Crisis in Psychoanalysis

Word has reached nearly everyone who knows anything and quite a few who know very little: Psychoanalysis is passé, dying, outmoded. Out.

And, hence, not to be mentioned publicly except in scornful, knowing tones. Cocktail-party pundits and stay-at-home intellectuals, the literary avant-garde and book-shunning social militants, New Left activists, pseudomasculine feminists and law-and-order conservatives all suddenly find it in fashion to sneer at psychoanalysis and to assert that what it labors long and ineffectively to do can be quickly and effectively done today by other methods: by drugs, for instance--Miltown to calm you down, Elavil to lift your spirits, Dilantin to check your rages; by behavior therapy--if rats, cats and dogs can be "conditioned" into a neurosis and then deconditioned out of it by laboratory "rewards" and "punishments," so can you; or by such new, Now, turned-on techniques as encounter groups, weekend marathons, sensitivity training, awareness groups, hypnoanalysis, touch therapy and other forms of instant break throughs, existential reality, therapy as fun.

News of the deathbed throes of psychoanalysis has gone around not only by word of mouth but in print--and lots of it. Without making a complete search, I easily found over 70 such articles in popular as well as technical publications in the past five years. Significantly, many had been written by psychoanalysts who were either flagellating themselves and their fellows with the whip of self-criticism or viewing the present and future of their profession with gloom. In Harper's, Dr. Donald Kaplan, a busy and respected practitioner in New York, pessimistically wrote about "The Decline of a Golden Craft" and asserted that psychoanalysis was fast vanishing. Dr. Thomas Szasz, a psychoanalyst and professor of psychiatry at the Upstate Medical Center in Syracuse, New York, and perennial gadfly to his own profession, has said in The New York Times and many other places that it is dying because, among other things, it was captured some time ago by the medical profession and thenceforth founded upon a "big lie"--the "myth" that mental ills are medical diseases. (They aren't, Szasz claims: they're just poor or unacceptable ways of handling life situations.) The New York Times, in a special roundup article last year, quoted a number of anti-analytic psychiatrists and renegades from analytic practice to the effect that psychoanalysis was all washed up; and some months ago, Time magazine, surveying "Psychoanalysis in Search of Its Soul," did much the same thing.

Many loyal psychoanalysts who would never make such confessions or charges in public have done so within the closed circle of their compeers. Dr. Leo Rangell, addressing a meeting of the American Psychoanalytic Association when he was its president, some years ago, told his audience that the profession was in critical period of "drift and doubt." Dr. Jurgen Ruesch, an eminent practitioner in San Francisco, wrote in Science and Psychoanalysis of the severe "status decline" of his profession, lamenting that in movies such as What's New, Pussycat? and Casanova 70, psychotherapists are portrayed as "lecherous, effeminate, confused, ineffective, deviant and, above all, ridiculous." Other psychoanalysts have told each other that their profession has made no important discoveries in many years, that the frontiers of psychology and psychiatry have moved elsewhere, that the institutes of psychoanalysis are having trouble getting enough high-grade applicants for training and that many practicing analysts are suffering from dwindling practices. Summarizing, Dr. Judd Marmor, a past president of the American Academy of Psychoanalysis, recently said, "The handwriting is on the wall for all to see. Psychoanalysis is in serious danger."

With friends like this, who needs enemies? But psychoanalysis has plenty of them and they're currently in full cry. Psychiatrist William Sargant, writing a polemic in Atlantic Monthly, asserted that "the claim of psychoanalys is to be able to get at the cause and treatment of mental illness is based on blind Freudian faith engendered on the couch rather than by any proven scientific fact.... There has never yet been any really satisfactory evidence published to show the special types of patients who can be helped, let alone cured, by Freudian methods of treatment." Psychologist james V. McConnell, proclaiming in Esquire that "Psychoanalysis Must Go," terms it antiquated as a psychology and ineffective as a therapy. And not just ineffective; he actually portrays it as a hindrance to getting well, saying that while psychoanalysts are probably "nice guys" and well meaning, the therapy they employ interferes with the neurotic's natural tendency to get better by himself and makes his neurosis last longer than need be.

