For many years, psychoanalysis dominated the mental health care system in the United States and many other countries. Since the late 1960s until the present time, however, psychoanalysis in the United States has become increasingly marginalized within both the healthcare system and clinical training programs. There are many reasons for the declining fortunes of psychoanalysis. One important factor is that during its heyday, psychoanalysis justifiably earned a reputation as a conservative cultural force with a tendency towards orthodoxy, insularity, arrogance and elitism. It also earned a reputation as a somewhat esoteric discipline with limited interest in grappling with the concrete problems that many people deal with in their everyday lives, as well as a limited appreciation of the social and political factors that affect their lives. Psychoanalysis came to be seen by many as a self-indulgent pastime for the financially comfortable.
The fact that psychoanalysis came to earn this reputation is ironic. Although Freud initially began developing psychoanalysis as a treatment for patients presenting with symptoms that other physicians were unable to treat, his ambitions and the ambitions of subsequent psychoanalysts ultimately came to extend beyond the realm of therapy into social theory and cultural critique. Though Freud and many of the early analysts came from medical backgrounds, Freud came to feel that psychoanalysis should not become a medical sub-specialty and in fact prized the cultural and intellectual breadth that could be brought to the field by analysts with diverse educational backgrounds and intellectual interests. Many of the early analysts including Freud were members of an emerging, educated Jewish middle class whose upward social mobility was made possible by the open, politically progressive policies of the Austro-Hungarian empire at the turn of the century, and who contributed to the development of this culture. Western European Jews at the turn of the century formed a unique group of marginal intellectuals. Alienated from traditional Judaism and not fully accepted into European society even when they assimilated its customs, they developed a characteristically skeptical point of view.
The early analysts thus tended to be members of a liberal, progressive intelligentsia — a traditionally oppressed and marginalized group. They aspired towards social acceptability, but at the same time tended to regard prevailing cultural assumptions from a critical perspective. This critical and in some respects subversive stance went hand in hand with a vision of progressive social transformation. Psychoanalysis began in part as a radical critique of the illness-producing effects of social suppression and consequent psychological repression of sexuality. Freud was deeply interested in broad social and cultural concerns. He was critical of various trappings of the physician’s privilege, and until the end of his life he supported free psychoanalytic clinics, stood up for the flexible fee, and defended the practice of psychoanalysis by professionals without medical training. Many of the early analysts were progressive social activists committed to political critique and social justice. Sandor Ferenczi, one of Freud’s closest colleagues, critiqued social hypocrisy and conventionalism, founded a free clinic in Budapest, and passionately defended the rights of women and homosexuals. Karl Abraham, Ernst Simmel and Max Etington set up a public psychoanalytic clinic in Berlin in the 1920s that became a bastion of social and political progressiveness.
A number of these analysts were influenced by left wing, socialist thinking. This is not surprising given the fact that they came of age in the politically charged culture of Vienna and Berlin, where the Marxist critique of capitalism was widely discussed in intellectual circles. They viewed themselves as brokers of social change, and saw psychoanalysis as a challenge to conventional political codes, and as more of a social mission than a medical discipline. Prominent analysts such as Wilhelm Reich, Erich Fromm, and Otto Fenichel were well known for their socialist or Marxist commitments and their fusion of psychoanalysis and social concerns.
Many of the European analysts who immigrated to the United States because of the rise of Nazism in Europe downplayed their more politically progressive and socially critical commitments in order to fit in with American culture and avoid arousing the fears and suspicions of Americans who might potentially see them as dangerous foreigners. This was especially true following World War II as the wartime alliance between the United States and the Soviet Union broke down and the rampant fear of communism, socialism, and Marxism reached its heights in the McCarthy era. During this period, émigré psychoanalysts reasonably understood that the fight for a politically progressive psychoanalysis informed in part by a Marxist critique of capitalism was out of step with the times, and might easily jeopardize the future of psychoanalysis in North America. They thus kept their political views to themselves and focused on establishing psychoanalysis as a profession.
In many ways, this effort succeeded. During the early 1920s, when psychoanalysis was beginning to take root in the United States, the American medical profession was struggling to upgrade and standardize the quality of medical training. The physicians who played a dominant role in developing psychoanalysis in the United States were concerned about jeopardizing the future of the profession by training candidates who did not have a background in medicine. In 1938 a fateful decision was made early by the American Psychoanalytic Association to restrict formal psychoanalytic training to physicians. A concern about protecting the professionalism of psychoanalysis played a role in developing a purist, elitist, and rigid form of psychoanalysis with a veneer of scientific respectability, a discouragement of innovation, and a tendency toward social conservatism. Over time, as medicine consolidated its privileged status within the healthcare professions, and psychoanalysis became established as a sub-specialty of medicine, the social prestige of the psychoanalytic profession grew as well. For residents training as psychiatrists, the rigorous, time-consuming process involved in undergoing psychoanalytic training also contributed to the sense that psychoanalysis was an elite sub-specialty within psychiatry. Chairs in most major psychiatry departments were psychoanalysts and most psychiatry residency training programs provided at least some training in psychoanalytically-oriented treatment.
As the United States became the center of the psychoanalytic world, massive amounts of time, effort, and money went into the training and development of the profession. Psychoanalysis became a lucrative, high prestige and socially conservative profession, attracting candidates who had an interest in becoming respected members of the establishment rather than in challenging it.
Unlike the original psychoanalysts in Europe coming from backgrounds that tended to be culturally and intellectually diverse, most candidates entering psychoanalytic training in the United States came from educational systems that were relatively narrow. There was thus a tendency for psychoanalysis to be applied as a focused technical approach with rather inflexible ideas about correct and incorrect technique, analogous to the way one tends to think of medical procedures. Psychoanalysis became a purveyor of conservative American middle class social values rather than a culturally subversive force. Consequently, mental health tended to be viewed in terms of conformity to these values.
