"There is no doubt that the organization is hierarchical, and that the people in charge do not extend an attitude of invitation and incorporation to the younger generation and to the people on the periphery," complained the pseudonymous psychoanalyst Aaron Green in Janet Malcolm’s 1980 Psychoanalysis: The Impossible Profession. "Interesting, isn’t it? That a profession which gears itself so much to progressive maturation should conduct its education as an infantilizing experience."

Malcolm’s work was a widely read and acclaimed portrait of psychoanalysts practicing a nearly ascetic craft—an impossible profession—removed from the concerns of the larger community and all but inscrutable to the public. And it sketched a picture of the institutes where psychoanalysis is nourished and future analysts are educated as furtive hothouses of intellectual intrigue and insularity.

It was also a portrait of a profession on the verge, unwittingly, of a great fall, before managed care would transform the landscape of American medicine. Twenty years later—in the age of Prozac and short-term therapy, when genetic theories have usurped the popular cachet that once belonged to Freud, and with the Viennese founder derided by critics who scorn his methods as unscientific and his theories as anachronisms—what has happened to psychoanalytic training? What has become of the institutes whose secretive nature was captured by Malcolm in her description of "decrepit mansions with drawn shades"?

Detractors may be surprised to learn that the mansion has been refurbished, and the shades are up. Analytic training is on the rebound, with a 10 percent increase in the number of candidates over the last decade, a renewed interest in reaching out to surrounding communities and other disciplines, and a more receptive, less rigidly authoritarian disposition toward its candidates.

"In some ways, all that has happened to us has been a real wake-up call," said Robert Pyles, M.D., president of the American Psychoanalytic Association. "It has been to the health of psychoanalysis that we have begun to understand the need to interact with our communities, including with colleagues in other disciplines and knowledge bases. The result is that we are getting a much more forward thinking and healthier psychoanalysis. I think it has had a highly beneficial effect on the field in general."

Pyles and other leaders who spoke with Psychiatric News agreed that some psychoanalytic institutes have been more successful than others. And to be sure, the newly polished image may be the window dressing of a profession that has learned to play the American game of "spin": the American Psychoanalytic Association now employs a public relations consultant, and many institutes have elected public relations officers.

But it is equally clear that authentic changes in the way institutes train candidates and relate to the larger community have occurred. Some of these have been necessary responses to changes in the world outside the institutes. In other instances, the enduring need for psychoanalytic treatment and the sturdiness and maturation of analytic theory itself have given rise to a more protean profession.

The most obvious indication that psychoanalysis is thriving is the increased number of candidates in training. In 1997-98, 995 candidates were training at the 29 institutes affiliated with the American Psychoanalytic Association. This figure is up from the low of 909 in 1989-90, and edging toward the high of 1,184 in 1980-81.

Supporters and skeptics would be quick to point out that a large and increasing number of these candidates are nonmedical professionals. Approximately 41 percent of the 1998 candidates—407 of the 995—do not have a medical degree; these are psychologists, social workers, and educators. The result of a lawsuit by the psychological profession that ended the ban on nonphysicians entering institutes affiliated with the American Psychoanalytic Association, it is a development that is bound to have profound implications for the relationship of psychoanalysis to psychiatry and organized medicine.

Pyles noted that the medical exclusion was an idiosyncrasy peculiar to American psychoanalysis; European countries have long admitted nonphysicians, and many of the brightest lights in psychoanalysis have not been medical doctors.

"I think [the influx of nonmedical candidates] has greatly enriched the cultural and academic life of institutes because what you get are different disciplines bringing their traditions to a much richer discussion," said Pyles.

The decline in the status of psychoanalysis—both in general and within the hierarchy of psychiatric departments at academic medical centers—has also had a paradoxically beneficial effect on the quality of recruiting at institutes: People who enter analytic training now are liable to be doing it out of an authentic dedication, not to pursue academic success.

"We get people who are dedicated because of their interest in psychoanalysis, unlike in the 1950s, when many people took psychoanalytic training to punch an academic ticket," said Ronald Benson, M.D., chair of the Committee on Institutes at the American Psychoanalytic Association and a training and supervising analyst at the Michigan Psychoanalytic Institute and Society.

Jerome Winer, M.D., director of the Chicago Psychoanalytic Institute, noted that in earlier times a psychiatrist who wanted to be the chair of a department had to be an analyst. "Now, if you are an analyst, you cannot be a chair because you don’t control biologic research grant funding."

Far from believing that analysis has been harmed by the inclusion of nonmedical candidates, analysts say it is psychiatry that stands to lose by divorcing itself from its psychoanalytic roots. And they say that the institutes are picking up the slack in psychodynamic training, where psychiatry departments are falling short.

"I think the skills of psychotherapy have been largely lost in psychiatry departments," said Benson. "Psychoanalytic institutes are going to carry the burden of teaching those skills until the worm turns in academia."

Similarly, leaders in the field say analysis and analytic training are thriving—and will endure—because of public dissatisfaction with the current trend toward short-term therapy.

"Profit-driven managed care focuses on giving as little care as possible with people who are as little trained as possible," Pyles said. "In a managed care outfit here in Boston, psychiatrists are used only for medication dispensing. You get 15 minutes per patient four times a year. What we are getting is the fallout from this failed system. In fact, I think managed care is making us look very good."

