Psychoanalysis: The Next Generation1
Nancy McWilliams, PhD2
Inspiration for this column came to me suddenly, in the unlikely form of an article by Nicholas
Cummings in the summer issue of The National Psychologist. Writing under the title “Are
Graduate Students Being Deceived?” Cummings observes that since 1995, while inflation has
exceeded 15 percent, psychotherapy reimbursements from health insurance and government
sources have declined 15 percent, leaving many practitioners unable to pay off the considerable
debt they incurred during their training. He notes that referrals from physicians for psychotherapy
have fallen 40 percent to 50 percent, as doctors have learned to prescribe for problems they used
to send to therapists, and he reminds us that it is cheaper for managed care companies to hire less
educated rather than more educated clinicians. Concluding that doctoral-level psychotherapy
practice has become unprofitable, he urges students to consider other careers.
There is more than a little irony here. Cummings was an early enthusiast for the managed care
movement. As founding CEO of American Biodyne and for many years Chief of Mental Health
at Kaiser Permanente, he has presumably profited handily from that movement. Along with other
prominent psychologists, Cummings, a former APA president, was happy to supply insurers with
rationales for cost-cutting that they later used to devastate services to clients needing long-term
and open-ended therapies. Such arguments involved putatively scientific claims that therapy can
be done much faster and more cheaply than most clinicians were doing it—a demonstrably
inaccurate or, at the very least, incomplete reading of the evidence. So now a man who
contributed to the conditions that demoralize and impoverish beginning therapists is faulting
mentors and educators for continuing to train them to work in such an unrewarding environment.
As the late Kurt Vonnegut would have quipped, so it goes.
In these times when college counseling services report significantly more serious mental health
problems among students than ever before; when diagnoses of ADHD, Asperger’s disorder,
bipolar illness, eating disorders and body-image problems are ubiquitous; when huge numbers of
teenagers regularly self-mutilate; when jails overflow with the addicted, when traumatized
soldiers and their suffering families overwhelm available services; when the culture we live in
seems to have lost any respect for the examined life, I doubt that many therapists, even those who
are feeling squeezed by competition from their colleagues, believe that there are too many mental
health practitioners and that they are too extensively trained. But to give Cummings his due, it is
a hard world out there for the new practitioner—a very different world from the one that greeted
me when I was a newly licensed psychologist and aspiring analyst. And it is not much better for
psychoanalytic academics.
THE PLIGHT OF THE COMING GENERATION
In the last decade, I have felt a subtle but profound shift in attitude among graduate students
pursuing a PsyD at Rutgers University. As I lamented in an earlier newsletter column,
contemporary students know much less about psychoanalytic concepts than their predecessors
did, with the result that every year I have to start my Psychodynamic Foundations of Intervention
course at a more basic level than the year before. Once exposed to analytic ideas, however, many
fall in love with them, and for the same reason that most of us did: They make sense of the world,
1
This Presidential Column originally appeared in the Summer 2008 issue of Psychologist-Psychoanalyst
(Vol. XXVIII, No. 3, pp. 1-3) and is printed here with permission. All rights reserved.
2
Nancy McWilliams is the president of the Division of Psychoanalysis (39) of the American Psychological
Association. She is the author of Psychoanalytic Diagnosis (Guilford, 1994), Psychoanalytic Case
Formulation (Guilford, 1999), and Psychoanalytic Psychotherapy: A Practitioner’s Guide (Guilford, 2004)
of the self, of relationship. But these recent students also regard a psychodynamic practice as a
professional luxury they cannot afford.
For one thing, they have been thoroughly indoctrinated in the belief that there is no place for
psychoanalytic treatments in the contemporary health care scene. Unless they are lucky enough to
have had some psychodynamic help themselves and noticed that their therapist was making a
living, they view an analytic practice somewhat like Fairbairn’s tantalizing object: a valuable
resource available only to the blessed. That is, they believe that analytic work is limited to
patients who can afford intensive and ongoing sessions and to therapists who work in moneyed
subcultures, or who teach in institutes that supply them with candidate-analysands, or who are
independently wealthy enough to reduce their fees to accommodate frequent sessions and longer
treatments. There may be a lot of truth in this assessment.
Recently, while presenting a case to a graduate class, I noticed a sense of depression in the room
that did not seem to be accounted for by the affects infusing the therapy I was describing. When I
asked about the dysphoric atmosphere, the students told me that they were in a morass of envy
about the fact that I could work in depth with people for months or years and help them in lasting
ways. This was the kind of meaningful work that they wanted to do, that they had come to
graduate school to learn how to do—but now they could not imagine doing it. If they saw any
possibility of such a career for themselves, it would be far, far in their futures, and it would
require their selling their souls for years to agencies or a managed-care practices where they
would have to attend more to paperwork than to patients, where their caseloads would be too big
to permit genuine caring for all their clients. These students are analytically oriented, but they are
diligently learning to do EMDR, DBT, various CBT treatments, and other structured approaches
that are currently in favor with reimbursing bodies.
It seems clear that would-be analytic practitioners are facing the future with a pervasive
pessimism. Their academic peers seem to be struggling just as painfully. I keep hearing stories
about analytically interested psychologists whose department chairs have insisted that they either
distance themselves from all things psychoanalytic or jeopardize their chances of getting tenure
or promotion. Some professors have been explicitly discouraged from publishing in
psychoanalytic journals, including Psychoanalytic Psychology, despite the fact that it is an APA
peer-reviewed journal. Others have been urged to omit from their CVs any mention of their
membership in Division 39. The general rule seems to be that they can study whatever they are
interested in, but woe to them if they characterize that work as psychodynamic. When Jim
Hansell tried to publish a psychoanalytically friendly abnormal psychology textbook (see Hansell,
2005 for his mordantly funny account); similar prohibitions applied.
