brought the concepts of psychoanalysis to American psychiatry. Of course, this early interest was not in psychoanalysis as a therapy for major mental illnesses but rather as a framework for understanding its symptoms and pathogenesis. The awareness that the symptoms were meaningful had an important humanizing effect on psychiatry but it did not, at first, influence the treatment directly.

At the same time, the domain of psychiatry was also expanding to include some of the conditions and patients first identified by psychoanalysis and to offer them new psychiatric treatments that leaned heavily on psychoanalytic principles. Psychotherapy, a kind of dilute psychoanalysis, was applied to patients who were not psychotic but suffered from severe neuroses, or a variety of other disturbances in character or adaptation, that had long been recognized but only recently considered as falling within the medical or therapeutic model.

As is so often the case, once started, the relationship soon reached a passionate intensity, accompanied by one of the predictable features of such relationships: outsiders looking on were often bewildered by the blind idealization each of the parties showed for the other and urged them to play the field and date around a bit before excluding other options, with the ineffectiveness customarily associated with such advice.

Psychoanalysis and psychoanalytically-based treatments originally developed for neurotic patients were now extended to the most serious mentally ill. The Washington psychoanalytic community has a special place in the history of the affair, serving as the center of enthusiasm for the application of these methods to psychotic patients. Chestnut Lodge, Shepphard and Enoch Pratt, Fromm-Reichmann, Hill and, of course, that most creative of American-born psychoanalysts, Harry Stack Sullivan, are central figures in the history of the affair. Psychoanalytic treatments were scientific, rational and based on the study and understanding of patients and their problems while other treatments in psychiatry were blind, empiric and shotgun. Psychoanalysis was prestigious, other schools of psychiatry were inferior. Psychoanalysis was intellectually exciting. It touched on philosophy, psychology, sociology, art and literature while the rest of psychiatry was shallow or boring. It was true, and somewhat embarrassing, that psychoanalytic treatments did not seem to be dramatically effective but that was easily explained—they were new, difficult to master and often compromised or interrupted by practical problems, inadequate resources and inexperienced therapists; and there were a few well-known cases of remarkable success in the hands of gifted practitioners.

Psychoanalysis was as infatuated with psychiatry as psychiatry was with psychoanalysis. Freud himself pleaded to expand analysis to include other than physicians, but was defeated, primarily by the American analysts. Only physicians were to be accepted and trained by recognized analytic institutes. Psychoanalysis and psychiatry were well on the way to virtual fusion. As often happens with intense romantic infatuations, the relationship was cemented by the tremendous elation and success that the couple experienced when they faced an emergency together. The Second World War brought with it the expected problems of gross stress reactions in soldiers at the front, but it also brought the unanticipated success of psychoanalytically-informed therapeutic interventions in dealing with these problems. The leading psychiatrists and psychiatric thinkers for the American armed forces—Menninger, Grinker and others—adapted and popularized psychoanalytic theory for application at the battle front. American physicians became enthusiastic about psychiatry and its new therapeutic potential; many returned from their 90-day crash courses and wartime experience to pursue training in the new discipline, confident that the psychiatric problems of the nation could be solved by the use of dynamic psychotherapeutic principles. Of course, they favored their leaders and heroes—the largest training program in psychiatry that has ever existed was at the Menninger Clinic in post Second World War days, with over 100 residents per year being trained in psychoanalytically-oriented psychiatry. If such a program existed today, it would represent 10 per cent of our nation-wide psychiatry education establishment!

However, affairs are, by definition, of limited duration and this one was no exception. The early seeds of difficulty were easy to recognize:

1. Psychoanalysis was designed for neurotic patients; its success in treating the more seriously ill was never convincing and the psychotherapeutic methods derived from it worried both psychoanalysts and other psychiatrists by their vagueness and lack of definition. This was true even as they increasingly constituted (and still do) the dominant professional activity of American psychiatrists.

2. The success in treating gross stress reactions in the Second World War was obtained with a population of young patients with good premorbid functioning who decompensated acutely under extreme stress—in other words, patients with excellent prognoses. The typical patient of peacetime psychiatric practice is older, more chronic, has considerable constitutional predisposition, less apparent environmental precipitant and, often, considerable secondary and contributing social pathology. Dynamic methods of treatment did not seem as effective with these populations. Further, the elitist characteristics of the patients suitable for the treatment became a growing embarrassment to the increasingly socially conscious profession. Finally, psychoanalysis was viewed as too expensive. Most of the public today would be surprised to learn that a year of psychoanalysis costs about as much as a month in a psychiatric hospital. Of course, that was not true a few decades ago; the cost of psychoanalysis has gone up much less than the cost of hospital care.