This charge is only a repetition of what other behaviorist psychologists have been saying for some years. Their brand of psychology, largely based on laboratory studies of animal behavior, is thoroughly anti-Freudian, and most of them reject in its entirety the vast body of clinical observations, therapeutic methods and theoretical constructs that psychoanalysts have accumulated over the past 70-odd years. Their most articulate and best-known spokesman is H. J. Eysenck, a British research psychologist (not a therapist) who has argued in books, technical monographs and even in popular articles in mass magazines that psychoanalysis is not only a fraudulent theory but a distinctly harmful therapy. He maintains that two thirds of untreated neurotics get well on their own within two years, while less than half of those who receive therapy do so--from which it would appear that therapy actually retards recovery. This would be a devastating attack on analytic therapies but for one major flaw: Dr. Eysenck has compiled his statistics by adding up the results of a number of different studies made by different people and using different definitions of "neurotic," "recovery" and the like, yet he treats the figures as if they were all comparable. Even some of the most thoroughgoing anti-Freudians have been unable to accept his conclusions, much as they would like to.

Only one enemy of analysis has even more vigorously asserted that it is wholly lacking in value and validity. Dr. Albert Ellis, a New York psychologist and inventor of his own brand of therapy, had used psychoanalysis for about three years: it didn't work very well for him, he says, and he has been criticizing it in print ever since. In a recent article, for instance, he says that probing the past is irrelevant and unnecessary, that psychoanalysis encourages the patient to wallow in feelings rather than do something about the mess he's in, that it makes him a conformist, that it makes him dependent upon the analyst, that it takes the best years of his life and a lot of his money and, in sum, that it does him not only no good but a lot of harm.

This should not upset Dr. Ellis, since he believes that psychoanalysis is practically dead already. Yet he and many other enemies of analysis continue to attack it energetically and to denounce it in savage polemics, which seems more than a little odd: If psychoanalysis is on its deathbed, already cold in the lower extremities and rattling in the throat, why bother to do battle with it? Why exert oneself to slay what is so nearly a corpse?

And even if it were not in extremis. why this elephantine alarm at the sight of a mouse? For such it is, in numerical terms. Only about 1700 physicians in this country--a mere ten percent of the nation's psychiatrists within the American Psychiatric Association--have taken advanced training and become psychoanalysts; in addition, only about 700 to 1000 psychologists--two percent of the total--and a smattering of social workers have done the same thing after getting Ph.D.s or M. S. W.s. All told, there are no more than 2500 to 3000 well-trained psychoanalysts in the United States. And since, on the average, each of them has only about eight patients in individual analysis (plus others in less ambitious forms of therapy), there can be no more than 20,000 to 24,000 persons in the whole country currently in the process of psychoanalysis. This is only one half of one percent of the total number of Americans currently receiving some form of psychological or psychiatric treatment and about one tenth of one percent of all Americans who have any major or minor form of emotional or mental disorder.

Why, then, the intensity of the attacks and the disproportionate amount of space allotted to hopeful obituaries of both theory and therapy? Because figures can and do lie: Psychoanalysis, despite its minuscule numbers and its recent bad publicity, has had--and still has--immense influence. Friends and foes alike agree that the training of American psychiatrists, clinical psychologists, psychiatric social workers (including marriage counselors) and pastoral counselors is largely dominated by psychoanalysts or people who are analytically oriented. Only psychoanalysts are trained to probe the unconscious and to deal with the explosive materials they may find there: but all the others, though they are not directly concerned with the unconscious, are taught to think about their patients' difficulties in such "psychodynamic" (psychoanalytic) terms as repression, projection, sublimation, transference, regression, the anal character, the oral character, and many others. In sum, in America today, the diagnosis and treatment of emotional and mental ailments is very largely governed by psychoanalytic concepts.

