March 5, 1999

By Norman A. Clemens, M.D.

Psychoanalysis continues to be an active and vital part of American psychiatry. APA President-elect Allan Tasman, M.D., is the latest of a long series of analysts who have led APA in recent decades as officers in the Board and Assembly, and both candidates in the 1999 APA election for president-elect were analysts. The membership of APA's Commission on Psychotherapy by Psychiatrists, which I chair and Glen Gabbard, M.D., cochairs, includes seven analysts as well as others who have been extensively trained in psychodynamic psychotherapy.

The membership of the American Psychoanalytic Association (APsaA) has increased to 3,255, of whom 82 percent are psychiatrists. The membership of the American Academy of Psychoanalysis, which overlaps somewhat, counts around 700 physician analysts. Psychoanalysts in psychology and social work organizations bring the number of trained analysts in the U.S. to approximately 9,000. The 29 institutes and four new training facilities of the APsaA are currently training 972 analysts to be, of whom 58 percent are psychiatrists. New training facilities continue to develop. Many psychoanalysts direct psychiatric residency training programs or supervise residents in their psychotherapy training.

Although psychoanalytic practice in the U.S. has declined somewhat over the past 20 years, by a factor of about 1 percent a year, it remains quite vigorous. Fully trained members of the APsaA in 1996 had a mean number of 3.93 patients in full-scale psychoanalysis, in addition to their psychotherapy practices or other professional activities. Psychoanalytic practice and training are flourishing in many other parts of the world, so that it is likely that more people are in analysis worldwide than ever before.

In the 1996 survey conducted by the ApsaA, 15 percent of patients of graduate analysts had five sessions a week, 55 percent four sessions a week, and 30 percent three sessions a week. The APsaA standard for frequency of analyses of trainees and their supervised patients is five times a week. In surveys in the U.S. and Ontario, the average length of a psychoanalysis carried to a mutually satisfactory termination is approximately five years or 1,000 sessions, with U.S. analyses being slightly longer than Canadian. The fact that medical psychoanalysis is fully covered under Ontario's universal health insurance, whereas it is infrequently covered substantially by insurance in the U.S., indicates that the length of analysis is not determined by insurance subsidy. It was estimated in testimony on the Clinton health plan in 1993 that, at an average fee of $100, psychoanalysis in the U.S. costs less than 1 percent of all treatment of mental illness. Psychoanalytic societies and institutes across the U.S. arrange analysis at reduced fees for lower-income patients.

The criteria for selection for psychoanalytic treatment are rigorous. Neither patient nor analyst wants to embark on an expensive and time-consuming procedure without clear necessity and anticipation of benefit to the patient. Generally the difficulties that bring people to analysis are long-standing, symptomatic, and significantly detrimental to relationships, function, and/or well-being. In the U.S. and Ontario, surveys have consistently showed that 82 percent of patients have had previous mental health treatment that evidently they had found insufficient, and that they had a mode of two and a mean of four DSM diagnoses, commonly including one or more from Axis II. They also showed high rates of childhood physical or sexual abuse, traumatic separations, and early childhood loss. A growing proportion of analytic patients are concurrently on medications, sometimes prescribed by the analyst and sometimes by another clinician. Yet the successful conduct of psychoanalysis also requires important personality strengths, such as capacity for relationships and self-observation, strong motivation to overcome difficulties through understanding, and the ability to tolerate frustration and safely manage intense emotional states.

Psychoanalysis and psychoanalytic psychotherapy require absolute confidentiality. This standard was recognized by the U.S. Supreme Court in 1996 in the Jaffee v. Redmond decision, in reasoning explicitly referring to the psychoanalytic model. Subsequent lower court decisions around the country show the influence of that decision. In the current health care environment that increasingly demands the revelation of physician-patient interactions to third parties, many analysts have refused to engage in managed care or government insurance programs rather than risk damage to analytic treatment.

Scientific methods of studying phenomena must be appropriate to the subject at hand. The psychoanalytic method has yielded a wealth of knowledge about mental function, some of which is beginning to correlate with neurobiological studies. The knowledge base of psychoanalysis has been built up over a century of individual case studies, theoretical modeling, vigorous debate, controversy, and consensus building in professional organizations and peer-reviewed psychoanalytic journals. Because of the duration, intensity, and privacy of the psychoanalytic treatment process, and the uniqueness of each individual patient, no one has successfully devised a randomized, controlled, double-blind method of studying psychoanalysis. Since psychoanalysis treats a person rather than a narrow symptom complex, diagnosis-related studies have begun to appear only recently. However, there is a substantial body of literature that demonstrates the efficacy of psychoanalytically based treatments as well as cost-effectiveness through reduced disability and use of general medical services.

Dr. Clemens is the chair of APA's Commission on Psychotherapy by Psychiatrists and Area 4 Trustee. He is a training analyst in the Cleveland Psychoanalytic Institute and a clinical professor of psychiatry at Case Western Reserve University.