PROTECTING A PSYCHOANALYTIC FUTURE
What can Division 39 do to help the next generation of psychoanalytic clinicians, researchers,
scholars, and teachers as they cope with the current environment? First, we can offer support and
mentoring. We have three active committees oriented toward members in beginning or
preparatory phases of their careers: one that serves early-career professionals, one that mentors
aspiring academics, and one that addresses the needs and interests of candidates in psychoanalytic
training programs. Under the initial leadership of David Ramirez, we have reorganized our fee
structure so that early-career members can save some money on membership and conference
costs. We have made access to the PEP archive as affordable as we could manage. We continue
to look for ways to be of help to our younger and upcoming members and are open to all
proposals to extend that assistance.
We are also fighting on various fronts to correct the record about our tradition. One arm of the
American Psychoanalytic Association’s “10,000 Minds” project, for example, with which we
collaborated, systematically informs publishers of psychology texts about errors that their authors
have made in describing psychoanalytic history, concepts, and treatments. Despite considerable
anti-analytic bias on mainstream psychology editorial boards, the Division’s researchers are
continuing to get their work published. Jonathan Shedler (2008) recently finished an article that I
hope will appear in the American Psychologist in which he convincingly argues, on the basis of
exemplary research, that (1) empirical evidence for the efficacy of psychodynamic therapy is as
strong as that for other therapies that have been actively promoted as “empirically supported,” (2)
after ending psychodynamic treatments, patients maintain their gains and keep improving, and (3)
a major contribution to the effectiveness of nonpsychodynamic therapies are the psychodynamic
elements within them (e.g., attention to the relationship), not the particular techniques employed.
Second, we can survive. I do not mean this facetiously but in the profound way that Winnicott,
Pine, Eigen, and others have written about the importance of the analyst’s survival. We need to
keep doing what we believe in while the evidence accumulates, as it has been doing, that
psychoanalytic concepts and treatments are valid and effective. We need to become familiar with
the already abundant empirical evidence of their worth so that we can respond effectively to
critics of psychoanalytic approaches and counter the myth that our work lacks empirical support.
Beginning therapists probably do need to be conversant with many techniques that are not
psychodynamic, but they can be encouraged to do so without losing a psychoanalytic overview. If
we have to keep psychoanalysis alive as a niche treatment, we will still be keeping it alive. I
personally look forward to frustrating the considerable number of our non- and anti-analytic
colleagues who are impatiently waiting for us all to die off.
I think we are starting to see evidence of a swing of the proverbial pendulum back toward more
sanity about mental health and health care in general. There is beginning to be some
acknowledgment, even in cognitive–behavioral strongholds, that short-term CBT therapies have
been oversold (just as psychoanalysis was originally oversold as a universal panacea). The limits
of symptom-focused techniques and what Freud called “suggestion” are being rediscovered.
Managed health care is almost universally hated. Pharmaceutical companies are undergoing
increasing scrutiny about their procedures for studying and marketing medications.
The coming election may open up new ways of talking about what is needed. Paul Krugman’s
(2008) analysis of the recent Medicare victory is that it represents the critical first step away from
the subsidization of the private insurance industry in favor of valuing doctors and patients over
insurance company profits. On the cultural front, a coalition of mental health professionals, child
development experts, and psychoanalysts barraged NBC sufficiently that it canceled further
production of a horrifying reality show, The Baby Borrowers, in which infants and toddlers were
handed over for three days to teenage couples so that they could learn, amid the child’s
traumatization, that they were not fit parents. “Sometimes,” Kerry Kelly Novick noted in
announcing this accomplishment, “our efforts bear fruit out in the world.”
Life is never static. Empires rise and fall. Intellectual movements become hot and then get
replaced by the next new thing. The academic and service environments in which my generation
came of age will certainly evolve and change, and despite the attractiveness of the myth of
progress, not necessarily for the better. Given that stark fact of life, psychoanalysis has actually
survived pretty well—certainly far longer than the strict behaviorism that once was its most
serious intellectual adversary. Psychoanalytic therapists will survive because we help people to
understand themselves and to cope with life, and because people who are helped that way spread
the word. And psychoanalytically oriented research will survive, notwithstanding the fact that
most academic psychologists have always been ambivalent at best about psychoanalysis and are
now in the habit of couching their objections in vague references to “the data.” It is still possible
to ask psychoanalytic questions and pursue psychoanalytically oriented scholarship and research,
whether or not the pursuit is tagged that way.
It is hard to know whether psychoanalysis will survive in the language we currently speak or
whether it will be reinvented in nomenclature more compatible with other intellectual traditions.
As their orientation matures, cognitive–behavioral psychologists are discovering the same
phenomena we have been talking about for decades and calling them by new names (“implicit”
instead of “unconscious,” for example). The next generation will have to make accommodations
to the world they inherit, and perhaps they will have to change some of our favorite terminology
in order to be a valued part of that world. But let us hope that, unlike Dr. Cummings, who
counsels capitulating to market forces that undermine people’s access to desperately needed
psychotherapy services, psychoanalytic professionals in the upcoming generation will work to
preserve the best elements of a tradition that values the whole person, recognizes individuals’
unique subjectivities, endorses the search for meaning, and enables the emergence of the most
authentic aspects of self.
REFERENCES
Cummings, N. A. (2008). Are graduate students being deceived? National Psychologist, July/August, p. 14.
Hansell, J. (2005). Writing an undergraduate textbook: An analyst’s strange journey. PsychologistPsychoanalyst, 24 (4), 37-38.
Krugman, P. (2008). Kennedy’s big day. New York Times, July 11, p. A 17.
Shedler, J. (2008). The efficacy of psychodynamic psychotherapy. Unpublished manuscript.