Equally pervasive is the influence of psychoanalysis on American intellectual life. Educators, ministers, writers, literary critics, historians, anthropologists, sociologists and criminologists have all absorbed various Freudian concepts into their own disciplines. The truant pupil is viewed as a troubled child, not a naughty one; the Nazi mentality is seen, in part, as the outgrowth of a rigidly paternalistic family life; a growing number of criminals are adjudged mentally disturbed and sent to hospitals rather than prisons, or are imprisoned but given group therapy; and in many novels and films, the past is brought in as often, and fantasy and symbolism used as meaningfully, as in analytic sessions or dreams. Sociologist Philip Rieff sweepingly says that Freud's writings constitute "perhaps the most important body of thought committed to paper in the 20th Century" and that this body of thought "has changed the course of Western intellectual history."

And even the thinking of everyman. Virtually everyone who reads a newspaper, goes to the movies or watches television is quite at home with certain assumptions derived from analysis: for instance, that much bad behavior is caused not by wickedness but by emotional sickness, that physical diseases often have psychological causes, that even little children have sexual desires, that the real reasons for the way an adult acts are often the forgotten experiences of his childhood. Which is not an unmixed blessing: for along with increased understanding of ourselves and others, it has led too many of us to reject responsibility for our own actions. Criminals, militant blacks, student rioters--and everyday run-of-the-mill citizens who drink too much, or gamble, or commit adultery, or are mean to their kids--often use their childhood experiences and their unconscious as the easy cop-outs, the routine apologia for their aberrant behavior.

No wonder the barrage is so intense, the deployed forces so large: What is under attack is no minute subspecialty of medicine but the dominant force in the whole field of mental health and a major philosophic influence in our culture.

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Incredibly enough, all this stems in very great part from the work of a single man. When Sigmund Freud was studying medicine in Vienna in the late 1870s, the prevailing view of mental illness was organic: Psychiatrists thought that each kind of mental disorder had a specific (if still unknown) physical cause--a weakness of the nerves, a lesion of the brain, a toxicity of the blood stream. Freud himself accordingly began his career as a neurologist and, like his colleagues, administered cocaine, mild electric currents and other physiological therapies to his neurotic patients. Unlike his colleagues, however, he soon recognized that these did little good and turned to psychological methods. At first he and a collaborator, Dr. Josef Breuer, used hypnotism to eliminate symptoms through suggestion, but shortly they recognized that under hypnosis, a patient could recall painful repressed experiences that seemed related to the symptoms, and that ventilating their bottled-up emotions seemed to bring major relief. The results, however, were temporary, and Freud, working by himself, sought a better method both of investigating the patient's past and of maintaining the improvement in his condition. Freud found the answer in free association--a procedure in which the patient, not under hypnosis, lets his thoughts wander freely and says out loud whatever comes into his mind. The way he proceeds from one thought to another not only reveals the hidden interconnections of his mind and the structure of his neurosis but allows him to gradually remember his hidden feelings and to "work them through" consciously until they no longer exert a malign influence on him.

This "talking cure" (as one of the first patients called it, for want of a better name) is the heart of psychoanalytic therapy. Although it is slow, expensive, trying (involving a tricky and sometimes painful interplay between patient and therapist) and far from infallible. Freud found it much superior to any other then-existing way of treating the neuroses. Even more important, it was the first--and remains the most important--technique for investigating the unconscious workings of the mind.

