Clin Soc Work J (2009) 37:8183 DOI 10.

1007/s10615-008-0188-7

CLINICAL SOCIAL WORK FORUM

Some Thoughts on the Survival of Psychoanalytic Practice

Nancy McWilliams

Published online: 2 December 2008 Springer Science+Business Media, LLC 2008

I am pleased to have been asked to contribute some thoughts to this issue of the Clinical Social Work Journal, partly for very personal reasons. Although my route to becoming a therapist was through psychology, I am deeply identied with social work and social workers. My analyst, the late Lou Berkowitz, was a social worker. In early 1969, when we began working together, I was an opinionated, defensive twenty-three-year-old who wanted to undergo psychoanalysis for professional reasons. I was braced for a know-it-all analyst who would try to attribute all my passionate political involvements of the time to some kind of pathological acting out (my father was a fairly authoritarian conservative, and the transference preceded the treatment). The fact that my analyst directed a settlement house on New Yorks Lower East Side and was trying to adapt its services to an ethnically diverse, poor population gave me hope that he would take my social justice interests seriously. Knowing his values allowed me to take the risk of exposing my inner world to him. His training had obviously reinforced in him the social work directive to start where the client is, and he never fell into the arrogance that was all too common in analytic circles at the time. To my immense surprise, this supposedly strictly educational experience became profoundly therapeutic; its ramications have enriched my life in uncountable ways and underpin my deep conviction in the value of psychoanalysis.

Many of the following thoughts appeared previously in a presidential column I wrote for PsychologistPsychoanalyst (Fall 2008), the newsletter of the Division of Psychoanalysis of the American Psychological Association. David Phillips has asked me to adapt them to the themes of this compilation.

The Current Climate It has become a hard world for beginning psychoanalytic therapists. Pre-institute training programs tend to discourage those who want to do psychotherapy, a curious stance given the general state of mental health in Western cultures. College counseling services report signicantly more serious mental health problems among students than ever before; diagnoses of ADHD, Aspergers disorder, bipolar illness, eating disorders and body-image problems are ubiquitous; huge numbers of teenagers regularly selfmutilate; jails overow with the addicted; traumatized soldiers and their suffering families are overwhelming available services; and the culture we live in seems to have lost any respect for the examined life. Attitudes that I once thought were so self-evident that they needed no particular support (for example, that if one seeks to be a therapist, one should undergo personal treatment) have been vaporizing. Whereas it used to be assumed that we treat whole persons and try to develop a relationship that makes them safe enough to expose to us the complex developmental, defensive, and contextual origins of their suffering, it is now assumed that we should identify their discrete disorder, treat it with a manualized protocol, and consider our work done if the patients overt symptoms are temporarily eliminated. The paradigm shift from therapy as a healing relationship to therapy as the

This article is an expanded, adapted, and revised version of the paper, Psychoanalysis: The Next Generation, by Nancy McWilliams, that appeared in Psychologist-Psychoanalyst, 28(3), 14. N. McWilliams (&) 9 Mine Street, Flemington, NJ 08822, USA e-mail: nancymcw@aol.com

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application of specic, pre-validated techniques (an appealing paradigm if you work for the insurance industry or Big Pharma) threatens one hundred years of psychoanalytic clinical experience, research, and scholarship. Even analytic ideas that had started to infuse the larger culture, that had come to be seen as common sensee.g., that ambivalence is inevitable; that evil thoughts are not tantamount to evil actions; that insight is valuable not only for symptom reduction but for its own sakehave been silently disappearing. When I teach beginning therapists, I nd myself having to start at more basic levels every year. It is rare that any of them have read Freud, and few have had even a personality course that has introduced them to major psychoanalytic thinkers. Once exposed to analytic ideas, however, many fall in love with them, and for the same reason that most of us did: They make sense of the world, of the self, of relationship. But these recent students also regard a psychodynamic practice as a professional luxury they cannot afford. For one thing, they have been thoroughly indoctrinated in the belief that there is no place for psychoanalytic treatments in the contemporary health care scene. Unless they are lucky enough to have had some psychodynamic help themselves and noticed that their therapist was making a living, they view an analytic practice somewhat like Fairbairns tantalizing object: a valuable resource available only to the blessed. That is, they believe that analytic work is limited to patients who can afford intensive and ongoing sessions and to therapists who work in moneyed subcultures, or who teach in institutes that supply them with candidate-analysands, or who are independently wealthy enough to reduce their fees to accommodate frequent sessions and longer treatments. There may be a lot of truth in this assessment. Recently, while presenting a case to a graduate class, I noticed a sense of depression in the room that did not seem to be accounted for by the affects infusing the therapy I was describing. When I asked about the dysphoric atmosphere, the students told me that they were in a morass of envy about the fact that I could work in depth with people for months or years and help them in lasting ways. This was the kind of meaningful work that they wanted to do, that they had come to graduate school to learn how to dobut now they could not imagine doing it. If they saw any possibility of such a career for themselves, it would be far, far in their futures, and it would require their selling their souls for years to agencies or managed-care practices where they would have to attend more to paperwork than to patients, where their caseloads would be too big to permit genuine caring for all their clients. These students are analytically oriented, but they are diligently learning to do EMDR, DBT, various CBT treatments, and other structured approaches that are currently in favor with reimbursing bodies.