3. Psychoanalysis itself engaged in a brief flirtation with psychiatry’s parent, general medicine, in its early enthusiasm for psychosomatics. In fact, for a time, one of the appeals of psychoanalysis to psychiatry was that it seemed to offer a chance for psychiatry to join the mainstream of medicine. Surprising though this may seem today, psychoanalytic ideas concerning psychosomatic illness marked the first legitimization of the return of the alienist-psychiatrist to the general hospital and medical community—in many ways, playing the same sociologic role in the 1940s that neurobiology and psychopharmacology played in the 1970s.

4. Psychiatry engaged in two much more serious and continuing flirtations—one with psychopharmacology and the other with social and community models. Interestingly, American psychiatry seemed consistent in its preference for European liaisons—the ego and the id from Vienna, the chlorpromazine molecule from France and the open door and the therapeutic community from England. Like psychoanalysis, each of these relationships opened with great promise and enthusiasm. Unfortunately, also like psychoanalysis, each has turned out to be less than a panacea, with the limitations and problems appearing after the early enthusiasm has waned. The drugs are helpful in treating acute symptoms but their impact on the negative features of the illness, on social withdrawal, chronicity and on the course of the patients’ lives is less clear. In addition, the undesirable biologic sequelae are increasingly disturbing. Similarly, although the social psychiatrists have convinced most of us that hospitals are evil places, we have since learned, painfully, that communities may be evil as well and ‘de institutionalization’ is today more likely to suggest political propaganda for reducing budgets than public health strategy for caring for the mentally ill.

Where is psychoanalysis today? It is troubled by the concerns that trouble psychiatry and medicine in general but, often, are particularly worrisome for psychoanalysis. Scientific evidence concerning efficacy is essentially non-existent but, unlike most other treatments in medicine, there is not the general public trust and acceptance that embraces most other treatments from penicillin for viral pharyngitis to laetrile for cancer and bypass surgery for coronary disease. Accountability and peer review are of concern but the privacy of the psychoanalytic process makes true review difficult. Maldistribution is a problem throughout medicine but psychoanalysis is extreme—at my last count there were 20 States that had among them a total of only 19 members of the American Psychoanalytic Association.

However, other factors have a positive, rather than negative, impact. The history of medicine is a history of rising expectations concerning the level of health and healthcare to which citizens are entitled, and psychoanalysis is interested in such emerging themes in health as the nature of sexual experience and pleasure. Further, there is growing awareness that behavior and life style are more powerful determinants of morbidity and mortality than are hospitals and medicines. Most medical care has little impact on behavior of life style, it deals only with their sequelae; psychoanalysis, at least potentially, can deal with the cause. These are new areas of inquiry and the results are not yet in. For example, psychoanalysis has traditionally staked its claim to behavior that results from psychic conflict while the deleterious or even lethal behaviors in which behavioral medicine has been interested are generally conflict-free. However, our theories are changing and the domain of psychoanalytic interest continues to increase, so that some contemporary psychoanalysts see psychic conflict as only one type of pathology amenable to analytic intervention.

Today, psychoanalysis still is an important treatment in psychiatry. It is indicated in character disorders or persistent and recurrent symptomatic neuroses. It is no longer considered appropriate for the simple neurotic symptom without evidence of more pervasive or long-standing difficulty—faster and simpler treatments are available. Today, if we saw Freud’s earliest cases as he did, as simple neuroses in individuals who were otherwise healthy, we would prescribe simple forms of psychotherapy rather than psychoanalysis. Of course, it is only fair to add that we would view Freud’s treatment of those patients as psychotherapy rather than what we would today call psychoanalysis. Psychoanalysis is the dominant framework for organizing and integrating our treatment programs for severe character disorders, stress responses (whether developmental, medical or traumatic) and, in some settings, the combined characterologic, medical and other stress problems that constitute the major psychoses. It has a non-medical role in the optimalization of experience and the enhancement of sensitivity in those whose professions may require it. It is the most effective structure for organizing the psychiatric curriculum and for teaching clinical skills, both to medical students and psychiatrists. It is the dominant theoretical structure for discussing child development and is an important contributor to our understanding of small groups of linguistics.