Peering deep into areas of the psyche no one had seen before. Freud began to formulate a psychoanalytic psychology--not just of the sick human being but of the well one. Indeed, the most significant, the truly revolutionary aspect of Freud's psychology was his recognition that mental illnesses are not separate entities, like bacterial infections, but exaggerations of normal processes that go on within every healthy human being. We all begin life as selfish, aggressive, lustful little animals; we all learn that in order to live with our parents and with society, it is necessary to obey certain rules, set limits on the natural desires, forbid ourselves certain kinds of behavior. We all, therefore, experience painful inner conflicts as children, which we deal with by burying our unacceptable desires out of consciousness and denying that we ever had them, and by other similar (continued on page 116) Psychoanalysis (continued from page 108) "defense mechanisms." Some of these defense mechanisms do us no harm and even bring us rewards: A man with murderous impulses may. for instance, sublimate them in his career, becoming a driving, competitive and highly successful businessman. But some defense mechanisms are poor ways of solving the problems, being in themselves impairments rather than benefits. An example given by Dr. Franz Alexander: A man is furious at his father and would like to swear at him; this wish conflicts with his superego--his ingrained sense of right and wrong or, in a word, his "conscience"; he unconsciously solves the dilemma by losing his voice--but this defense is costly, because he needs his voice in his business. Another example: A woman marries a man like her father; sexual pleasure with this father figure would make her feel unbearably guilty; she becomes frigid, thereby sparing herself the guilt--but at the cost of denying herself fulfillment. Such neurotic defenses, like scar tissue that hinders movement, involve "limitations of function." But at least they preserve sanity: It is when defenses fail, and the unconscious conflicts burst through suddenly upon the conscious mind, that the ego collapses and the person becomes psychotic or "mad." There is a madman within each of us, imprisoned by our defenses and glimpsed only in nightmares or when we are drunk or drugged.

Freud and Breuer published their initial findings in 1895; Breuer bowed out thereafter. By 1900, Freud had brought forth his epochal The Interpretation of Dreams, which opened up the whole subject of unconscious dynamics; and by 1905, he had published his theory of infantile sexuality and outlined the immense role it plays in our psychological, development. But his books and his findings were shunned by the horrified prudes of that time. It took eight years to sell the 600 copies printed of The Interpretation of Dreams, and his writings on infantile sexuality did little better. Most physicians considered his ideas unscientific and, far worse, disgusting. When Freud's theories were mentioned at a psychiatric congress in Hamburg in 1910, one eminent professor pounded the table and shouted, "This is not a topic for discussion at a scientific meeting; it is a matter for the police!"

All the same, a small band of interested men gathered about Freud to study with him, and psychoanalysis began to grow slowly but steadily. In Europe. however, it remained a semiseparate specialty; only in the United States did it enter both the mainstream of psychiatry and the cultural life of the country. The American Psychoanalytic Association was founded in 1911; by the 1920s, psychoanalytic concepts were familiar to the intellectual avant-garde; and by the 1930s, it was a "movement" with training institutes turning out analysts by the score, European analysis (fleeing from Nazism) arriving by the hundreds and patients enough turning up to keep them all busy.

World War Two gave psychoanalysis a further boost. Under the guidance of psychoanalysts, medical officers throughout the Army used "front-line psychiatry"--makeshift forms of mental first aid, consisting of reassurance, the freedom to talk out the soldiers' fears, and rest. This gave limited but immediate relief to those suffering from combat fatigue and salvaged large numbers of men whose brand-new neuroses, if untreated, might have cost them many months in hospital wards or left them emotionally crippled the rest of their lives. Vastly impressed, many medical officers turned to psychiatry after the War, bent on becoming psychoanalysts.

The 1950s were the high-water mark of its influence and prestige. Indeed, the tide rose too high; psychoanalysis became a fad, its tentative suggestions being uncritically accepted by enthusiasts, its principles being vulgarly used (and misused) to tell all to everyone, to play all games of amateur analysis, to place all the blame for one's failures on one's parents. As Erik Erikson, the distinguished elder statesman of psychoanalysis, once said, "Even as we were trying to devise a therapy for the few, we were led to promote an ethical disease among the many."

Moreover, its early succès d'estime thrust it into the bright light, exposing contradictions and absurdities it had not had time to eliminate. For one, it had breathed life into the infant science of psychology, yet itself remained chronically unscientific; its practitioners, being participants in the process, could never be impartial observers and judges of it, but they would not let anyone act as observer, lest the alien presence alter the interaction between analyst and patient. Even today, research occupies only two percent of the collective working time of all American analysts, according to a survey made for the National Institute of Mental Health and the American Psychiatric Association.

