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Organized psychoanalysis, having discarded the habits of isolation and divisiveness that brought it to the brink of extinction in the era of managed care and "managed competition," is fighting back.
That’s what Robert Pyles, M.D., president-elect of the American Psychoanalytic Association, said at a scientific meeting last month of the New York Psychoanalytic Society.
"I believe we are in the midst of a creative and healthy evolution in psychoanalysis and in our psychoanalytic identity," Pyle said. "To meet these challenges, we should develop nothing less than a new vision of ourselves as psychoanalysts of the 21st century and a new concept of the role of our societies, institutes, and association.
"Our methods should be education, outreach, and advocacy, each a coordinated part of an overall strategic policy," Pyles said.
It is precisely such outwardly directed activities - education, outreach, and advocacy - that psychoanalysis has lacked in the past, the legacy of a long history of isolation and infighting, he said.
Pyles traced that legacy back to Sigmund Freud himself, noting that the Viennese founder of psychoanalysis became concerned early on about the effect of scientific and medical criticism of his work.
"Freud began to turn away from his role as a scientific ‘conquistador’ to create an organization that could be relied upon to defend his psychoanalytic ideas," Pyles said. "Here was established a pattern that has become familiar to us, reacting to external threats to psychoanalysis by turning increasingly inward, ‘circling the wagons.’"
This trait has been compounded by an organizational rigidity that has survived from the earliest days of psychoanalysis, Pyles said. The structure of psychoanalytic institutes and societies is "deeply rooted in the 19th century European hierarchical tradition," he noted.
"The report of the first institute - the Berlin Institute - describes a structure that has been reproduced almost unchanged from one analytic generation to another and would be immediately recognizable by all of us, with a central education committee composed almost entirely of training analysts."
A result of this structure has been "to produce compliance and isolation," Pyles said, "with decisions being made by a senior leadership, who may be, to some degree, insulated from the internal and external community, as well as market forces."
Ultimately, the habits of isolation that have rendered the practice vulnerable to current political and economic forces originate in the very work that analysts do, Pyles said.
"Dealing hour by hour with the deepest, wildest, raging torrents of feeling in our patients and ourselves - all of our structures are designed to contain it," he said. "We are suspicious of any kind of spontaneity. We have learned to deeply distrust any tendency toward aggression and power.
"To some extent we have been trapped by our history," he added. "But what is our history but. . .a prolonged attempt to control, channel, and hopefully understand the powerful emotions contained within our work?
"Unfortunately, what is clinically useful does not necessarily translate into what prepares us to deal with rapid, profound social and political change," Pyles said.
This isolation - as well as what Pyles called the "hubris" of the profession during its heyday in the 1940’s and 1950’s - helped to distance psychoanalysis from organized medicine and from important groups such as the American Medical Association and APA.
That alienation would spell trouble for the profession when health care costs began to rise and payers began to demand efficiency and accountability.
Pyles cited two turning points that were especially critical: the development of APA’s Diagnostic and Statistical Manual (DSM) and the passage of the Employee Retirement Income Security Act (ERISA).
The former, Pyles said, heralded a "specific shift back to a neo-Kraepelinian descriptive model, and away from the humanistic and dynamic."
The latter ensured that "managed care companies and case managers can effectively dictate medical therapy decisions without concern about being held responsible for them," Pyles said.
ERISA laws "put managed care beyond the reach of any malpractice or liability suit brought within the state," he said. "It makes managed care plans and HMO’s bulletproof in regard to liability."
Together, Pyles said, the descriptive nosology of DSM and the power of managed care to dictate practice rendered psychoanalysis an easy target for cost cutters.
"DSM provided the weapon, ERISA cocked the gun, but it was the Jackson Hole group that pulled the trigger," Pyles said in reference to the informal group of physicians, health-policy thinkers, and economists credited with formulating the principles of "managed competition."
That formulation would serve as the model for the Clinton Administration’s Health Security Act, which Pyles called "the darkest hour" for psychoanalysis.
"[I]ndependent practice would have been illegal," Pyles said of the plan. "Managed care would have been imposed on all of us. For the first time, the quality of health care would not have been protected by independent practice, because there would be no independent practice."
Yet the tide is turning, Pyles said.
The "dark hour" of the Clinton Health Security Act was a "much needed wake-up call" that psychoanalysts have begun to heed.
"We have learned a great deal," he said. "We have learned that the world is not going to leave us alone. Psychoanalysis and psychotherapy will continue to be under relentless attack by profit-driven health maintenance organizations, managed care companies, and government regulators."
Pyles emphasized that managed care "rests on the thin and vulnerable reed of the ERISA legislation," and that a public backlash against managed care can reverse the situation.
"ERISA reform is like a dagger aimed at the heart of managed care," he said. "Operating through some of our new alliances, we can begin to create pressure for ERISA reform.
"We need to mount a vigorous campaign of education regarding the nature and value of psychoanalysis," he said. "Our members should be trained in the area of media contact and representation. Each society should develop its own public information committees to develop media contacts."
Pyles also said that analysts who are willing to speak to the media on particular issues should come forward and be available for public comment.