In spite of the frequent reports of its demise, the profession of psychoanalysis appears still vigorous. Membership of the American Psychoanalytic Association continues to grow and, perhaps even more surprising, it is expanding rapidly in western Europe and the rest of the world. Just as psychiatry has strengthened its extrapsychoanalytic interests, so has psychoanalysis strengthened its extrapsychiatric ones. Major theorists are re-evaluating the biologic underpinnings of psychoanalytic theory, suggesting that they grew out of Freud’s and the field’s background rather than the inherent demands of the subject matter. Klein, Schafter, Ricoeur, Lacan and others have suggested the development of psychoanalysis that stems from the study of language, symbols and meaning rather than biologically-rooted somatic sources of mental life. Much further from contemporary medicine and biology than was true in Freud’s day.

Perhaps even more striking is the shift in the trade union stance of organized psychoanalysis in the United States toward the training of non-physicians. (The issue has never been much of a problem in the rest of the world, where ‘lay’ analysts have been accepted readily.) At first, the American Psychoanalytic Association was adamantly opposed to training anyone but physicians. Then they agreed to admit selected scholars and researchers who were to be trained to enhance their scientific capacity, not to become practising clinicians. Gradually, the definition of this group has broadened until, in the past few years, it has finally decided to go the way with the admission of other than physicians to training as clinical psychoanalysts for the first time. What of contemporary psychiatry? Psychoanalysis continues to be an important theme of American psychiatry but is no longer the only theme. Today, if a young medical student is seeking a career in academic psychiatry, the advice to go into psychoanalysis is more likely to suggest that he needs treatment than to point to an optimal career pathway. Some of our most prestigious psychiatrists and psychiatric institutions are heavily dominated by psychoanalysis but increasingly more are not. It is respectable to be a biologic or behaviorist or social psychiatrist; one can advance in those traditions to recognition as a leader in the field. It is interesting to note in this regard that many psychiatric trainees still want psychoanalytically-oriented training. American psychiatry is reassessing its relationship to psychoanalysis and has recognized that some of the problems it now views as falling within its domain are not going to be solved by psychoanalytic strategies. Leaders of the psychiatric profession are directing their attention to these problems and interesting and important researches have resulted. Psychiatry has to define professionally and personally rewarding and socially valuable roles for clinicians who will work outside of the psychoanalytic model, and the crisis in recruiting medical students to psychiatry is one manifestation of this problem.

Psychoanalysis continues to be an important paradigm organizing the way many psychiatrists think about patients and treatment. However, its limitations are more widely recognized and it is assumed that many important advances in the future will come from other areas, particularly biologic psychiatry. As yet unresolved is the appropriate role of psychoanalytic thinking in organizing the treatment of patients and the training of psychiatrists after that biologic revolution has born fruit. Will treatments aimed at biologic defects or abnormalities become technical steps in a program organized in a psychoanalytic framework? Will psychoanalysis serve to explain and guide supportive intervention for individuals whose lives are deformed by biologic defect and therapeutic interventions, much as it now does for patients with chronic physical illness, with the psychoanalyst on the psychiatric dialysis program? Or will we look back on the role of psychoanalysis in the treatment of the seriously mentally ill as the last and most scientifically enlightened phase of the humanistic tradition in psychiatry, a tradition that became extinct when advances in biology allowed us to cure those we had so long only comforted?

Psychoanalysis and psychiatry, with separate origins, formed a natural and intimate alliance, each providing something the other desperately desired—psychoanalysis, when at its best, offering psychiatry an intellectually exciting and profound understanding of psychopathology and at least the possibility of a rational treatment; psychiatry offering psychoanalysis the respectability and status of the medical profession and the opportunity to influence a major area of mental healthcare. However, both paid a price for the exclusive relationship. Psychiatry was temporarily distracted from some of its other important scientific bases—especially neurobiology—and, at the same time, its therapeutic efforts were disassociated from the community’s health needs. Psychiatry without psychoanalysis would be weakened immensely; psychiatry with nothing but psychoanalysis would be seriously limited. Psychoanalysis was also deprived of an important source of new thinkers and new thoughts as the exclusive medical-psychiatric pathway ruled out many of the more gifted scholars trained in the tradition of humanistic and hermeneutic studies. Today, both psychiatry and psychoanalysis are still retaining an important relationship with each other but are branching out and embracing other traditions and disciplines.

In spite of considerable present difficulties, we must strive for a psychiatry that includes the brain and the society as well as the mind—thus a richer, more complete psychiatry—and having far more to offer psychoanalysis as a result. We also must work towards a psychoanalysis that includes language and history and humanities as well as the drives, scientifically more vigorous, which can serve as a bridge between psychiatry and the other disciplines that study man. This would be a move from an affair to a more open, less monogamous, but more honest, relationship, and, I believe, a more promising future as a result.