With the rise of biological psychiatry and the explosion in the development of new psychotropic medications, psychoanalysis gradually became less fashionable within American psychiatry. Over time, training curricula within psychiatry residencies shifted away from introducing residents to the basics of psychoanalytic theory and practice, and the number of psychiatry residents applying for training in psychoanalytic institutes decreased exponentially. It was around this time that the American Psychological Association established a formal division of psychoanalysis — Division 39. In the mid-1980s Division 39 filed a class action suit against the American Psychoanalytic Association, arguing that the refusal to admit psychologists as candidates within psychoanalytic training institutes was a violation of antitrust regulations since, by establishing a monopoly of the field of psychoanalysis by physicians, they were preventing fair competition for clients by psychologists and depriving them of their livelihood. Ironically, by the time the lawsuit was settled, market forces were already opening the doors of psychoanalytic training institutes to psychologists, since as the number of candidates seeking psychoanalytic training continued to dwindle, traditional institutes became eager to recruit psychologists.
In the last twenty years many of the more significant and innovative contributors to the development of American psychoanalytic theory have been psychologists. This new breed of theorists and researchers have played a vital role in transforming psychoanalysis into a less insular and more intellectually vital discipline, grounded in an appreciation of contemporary developments in a broad range of social sciences including psychology, sociology, philosophy, and political science.
There is another important variable influencing the changing character of American psychoanalysis. Given the fact that pursuing formal psychoanalytic training in today’s culture is less likely to be a pathway to professional prestige or financial success, the typical candidate is more likely to be drawn to the field for intrinsic reasons. Especially given the increasingly marginal status of psychoanalysis within the general culture, and within mainstream clinical psychology, those attracted to the field are less likely to buy into prevailing cultural and professional values and assumptions and are more likely to approach things from a critical perspective. The marginalization of psychoanalysis therefore provides an ironic catalyst for innovative thinking. In this respect, important aspects of the emerging sensibility in contemporary American psychoanalysis may be closer in nature to the sensibility of the early psychoanalysts (who as I previously indicated, were members of a marginalized group) than that of American psychoanalysis during its heyday of the 1940s, ’50s, and early ’60s.
Given the current marginalization of psychoanalysis it is not surprising that the general public tends to have a limited and often caricatured understanding of it. Psychology undergraduates typically receive very little exposure to psychoanalytic thinking, and when they do it is not unusual for them to be taught to think of it as a discredited pseudoscience. Psychoanalysis is more likely to be taught in the humanities or philosophy than in psychology. And when it is taught it tends to be done so in a purely academic fashion that is disconnected from clinical and lived experience. There is a tendency for the mainstream press to equate psychoanalysis with Freud, and a failure to recognize that the value of psychoanalytic treatment and the validity of psychoanalytic theory are not tied to the validity of Freud’s thinking. Freud was one person writing in a particular historical era within a specific culture, and as such some of his ideas were more valid in their original context. Relative to Freud’s time, contemporary American psychoanalysis has a greater emphasis on the mutuality and fundamentally human nature of the therapeutic relationship, on flexibility, creativity, and spontaneity in the therapeutic process, as well as a more optimistic perspective on life and human nature. Contrary to the common misconception, there is actually a substantial and growing evidence base for the effectiveness of psychoanalytically-oriented treatments, and there is a growing emphasis on adapting psychoanalytic theory and practice in a culturally responsive fashion.
In the United States, psychoanalysis has evolved under the influence of a number of characteristic American attitudes including a tendency towards optimism and the philosophy of American egalitarianism. Another important factor is that many of today’s leading analysts came of age during the turbulent 1960s — a time when traditional social norms and sources of authority were being challenged. In addition, a number of prominent feminist psychoanalytic thinkers have challenged many of the patriarchal assumptions implicit in traditional psychoanalytic theory, raised important questions about the dynamics of power in the therapeutic relationship, and reformulated psychoanalytic thinking about gender. Another influence has been a postmodern sensibility that challenges the assumption that we can ever come to know reality objectively, maintains a skeptical attitude towards claims of universal truths, and emphasizes the importance of theoretical pluralism.
Unfortunately, many people in the broader mental health field and the general public are unaware of these changes within psychoanalysis, and are responding to a partial or caricatured understanding of the tradition based upon aspects of psychoanalytic theory, practice, and attitude that are no longer prominent. While there are many valid critiques of psychoanalysis in both its past and current forms, the current marginalization of psychoanalysis is partially attributable to certain contemporary cultural biases, especially in the United States, that are not unequivocally healthy ones. These biases include an emphasis on speed, pragmatism, instrumentality, and an intolerance of ambiguity and optimism. While all of these emphases certainly have value, they can also be associated with a naïveté that tends to underestimate the complexity of human nature and the difficulty of the change process. American culture traditionally tends to gloss over the more tragic dimensions of life, to espouse the belief that we can all be happy if we try hard enough, and to be biased towards a “quick-fix” mentality.
Although American psychoanalysis tends to be more optimistic and pragmatic than its European counterpart, it still retains many of the traditional psychoanalytic values such as the appreciation of human complexity, a recognition that contentment is not necessarily the same as a two dimensional version of “happiness”, and an appreciation that change is not always easy or quick. I believe that a greater understanding of the nature of contemporary psychoanalysis — and a deeper appreciation of the more valuable dimensions of psychoanalytic theory and practice in general — can enrich our understanding of how best to help people and serve as a corrective to some of our more problematic cultural blind spots. And finally, I am hopeful that psychoanalysis can continue to recover and deepen the culturally subversive, socially progressive, and politically engaged spirit that was once more characteristic of the discipline.