Psychoanalysis and APsaA in the Twenty-First Century

The Arts

If we take a closer view, I believe we can see that as a discipline psychoanalysis remains quite active and lively, with a good level of support in a number of circles that might be called “elite.” By this I mean that we are well interdigitated among many well-educated and intellectually sophisticated groups. Within such groups, psychoanalysis and psychoanalytic concepts have long played a significant role in informing views that are important components of the way our culture thinks about the arts (literature and film, for example). Indeed, within these groups our ideas inform much of artistic discussion and criticism and are generally seen as having considerable explanatory power in understanding the creative process. Many thinkers in these areas make abundant use of psychoanalytic concepts, which are accepted as foundational in explaining human behavior and motivation. Psychoanalysis has been a muse to many a director, artist, or poet. Many of our most respected literary and intellectual publications accept almost unequivocally the importance of analytic precepts, and many important authors, directors, artists, etc. readily include psychoanalytic concepts in their creations.

The relationship of psychoanalysis to film, indeed to aesthetics in general, is so embedded in our culture as to be taken for granted. Of historical interest is that film and psychoanalysis were both “born” at the same time, in the 1890s. From early on, filmmakers were interested in how scenes and images reflect psychoanalytic ideas. Remember, of course, that Sam Goldwyn once waved $100,000 in front of Sigmund Freud in the 1920s (a princely sum, greater than the salary of Babe Ruth, the highest paid athlete in America at the time) to act as a technical advisor for a romantic drama (Farber and Green 1993). Many directors have been identified as exemplifying analytic ideas through narrative and imagery (Truffaut, Cocteau, Kurosawa, Bertolucci, Bergman, Woody Allen, Kirostami, and Hitchcock, to name but a few). Indeed my own analytic grandparent, May Romm, long ago an officer of APsaA, was Hitchcock’s psychoanalytic technical adviser for Spellbound, a film that notably used Salvador Dali to create stunning visuals depicting dream images.

Psychoanalysis has a reach into many other art forms as well, including poetry, sculpture, and painting. A cursory look online shows numerous psychoanalytic essays on art, notably a recent effort to understand Manet’s Le Suicide, and another to understand the motivation of Max Ernst. Freud wrote in great detail about Michelangelo’s Moses, and of course about Leonardo da Vinci’s character. Recently an excellent Broadway play, Red, focused on Mark Rothko’s flirtation with a large commercial commission for the upscale Four Seasons restaurant and portrayed him as intimately familiar with analytic ideas and aware of their importance in his creative process.

The art world is far more eclectic in its use of psychoanalytic ideas than APsaA members often are. Freudian, Jungian, and Lacanian ideas frequently coexist amicably in artistic representations and discussions. APsaA should note the fecundity of this ecumenism.

These are connections we need to strengthen, as they are essential to psychoanalysis as a field.

The Academic World

If we take a further step and move into the realm of the academic world, we find even more evidence to suggest the importance of psychoanalytic ideas in contemporary culture. So let us look at some of the very solid collaborations that exist between psychoanalysis and the university. Consider the wide array of academic disciplines where there are major contributions and collaborations that involve psychoanalytic ideas. Just a few of the fields of study to consider include English literature and literary criticism, history, philosophy, religion, and anthropology. Additionally, it is quite common for scholars in French departments to have a familiarity with psychoanalysis, especially with the ideas of Lacan.

There is also of course our unique contribution to academia. Consider academic scholars, trained in APsaA institutes, who engage in scholarly research and publishing in their own fields, who make use of their creativity, now psychoanalytically informed. A further step in this development would be the creation of academic departments of psychoanalysis and/or departments of psychoanalytic studies. This area is a natural one for us to explore. Indeed, in recent years we have established a specific department within APsaA to enhance our involvement with education in the broadest sense, including the academic world.