But leaders are quick not to paint too rosy a picture. "We are in good shape, but not in overwhelmingly wonderful shape," said Benson. "There is an overall decline in psychiatry, social work, and psychology because of the relatively low status of helping the mentally ill. But within that framework, our membership is rising."

Benson acknowledges the flip side of the influx of nonmedical candidates: without those candidates, the institutes would be in grave trouble. And he noted that the fate of psychoanalysis continues to be tied to the fate of psychiatry.

"If psychiatry falls, then we fall," he said.

Training institutes continue to tout low-fee and sliding-fee analysis for people who cannot pay the going rate. But the future of institutes may lie not in training practitioners to perform analytic treatment, but in the transmission of analytic theory for application in a host of other nontreatment settings.

"It has always been true that psychoanalysis would never be able to treat large numbers of patients," said Pyles. "The idea has always been to use psychodynamic knowledge in a variety of ways."

Analysts agreed that much of the reputation for insularity at training institutes derives from a tradition dating back to Freud. The challenge of Freud’s theories to conventional wisdom—combined with the pervasive anti-Semitism of his time—caused psychoanalysis to seek shelter away from the academic establishment in freestanding institutions. The structure of institutes begun by Freud’s earliest followers tended to replicate a German academic training model—hierarchical and authoritarian. Added to this has been a custom of analytic training that some have thought peculiar—it requires candidates to undergo their own personal training analysis, which would be analogous to requiring a surgeon to undergo surgery to learn to operate.

For many years supervising analysts would write reports on the candidates’ progress in analysis—a practice that tended to subvert the privacy of analysis.

"When I was in training, there was a feeling of hierarchy, and since the analysis was conducted by some member of the faculty, you always had the feeling of scrutiny," said Pyles. "It was a model that tended to create a certain amount of compliance in the followers and graduates."

The result was an ethos of inwardness that survived through the generations and caused psychoanalysis to shun involvement in issues or concerns outside the institute. "In the 1950s I don’t think psychoanalysts were very interested in their communities," said Benson. "They were interested in advancing their theories with their own people."

Benson suggested that some of the change that institutes have undergone with respect to their surrounding communities has resulted from the maturation of psychoanalytic theory itself. In the past, protection of the transference—the all-important relationship between patient and analyst—from the contamination of outside influences was a paramount concern. For this reason, it was all but forbidden for an analyst or institution to take public stands or make public commitments.

"Historically, we have sought to protect the treatment from suggestion and to maximize the patient’s insight and autonomy," Benson said. "Our theories used to hold that if our patients knew our opinions, they couldn’t help but submit to them, but we have found that that is not true. Neither the patient nor the psychoanalytic situation is as fragile as we once thought it was, providing a theoretical reason for being interested in the community."

Now, analysts believe that active outreach to the community can only accrue benefits to the profession. "The more people we interest in psychoanalysis, the better off we are as psychoanalysts, financially and intellectually," Benson said.

Analysts say that the Chicago Psychoanalytic Institute has been a pioneer in extending psychoanalysis beyond the confines of the consulting room. Last month the Chicago Psychoanalytic Institute sponsored a conference on clinical issues in the treatment of gay and lesbian patients.

In May, during APA’s 2000 annual meeting in Chicago, the Chicago Psychoanalytic Institute will sponsor a similar program on psychoanalytic understanding of violent behavior in the community. The institute has an active outreach to allied disciplines in the Chicago area including teachers, social workers, and social service agencies, and a full curriculum of adult education classes for the layperson interested in learning about analysis and the history of the profession. The Harris-Barr Children’s Grief Center at the Chicago Psychoanalytic Institute serves children of any age who have lost a parent through death, divorce, or abandonment.

"We here in Chicago have always done other things [than train candidates]," said Winer. "We are one of the bigger institutes in part because we have all these allied programs. Some of the smaller institutes that have just the core program of training are realizing now that if they stay in that narrow focus, they may not be around."

Similarly, the extension division of the Michigan Psychoanalytic Institute has provided courses, consultations, and presentations for clinics, hospitals, and agencies in the surrounding community.

Analysts in the Professional Educator Program provide support and information to anyone who has relationships with students, from preschool through university: directors of educational programs, teachers, mental health staff, and parents.

The New York Psychoanalytic Institute is sponsoring an "open house" next month on "Training to Be a Psychoanalyst in the New Millennium." The institute’s Parent-Child Center touts itself as a "a unique place for parents to find out that they are the real experts for their children."

And the institute has developed a program in neuropsychoanalysis and an accompanying journal that looks at the links between psychoanalytic theory and the most recent findings in neurology and brain imaging.

Intellectual fads come and go. Freud, very definitely "out" for a period, has enjoyed a modest millennial comeback, as evidenced by his inclusion in Newsweek magazine’s list of the 100 most important thinkers in the 20th century. Leaders in the field believe that psychoanalytic theory is sturdy enough to last for the long haul; the most radical insights of psychoanalysis—about the formative nature of early childhood experience and the ubiquity of transference—continue to inform all types of treatment, as well as child-rearing and education.

"Freud has always aroused a tremendous amount of passion—even very early on he managed to provoke the Victorian culture by suggesting that children had sexual feelings," Pyles said. "There has always been this attempt [to banish psychoanalysis], but his theories of the mind don’t seem to go away. They are embedded in the culture."