Thursday, February 26, 2015

"Shrinks Can't Compete..."

As I and many others have said, psychoanalysis in America is over.

Those who have read my book and who keep up with this blog have already heard the news. Obviously, I am not the only one who holds this belief.

This morning in the New York Post, Susannah Cahalan writes about the demise of psychoanalysis in New York:

The couches have gone cold on the Upper West Side.

Lying down and talking to a psychoanalyst, a practice once as synonymous with New York City as the street-vendor hot dog, has fallen out of favor thanks to shifting fads, pharmaceuticals and the Internet, experts say.

Of the 3,109 members of the American Psychoanalytic Association, the largest group of its kind in the country, the average shrink age is 66 — up four years since 2003.

And shrinks’ average number of active patients on the couch has fallen to 2.75, according to a study of US analysts. Many of those surveyed said they meet with no patients.

It’s a far cry from the height of Freud mania — with its egos and ids, subconscious, Oedipal conflicts, Freudian slips and death wishes — in the 1950s and 1960s, when everyone and their mothers were in therapy.

In those decades, therapists would see between eight and 10 patients a day, according to analysts interviewed.

As Cahalan explains, Freudian psychoanalysis used to attract the best and the brightest. It treated those who had influence on the culture. These members of the intellectual elite, I have argued in The Last Psychoanalyst, helped create a cultural environment where psychoanalysis was considered to be an effective treatment. It was enormously helpful in producing placebo cures.

In Cahalan’s words:

This helped attract the best and brightest to the field — and also wooed a new type of patient dubbed “the worried well.” These patients were a “far more attractive group of patients than the socially marginal, often impoverished and ill-educated people who overwhelmed mental hospitals,” writes Andrew Scull, professor of sociology and science studies at the University of California, San Diego and author of the forthcoming book, “Madness in Civilization.”

These patients were members of the intellectual elite, many with significant clout. It would not take long for this interest to bleed into the upper-middle classes, where having a shrink was akin to owning a Rolls-Royce; it was a sign that you had made it.

This ushered in psychoanalysis’ “golden age,” and its epicenter was New York. At one point in the 1960s, according to Jonathan ­Engel’s “American Therapy,” there were more analysts on 96th Street and Fifth Avenue than there were in Tennessee, Wisconsin, Oklahoma, Delaware, Minnesota and Vermont combined.

Directors and screenwriters in Hollywood embraced the movement wholeheartedly, using Freudian themes in all kinds of films, from “Rebel Without a Cause” ­(juvenile delinquency caused by weak father, overbearing mother) to Alfred Hitchcock’s “Spellbound,” which even had an analyst on retainer.

Obviously, it was all built on air. In time, it succumbed to the competitive market. Cahalan grasps the concept in the first words of her title: “Shrinks Can’t Compete….”

Psychoanalysis was an expensive, time-consuming invitation to self-absorption that could not prove that it worked. It was inevitable that it would lose out to more effective forms of therapy.

Cahalan explains:

But the backlash began even before the golden years ended.

Psychotropic drugs — anti-psychotics, anti-anxiety meds and “mother’s little helpers” — quickly outmuscled talk therapy as a quick and effective treatment. People ­began to question: If it’s all a case of faulty neurotransmitters, what help will talking do?

Psychoanalysis did little to help its own case. Primal-scream therapy; “the orgone box” therapy, a metal box that claimed to increase “orgiastic potency”; and rebirthing therapy only further detracted from the legitimacy of the field.

Then there was the research — or lack thereof. One study in the 1970s showed that people benefited less from seeing a shrink than from seeing a clergyman. They even got more psychological benefit from seeing a lawyer than a shrink.

Another study around the same time showed that patients who ­believed they were seeing a shrink but were actually seeing an ­untrained but benevolent professor showed the same levels of ­improvement as they did when seeing an analyst.

Meanwhile, in an effort to make psychiatry a more rigorously scientific specialty, an effort was made to more clearly define psychiatric disorders. The result was the third volume of the Diagnostic Statistical Manual of Mental Disorders, which expunged any Freudian references, officially severing psychiatry’s tight link to psychoanalysis.

Analysis was “withering on the vine,” says Professor Scull. “All of this made them look more like a sect than a science.”

Another blow to the profession came in the form of managed care. Now insurance companies refused to pay for seemingly unending therapy sessions that were not backed by evidence-based research.

I would add that some patients who consulted with benevolent professors or even who remained on a waiting list did better than did those who consulted with psychoanalysts.

Naturally, psychoanalysts are adapting. They have changed their ways, offered more advice, coached more of their clients. Some of them even converse with their patients.

Some are happy to continue to call it psychoanalysis. If that makes them happy, so be it. And yet, it does not fulfill the requirements of classical psychoanalysis.

In truth, psychoanalysis as we knew it is over. Still, as I have argued it continues to exercise an outsized influence on the culture.


Sam L. said...

So, you're saying psychoanalysis attracted the psychocondriacs.

Unknown said...

Stuart you are on to something. Psychoanalysis has not been able to adapt its practice to fit the market demands and the socio-political times. Many principles of good and effective therapy, however, owe much to psychoanalytic practice. Psychodynamic therapy has been adapted to short-term treatments and is superior, in my opinion, to simplistic CBT. You can still have an emotional experience of your innermost self, grieve your losses, and reignite shut down potentials, without necessarily being on the couch for several years.