Steven Levy (2009) delivered a most scholarly, elegant, and provocative plenary paper in 2008 in which he addressed the current state of psychoanalytic education. As a university-based psychoanalyst, he sees the current reach of psychoanalytic ideas into many academic disciplines. He pointed out that many of his current psychoanalytic conversations take place with academic colleagues rather than with fellow clinicians. Levy spells out for us how a model of psychoanalytic education based in the academic world offers dazzling potential for the development of psychoanalytic scholarship. Such an academically based model would help bring us out of the current trade school, semireligious model (see Kernberg 1986), of which I will have more to say later, and, optimally, would bring us into the realm of a true university model where the focus would be on learning, and on gaining new knowledge through research and leadership, rather than on training, with obsessive adherence to standards and with certification the primary goal (Kernberg 2011). Students in university-based programs might become career academic researchers and scholars, while others might become writers and journalists who would contribute to the understanding of our culture, our politics, and our aesthetics. And of course some would also opt to become practitioners.

We owe Levy our gratitude for beginning to discuss a model that demands our attention and that may well open us to a much broader future and bring APsaA into greater congruence with where the discipline and the profession of psychoanalysis currently live.

Psychoanalytic Psychotherapy

Even in the arena of mental health treatment, where there are some serious obstacles, we have an established presence. First I will acknowledge the problems, which are legion and quite serious. We must accept that psychoanalysis several times a week is a treatment available and useful for only a very small number of patients. Admittedly, there have been major shifts away from psychotherapy toward pharmacotherapy (Olfson et al. 2002; Olfson and Marcus 2010). Over the course of a few decades insurance companies have moved through managed care and then into utilization review, while relegating long-term therapies such as ours to the dustbin. Another consequence of the shift toward third-party payers and restrictions on care is the burgeoning of competitive therapies, especially brief ones. And of course we must deal also with the increasing expectation among consumers that they need not bear the burden of a full fee and that their problem should be resolved forthwith. In my farewell remarks to APsaA in TAP and at the business meeting of members yesterday, I warned of the ominous and pernicious influence of the “pharmaceutical / insurance / organized psychiatry complex.” Despite all these obstacles, however, psychotherapy in this country remains a mainstay of mental health care, as well as an entity that has become embedded in our culture, at least in certain circles. A recent report (Olfson and Marcus 2010) indicates that in 2007 seven billion dollars was spent on psychotherapy and that twenty-three million people engaged in psychotherapy; at least a substantial portion of that, no doubt, was psychotherapy based on psychoanalytic ideas. References to psychotherapy, sometimes even explicitly to psychoanalytic psychotherapy, abound in films, books, and TV shows. Just consider such recent examples as In Treatment and The Sopranos, or the movie Analyze This. The Sopranos attracted a substantial following to a weekly blog run by one of our most creative and prominent members. In these examples, the psychotherapy depicted is clearly psychoanalytically oriented. Further, a major film studio, Sony, was willing to put its backing behind A Dangerous Method, a cinematic version of Jonathan Kerr’s book A Most Dangerous Method (1993), which presented the story of Freud, Jung, and Sabina Spielrein. Big-name actors like Keira Knightley, Viggo Mortensen (Freud should be flattered), and Michael Fassbender were cast in major roles. I showed and discussed this film with psychiatric residents at both USC and Harbor/UCLA, and assured them that Freud looked not at all like Viggo Mortensen. The film grossed thirty million dollars. While this hardly made it a blockbuster, the figure definitely indicates that at least a modest-sized audience wanted to see the film, so singularly focused on psychoanalysis and on three of its key figures.

Yet another indication of the popular interest in analysis is the play Freud’s Last Session, the longest-running straight dramatic production in Manhattan in a recent theatrical season. It ran off-Broadway for well over a year, a remarkable achievement for a legitimate theatrical play.

Scholarship

A further example of the health of our field is the ever increasing number of scholarly journals and the ever expanding scope of the articles presented. A look at the tables of contents of JAPA in its early years compared with recent years shows an exponential increase in the range of ideas and of theoretical approaches represented. At present there are even occasional articles of a much more clearly scientific nature, especially in JAPA, that highlight yet another sign of health in our field, namely, the expansion of empirical research into the nature of the psychoanalytic process and the outcome of psychoanalytic treatment. There are articles in major journals, even mainstream medical journals such as JAMA (Leichsenring and Rabung 2008; Shedler 2010), reporting outcome research on psychoanalytic treatments. To our great relief, for some perhaps even surprise, there is a small but growing body of data demonstrating the effectiveness of our treatment.