It seems clear that would-be analytic practitioners are facing the future with a pervasive pessimism. Their academic peers seem to be struggling just as painfully. I keep hearing stories about analytically interested professors whose department chairs have insisted that they either distance themselves from all things psychoanalytic or jeopardize their chances of getting tenure or promotion. Some have been explicitly discouraged from publishing in psychoanalytic journals. Others have been urged to omit from their CVs any mention of psychoanalytic associations. The general rule seems to be that they can study whatever they are interested in, but woe to them if they characterize that work as psychodynamic. Meanwhile, psychoanalytic publishers have been going out of business at a frightening rate.

Protecting a Psychoanalytic Future We need to ght on many fronts to correct the remarkably pervasive misunderstandings about our tradition. This is not easy, as most therapists temperaments do not dispose them toward ghting. We tend to see the other guys point of view, to reduce conict rather than to initiate it, to assume that our critics must be at least partly right. We would rather teach what we know than defend what we do. Furthermore, we are isolated in our ofces, and we lack the resources that the drug and insurance industries can easily command when they want to further their own aims. But it is simply not true that there is no empirical basis for psychoanalytic therapies, and we need to keep saying so, and with the ammunition of good data. Insurance functionaries, who were fed their lines by anti-analytic psychologists and biological psychiatrists, have created a climate in which that lie is repeated so often that we ourselves are starting to believe it. But as I write this, the New York Times has just publicized Falk Leichsenrings landmark meta-analysis, published in the Journal of the American Medical Association, attesting to the superiority of long-term psychoanalytic psychotherapy for complex problems (i.e., most problems!). Jonathan Shedler (2008) recently nished an article that I hope will appear in the American Psychologist in which he convincingly argues, on the basis of exemplary research, that (1) empirical evidence for the efcacy of psychodynamic therapy is as strong as that for other therapies that have been actively promoted as empirically supported, (2) after ending psychodynamic treatments, patients maintain their gains and keep improving, and (3) a major contribution to the effectiveness of nonpsychodynamic therapies are the psychodynamic elements within them (e.g., attention to the relationship), not the particular techniques employed.

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It is important to future generations of therapists that we survive. I do not mean this facetiously but in the profound way that Winnicott, Pine, Eigen, and others have written about the importance of the analysts survival. We need to keep doing what we believe in while the evidence accumulates, as it has been doing, that psychoanalytic concepts and treatments are valid and effective. We need to become familiar with the already abundant empirical evidence of their worth so that we can respond effectively to critics of psychoanalytic approaches and counter the myth that our work lacks empirical support. Beginning therapists probably do need to be conversant with many techniques that are not psychodynamic, but they can be encouraged to do so without losing a psychoanalytic overview. If we have to keep psychoanalysis alive as a niche treatment, we will still be keeping it alive. I personally look forward to frustrating the considerable number of our non- and anti-analytic colleagues who are impatiently waiting for us all to die off.

Some Reasons for Hope I think we are starting to see evidence of a swing of the proverbial pendulum back toward more sanity about mental health and health care in general. There is beginning to be some acknowledgment, even in cognitivebehavioral strongholds, that short-term CBT therapies have been oversold (just as psychoanalysis was originally oversold as a universal panacea). The limits of symptomfocused techniques and what Freud called suggestion are being rediscovered. Managed healthcare is almost universally hated. Pharmaceutical companies are undergoing increasing scrutiny about their procedures for studying and marketing medications. The recent election may open up new ways of talking about what is needed. Paul Krugmans (2008) read on the recent Medicare victory is that it represents the critical rst step away from the subsidization of the private insurance industry in favor of valuing doctors and patients over insurance company prots. On the cultural front, a coalition of mental health professionals, child development experts, and psychoanalysts barraged NBC sufciently that it canceled further production of a horrifying reality show

about Baby Borrowers, in which infants and toddlers were handed over for three days to teenage couples so that they could learn, amid the childs traumatization, that they were not t parents. Sometimes, Kerry Kelly Novick noted in announcing this accomplishment, our efforts bear fruit out in the world. Life is never static. Empires rise and fall. Intellectual movements become hot and then get replaced by the next new thing. The academic and service environments in which my generation came of age will certainly evolve and change, and despite the attractiveness of the myth of progress, not necessarily for the better. Given that stark fact of life, psychoanalysis has actually survived pretty well certainly far longer than the strict behaviorism that once was its most serious intellectual adversary. Psychoanalytic therapists will survive because we help people to understand themselves and to cope with life, and because people who are helped that way spread the word. And psychoanalytically oriented research will survive, notwithstanding the fact that most academics have always been ambivalent at best about psychoanalysis and are now in the habit of couching their objections in vague references to the data. It is still possible to ask psychoanalytic questions and pursue psychoanalytically oriented scholarship and research, whether or not the pursuit is tagged that way. It is hard to know whether psychoanalysis will survive in the language we currently speak or whether it will be reinvented in nomenclature more compatible with other intellectual traditions. As their orientation matures, cognitive-behavioral psychologists are discovering the same phenomena we have been talking about for decades and calling them by new names (implicit instead of unconscious, for example). The next generation will have to make accommodations to the world they inherit, and perhaps they will have to change some of our favorite terminology in order to be a valued part of that world. But let us hope that psychoanalytic professionals in the upcoming generation will work to preserve the best elements of a tradition that values the whole person, recognizes individuals unique subjectivities, endorses the search for meaning, and enables the emergence of the most authentic aspects of self.

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