It's Ba-a-ack! Psychoanalysis Returns From the Near-Dead

From the WebMD Archives

Dec. 19, 2000 -- All across the globe, more and more men, women, and children are lying on couches and talking until they're blue in the face, but not in the head.

This is why the overall mood was so upbeat at a recent meeting of the American Psychoanalytic Association in New York City.

Psychoanalysis is based on the observation that people are often unaware of the many factors that make up their personal emotions and behavior. These unconscious factors may create unhappiness, troubling personality traits, difficulties in work or in relationships, or disturbances in mood and self-esteem. Typically, a patient comes to therapy four or five times a week, lies on a couch, and attempts to say everything that comes to mind. These conditions permit the emergence of aspects of the mind that are not normally accessible. Sigmund Freud (1856-1939) is considered the father of psychoanalysis.

The approach fell from grace about 10 years ago due in large part to cost-cutting efforts by managed care companies and the availability of Prozac and other drugs for emotional disorders.

Until 1996, the number of patients in psychoanalysis declined by 1% per year, but "my impression, from anecdotal data, is that it's going back up," says Leon Hoffman, MD, a New York City-based child psychoanalyst and chair of the American Psychoanalytic Association's committee on public information.

New York City psychoanalyst Arnold David Richards, MD, agrees.

"There are more people practicing psychoanalysis than ever before, and there are probably more patients," says Richards, editor of the Journal of the American Psychoanalytic Association. "For many years, there was just a small group that practiced psychoanalysis, but now, other mental health professionals, such as social workers and psychologists, can receive special training in the discipline ... and there are also more analytic institutes doing this type of training than ever before."

Ten years ago, he says, fewer candidates were applying to become analysts, institutes were going broke, and psychoanalysts had lost their power in medical school psychiatry departments.

Fueling this apparent resurgence, Richards says, is a growing sense that "a pill can't change a person's life or change the way a person deals with complicated personal and interpersonal problems.

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"And training-wise," he adds, "doctors are realizing that learning which pill to prescribe isn't that helpful, because after you write up the prescription, what do you do for the next 40 minutes?"

To keep up with changing times, psychoanalysts are also finding new markets for their trade. For example, some analysts treat entire corporations, with the intention of helping them unlock their profit-making potential. Others are honing their craft in nursery schools by helping teachers and parents realize how certain behaviors may mask psychological patterns or problems.

That's not to say the road ahead is completely clear. Two hurdles that remain are time and money. To address the problem of money, many analytic institutes now adjust fees on a sliding scale to make therapy affordable to all.

Which leaves the issue of time, and that's a tough one.

Ideally, analysis is scheduled " four or five times a week -- [because] you can't dig the Suez Canal with a spoon," Richards tells WebMD.

In the U.S., the average time it takes for a patient to complete psychoanalysis is a little more than 5 years -- and most American patients end up paying the full cost themselves because of insurance restrictions, he says. In Canada, where psychoanalysis is covered by insurance, the mean duration is less than 5 years.

Even factoring in time spent, the benefits of analysis can be astonishing, Richards says.

"My experience, in terms of my own patients -- books written, movies produced, and jobs gotten -- is that without analysis, patients would not have achieved what they have achieved," he says. "There is no other place that you can talk in an atmosphere of complete confidence and complete acceptance."

Hoffman credits the resurgence of psychoanalysis to several factors, including a greater visibility for psychoanalytic principles in legislative and judicial arenas, as leading analysts weigh in on hot-button issues such as the privacy of medical records and patient/therapist confidentiality.

Furthermore, psychoanalysis is getting a face-lift in the media on shows like HBO's The Sopranos, where psychoanalyst Jennifer Melfi (played by Lorraine Bracco) is successfully treating mobster Tony Soprano (James Gandolfini) for his recurrent panic attacks.

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And thanks to managed care and its demand for "evidence-based medicine" -- meaning insurers won't pay for a treatment unless there is hard data that it both works and is cost-effective -- psychoanalysts have had no choice but to develop outcome- and process-based studies showing that talk therapy works.

And it may give you more time to talk, too, Richards tells WebMD.

A study in an upcoming issue of the Journal of the American Psychoanalytic Association will report that male psychoanalysts live longer, on average, than men in the general population, he says -- longer, even, than men in other medical specialties.

The reason? All analysts are also in analysis, and something about all this talk may enable people to clear their conscious and live longer, healthier, and more fruitful lives. Or so the theory goes.

For one, Sally Satel, MD, a psychiatrist at the Oasis Drug Treatment Clinic in Washington, D.C., has some reservations about psychoanalysis.

"If someone is otherwise well functioning and wants to pursue self exploration and pay for it, that's fine, but if we ever get to the point where people with serious mental illness who do need medications are being seen by analysts, that would be a step backward," Satel says.

"The questions are: Who are good analytic candidates? Should analysis last [for] years on end? Who should pay for analysis?" she says. "Analysis should never be covered by insurance."

At the same time, she admits, the carte blanche use of medications is also distressing.

"In some health maintenance organization settings, where doctors are so limited in the time they can give to patients, there is pressure to prescribe first and talk later -- but the order should be other way around," she says. "When primary care doctors start prescribing psychiatric medications, they often do it too quickly, give wrong doses or too many pills at one time, and don't do follow-up. This is potentially as irresponsible as psychoanalysis without medication in people with severe mental illness," she says.

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