The PEP project is yet another example of the reach of psychoanalysis into our culture and particularly of the depth of psychoanalytic scholarship. Despite its somewhat hefty cost, this powerful resource has been widely subscribed to not only by psychoanalysts and psychoanalytic institutes but also by college and university libraries. Income from PEP has benefited the operational budget of APsaA to a substantial degree.

Our scientific meetings provide an additional example, albeit somewhat mixed, of the way in which psychoanalysis maintains a significant niche. While our twice-a-year meeting format may no longer be relevant—the Spring Meetings continue to decline in number of attendees and in revenue generated (there are many explanations for this)—the Winter Meetings in New York remain very well attended; indeed, they are better attended than they were a decade ago when held in December. These meetings attract a broad range of professionals who are not necessarily APsaA members. There is perhaps another important point embedded in the differing fates of the two meetings: psychoanalysis seems to remain a more potent cultural influence in the urban Northeast than in the rest of the country.

I might stretch my point a bit and view the fact that we have an estimated several hundred thousand licensed therapists of one form or another in the United States as yet another sign of the influence of psychoanalytic ideas. Since so much of psychotherapy in general, and so many psychotherapeutic approaches, can trace at least some of their genome to psychoanalysis, and can be considered kin, this is a reflection of the embedding of psychoanalysis, and of therapies derived from it, in our cultural surround.

As stated above, seven billion dollars was spent in the United States in 2007 on specifically psychotherapeutic treatment. To this point, during my presidency I insisted that APsaA modify its periodic practice surveys to include specific data about income and the nature of practices. We discovered a broad range of practitioner income, generally falling from somewhat below $100,000 at the low end and extending to the low- to mid-$200,000 range at the upper level. This higher end, while not in the notorious one percent and not comparable to the compensation of senior physicians or attorneys in practice areas we might consider at a professional level similar to our own, is nonetheless in line with the income of many other professionals. We also found that relatively few practitioners maintain practices with predominantly psychoanalytic patients; the overwhelming majority of our colleagues have few or even no psychoanalytic patients, but a good number of patients in psychoanalytic psychotherapy. In addition, many have salaried part-time positions, and presumably in at least some cases this reflects the employer’s interest in having a psychoanalyst on staff. I view these indicators as supporting the idea that psychoanalysis as a discipline is a body of knowledge and a form of treatment (if we include psychodynamic psychotherapy) that is at the very least in good health in our nation (and in much of the world as well), though perhaps not in robust health. In APsaA we need to ensure that these favorable trends continue; we must monitor them and take an active stance so we may see them grow. Support for all of these components of the psychoanalytic field should be an integral part of APsaA’s mission.

Historically we have been quite averse to taking action, especially when it regards “the real world.” Indeed, at times in the past we have reveled in the fact that we “labor in splendid isolation.” This is but one element of a sense of “psychoanalytic exceptionalism” we would be well advised to forsake. I’m sure we can all conjure up reasons why such an attitude has come so readily to APsaA, but quite clearly we cannot continue it. I will have more to say about our “real-world averse” attitude in my concluding remarks. We might well note that the ego psychology movement of the 1940s and 1950s recognized full well the necessity of taking into account the interaction of our mental apparatus with the real world.

Our Survival Is Not a Given

I will begin with a powerful cautionary note. When I began my presidency, I stood on this stage to lead a celebration of our centennial. But the fact that we have survived for a hundred years should be taken as no guarantee that we will continue to survive. If we examine the business world—and an essential tenet of my thesis today is that we must run APsaA with an eye to business models and practices, in addition to our devotion to the association’s other goals—we find it littered with the carcasses of businesses that once were well-established, even thriving, but that declined, failed, and ceased to exist. Many companies have lost their core businesses and withered; if they have survived at all, it is as little more than shells of their former selves, or they have morphed entirely in other directions (showing at least a capacity for creativity and resilience, qualities that we too must cultivate if we are to survive). Just consider a few iconic companies that are now gone: F. W. Woolworth (once the eponym of the world’s tallest building), Arthur Andersen, RCA, Montgomery Ward, American Motors, Packard Motor Cars, Pan Am (the eponym of another iconic building, just down the street from us here at the Waldorf), all the for-profit passenger railroads (many of which ran under the Pan Am Building into Grand Central), Westinghouse, E. F. Hutton, Howard Johnson, and Polaroid. There are well-documented reasons why these established companies failed. While each case carries its own unique fingerprint, there are a number of commonalities including such strands as failure of top leadership and middle management to respond nimbly enough to a changing consumer or workplace environment. I suggest that there may well be warning signs of danger, harbingers of crisis, evident even now within APsaA, that we must heed.

While doing my research for this plenary, I looked to see which companies have survived and which have failed. Most companies that have remained in business for a century or more have “morphed” considerably and no longer resemble the original. DuPont, Wiley, Jim Beam, State Street Bank, and Pratt-Read are all nearly two centuries old or even more. Today all have product lines significantly different from those they started with. This is a cautionary note for us. We at APsaA must recognize this and modify our mission statement accordingly. For example, we are long past due in firmly embracing psychoanalytic psychotherapy as a major “product line”; we also need to embrace the idea of psychoanalysis in the academy. Our historical preoccupation with “standards” can no longer be our calling card.

As an aside, I would note that the oldest American company still providing essentially the same product as when it was established (in 1816) is Remington Arms, proud provider of guns.

The examples of Kodak and Rolls-Royce offer us a special warning. Kodak, once the dominant force in the consumer market for cameras, at one time experienced a major ascendancy in engineering and emerging technology as well. Today it hovers on the brink of extinction. Rolls-Royce offers an even better parallel for us, though some of our members may bristle at the comparison. Rolls-Royce was once an automobile company that prided itself on building a fine luxury automobile, not a sports car or “performance” car; the Rolls was not a “flashy” product, but attention was paid to every detail. Only the highest quality materials and the very best workmanship went into this product. The company insisted on the “highest of standards” (sound familiar?). Even today, to refer to a product as the Rolls-Royce of its field is the highest testimony to quality. The company of course could command only a small share of the market and made but a small number of cars (does this also sound familiar?), but it was more committed to maintaining the highest of automotive standards than to going into mass production. This analogy with Rolls-Royce is in my view striking. We intend to provide the highest, uncompromised quality of care to a very limited number of patients. Rolls-Royce did well for decades, but never truly thrived. It certainly never enjoyed anything in the way of market expansion, though it did sell a steady number of vehicles worldwide for many years. But it did have enormous prestige, just as we have had (sales remained in the range of one to two thousand per year). However, as changes in automotive technology accelerated in recent decades, Rolls-Royce no longer generated sufficient revenue from its yearly sales to fund the research necessary to improve the technology and performance of its product. Thus, the vehicles slowly became less competitive and even technologically obsolete. The company never seriously considered making a secondary model of high, if not quite so exceptional, quality (think psychoanalytic psychotherapy). Prestigious wineries in Napa and in Bordeaux discovered the value of this practice years ago (even Screaming Eagle, the top Napa Valley “cult” cabernet, now produces Second Flight). Several years ago, with annual sales dwindling to fewer than six hundred units, Rolls-Royce confronted the possibility of bankruptcy. In fact, Rolls-Royce Motor Cars does not exist today as an independent manufacturer. Fortunately, however, the company had sufficient cachet that the high-end automobile maker BMW, which was by then supplying a full half of the car’s components, was interested in acquiring the brand and logos, including the famous hood ornament, and did so. But here the analogy with APsaA breaks down. In the event of decline and possible failure, it is unlikely we will find an “angel” interested in acquiring us.

Warning Signs

We should look within our organization for evidence of any potential difficulties lurking around the corner. A most crucial metric is our membership data. During my ten years as an officer we have experienced a somewhat deceptive stability in our membership. Our numbers have very slowly declined from a level of 3,418 in 2001 to 3,068 in 2012, a decline of 10.2 percent in little more than a decade. While this level of decline might alert us, it probably wouldn’t be alarming. The deceptive part is that the figures include all categories of membership and count associate membership categories such as psychotherapy associates and research associates. These are people we are quite pleased to have under our tent, but most of them do not aspire to become psychoanalysts; while very friendly to analysis, their goals generally involve using psychoanalytic concepts in their area of primary interest. These are new categories of membership. Thus we have “created” members who in the past would not have been eligible for membership. To paraphrase Freud, “Where interest was, now shall membership be.” We need a constant input of new psychoanalysts, along with their patients and their ideas.

A more serious and upsetting component of our membership travails is the dramatic and serious decline in our active member category. These are members paying full dues up to age seventy, colleagues in their most productive years. We have seen a decline from 1,775 such members in 2001 to 1,520 in 2012. This is a 14.4 percent decline, more substantial than the overall decline in membership, and we are not enrolling a sufficient number of new candidates to eventually replenish the ranks of active members. This loss of members paying full dues affects APsaA’s financial base, if not so alarmingly. Our operating income in 2001 was $2,192,000. In 2012 it was $3,085,000, an increase of 40 percent. While not sufficient to keep pace with our expanding needs, this is a sign that our leadership, and especially our professional leadership, is managing our limited and declining resources with great care and a measure of creativity.

The most distressing piece of data we can glean from membership rolls is the decline in our candidate base. A decade ago (2002) we had 799 candidate members. In 2012 we had 522, a drop of 30.3 percent, greater than the decline in active members. Enough said. We should be alarmed. Unfortunately, however, some members, when presented with these metrics, seem completely unfazed, smile wanly, and say, “Oh, well we’ll just be a smaller but more exclusive organization, continuing to focus, perhaps even more, on our high standards.” This is yet another example of our organizational blind spot regarding real-world exigencies. It is also another example of the psychoanalytic “exceptionalism” that must cease. While I have some sympathy for this position, I must caution that we cannot pay for the activities necessary for the advancement, or even maintenance, of the profession from a declining membership and revenue base. We absolutely need financial and membership capital to fund and support outreach efforts to the academic world and to the various other mental health disciplines. We must also be able to provide at least some level of support for psychoanalytic research, especially for investigators who as yet have not established a track record that would allow them to attract extramural research support. In disciplines embedded in academic settings, such as medical schools, small “seed” grants are often available from the institution to help beginning faculty members and researchers start their investigative careers. It is essential, I think, that APsaA provide such funds as well. Unfortunately, however, our shrinking membership won’t allow us to do this. Our Fund for Psychoanalytic Research and the Psychodynamic Psychoanalytic Research Society are constructive steps in this direction, but they are not enough.

APsaA’s Divided House

While I don’t wish to place blame, I think we do need to look at our organizational milieu, our traditions, and our history so we can better understand and combat these difficulties. A major factor that leaps out at all of us is the increasing division and divisiveness within APsaA. In part this is typical of society in general, but we should strive to do better. Last fall I came across a Wall Street Journal article that surveyed voting patterns in Congress over a forty-year span (Seib 2009). To no one’s surprise, voting patterns in Congress have become almost exclusively bimodal, with practically no middle ground or overlap in voting between the two major parties. Democrats and Republicans in both the House and Senate voted along party lines 90 percent of the time in 2009, as compared with about 60 percent in 1969. Just such division and divisiveness, though perhaps not quite as dramatic, has come to characterize APsaA. In our case the competing forces are not Republicans and Democrats but “conservatives” and “liberals” (I apologize because I know many of our members, especially the involved partisans, resist these labels). The hot-button issues are standards, TA appointment, certification, and eligibility for membership. Interestingly, these have been hot-button issues for decades and, unless we seriously decide to stop it, will remain so. Just as in Congress, there seems little room for compromise. We should do better. Indeed, we have evolved to the point where, because each side holds to a “principled” position, compromise becomes tantamount to complete betrayal. I believe the tenacity with which “principled” positions are held (think of Mark Twain’s comments on true religion) reaches its zenith around questions regarding our high standards and the language of certification as attached to the TA system. Again, these are concepts all too often attached to notions of “psychoanalytic exceptionalism.” This tenacity is seriously damaging us, yet precious little data confirms the more extreme contentions on either side.

Though for the good of our organization this divisiveness and exceptionalism must cease, we seem at a point where many members have such powerful feelings and concerns that collegiality and comity are swept to the wayside. This, tragically, is very likely a factor in the decline in our membership. The various antagonists seem to sense not so much the threat to the organization as to their own position.

As I have suggested, we do not as an association, or even as a profession, pay appropriate heed to the “real world.” No doubt this is an aftereffect of our discipline’s discovery and championing of the importance of the “inner world,” but we ignore the real world at our peril. When a gun is pointed to our heads, we need to attend to it and not be so concerned about our fantasies or associations to it, or about those of the person holding the gun. The crucial question at such a moment is not “How are we going to think about this,” a common stance in APsaA, but rather “What are we going to do about it?” In addition to the real-world challenge of our decline in members, candidates, and analytic patients, we are faced not only with competing mental health treatments, but with competing psychoanalytic organizations, both institutes and a national organization. We do not have such a good track record of establishing collaborative links with these colleagues.

I came to office in APsaA to focus on what we need to do about this. I think many will wonder why we are in such a position. Several writers have offered credible texts detailing the profession’s travails (see, e.g., Hale 1995; Kirsner 2009; Reeder 2009). I recommend these works to all of you.

Reeder spends a good deal of time describing the development and subsequent perniciousness of an “institutional superego.” In its early days psychoanalysis was not only unregulated; it also had no formal mechanisms or procedures for establishing the qualifications to become a psychoanalyst. Obviously there was a legitimate need to develop a set of standards and implement them. The IPA and APsaA both saw this need and worked diligently to establish standards of excellence. Reeder notes, however, that this very process soon became calcified, as standard-setting and certification morphed into a preoccupation that stifled creativity and innovation for the sake of demonstrating to the world that we were indeed a profession with rigorous standards. Some members of the profession and some components of APsaA have become so attached to this function, in Reeder’s view, that the process has become excessively bureaucratized; some might even say that the issue of standards has become fetishized. The need to demonstrate our legitimacy to the public has in large measure overtaken concerns about what might be ideal for the profession, the field, and our patients. Much of this came about in the absence of any empirical data concerning issues of training and certification, yet another instance of our difficulty dealing with the real world.

Both our profession generally, and APsaA particularly, have been slow to respond to and/or embrace developments in psychoanalytic thinking and other mental health disciplines that have occurred in the decades since the “golden years” after World War II. Indeed, the very groups and individuals who once were excluded from our lair for lack of proper credentials, or because they explored modifications in established theory and so were considered apostates, have provided innovations that have led to some of the healthiest and most exciting developments in our field—regrettably, all too often outside of APsaA.

Even what some might consider the major postwar advance in American psychoanalysis, self psychology and its derivatives, has not always been met with welcoming arms within APsaA. Strozier (2004), in his excellent biography of Heinz Kohut, points out not only his difficulty being admitted to the Chicago Institute for Psychoanalysis as a candidate (“fluid sexual boundaries”), but his dismay that, once he voiced disagreement with established theory and advanced his own ideas, he spent the rest of his professional life in a state of siege, at every turn needing to defend himself and his positions. Suffice it to say that APsaA has not always been open to accepting challenges to psychoanalytic orthodoxy, frequently to its detriment, yet another derivative of Reeder’s “institutional superego.”

It isn’t merely with the acceptance of new ideas that we have faltered, but also with the question of broadening our membership. In recent times we have appeared more willing to talk about accepting members through routes other than the traditional ones, but we often stumble badly when we move from thinking and talking about change to actually implementing it. Witness the situation regarding the William Alanson White Institute. For more than a decade we have been in a dance with them, and yet we have still not brought them in as full members. Somehow at the very last moment we have found ways to avoid “closing the deal.”