An even more serious internal conflict is the perennial debate over what sort of thing psychoanalysis is--a medical therapy or a psychological re-education Freud himself, rejected by the medical societies, trained psychologists as well as physicians to perform analysis and considered it as much a branch of Psychology as of medicine. In this country, however, the medical profession took over analysis while academic psychologists in the universities generally ignored it and clung to their no therapeutic studies of intelligence, perception and learning. As a result, the American Psychoanalytic Association, the largest body of psychoanalysts in this country, takes the official position that analysis is a subspecialty of psychiatry, that the analyst needs to know the body as well as he knows the mind and that no one but a physician should practice analysis. (Psychologists and social workers who want to study psychoanalysis are unacceptable to the 20 institutes affiliated with the association and have to get their training at any one of a dozen or more independent institutes or at the graduate schools of New York University or Tulane.) Yet the orthodox Freudians of the American Psychoanalytic Association--the very people who are most emphatic about excluding nonphysicians--would not dream of examining a patient physically, lest the psychological interplay between them be affected by it; many, indeed, would not even give an aspirin to a patient with a raging headache.

The nonmedical (sometimes called "lay") analysts, for their part, regard the orthodox medical Freudians as rigid, uncreative and power hungry, and scoff at the idea that analysis is a medical specialty. Nonetheless, nonmedical analysts call what they do treatment or therapy, call their clients patients and consider it only right and proper that the Internal Revenue Service classifies psychoanalysis as a deductible medical expense--even when performed by a nonmedical analyst.

Also troubling and disillusioning to the believer in psychoanalysis is the spectacle of the continuous schisms that afflict it--schisms within nonmedical ranks as much as within medical ones. From the beginning, psychoanalysis was plagued by a tendency to adhere rigidly to what the founder said--it is often remarked that "many of today's Freudians are more Freudian than Freud"--and to expel dissidents and innovators, or at least to be so inhospitable to their ideas that they would break away and found their own cliques. But each new heresy rapidly became orthodoxy and led to new heresies and splits. Perhaps the hostility psychoanalysis originally faced has given it an undying legacy of defensiveness: though basically nonreligious, psychoanalysis, like Christianity, is afflicted with a multiplicity of doctrines, credos, apostasies and excommunications

Some of the issues analysts disagree about seem substantive: How large apart do the unconscious, the instinctual and the infantile play in neurosis, and how large a part the conscious, the learned and the adult? But sometimes it seems much of the quarreling deals with procedural trifles. If the analyst lets the patient face him, sitting up, is it "real" analysis or does it so change the relationship that_ it becomes "only" psychotherapy? Conversely, is the use of the couch not genuinely therapeutic but a mere (continued on page 174) Psychoanalysis (continued from page 116) cop-out--a way in which the therapist side-steps real interaction? (Freud himself started putting his patients on the couch because he couldn't bear being stared at all day long.) How many visits a week is the essential minimum--five or four? Or can you still call it analysis at only three? Or two? Some even claim they perform analysis once a week; others regard this as an absurdity if not outright dishonesty.

How far may the analyst go in expressing his personal taste in the decor of the office? Or does it really matter? How soundproof need the office be? Is it important if the sound of voices, even sometimes of intelligible words, reaches the waiting room; or is concentration on soundproofing only an indication of a hang-up on the analyst's part? Dare an orthodox Freudian practice without a picture of Freud on the wall, the 24-volume edition of Freud's works in evidence, a few pieces of primitive art, such as Freud collected, on display? More seriously, if a patient falls silent, how long should the analyst let him lie there without saying anything? Letting him do so may be therapeutic (his discomfort may produce a breakthrough), but when the layman hears of a patient who spent a whole hour with his analyst in total silence, he may well think it quackery. A whole hour? Yet, in the profession, it is well known that some analysts have let patients lie mute for five hours, ten hours and even more--and, of course, charged them the usual $25 to $50 for each of those 50-minute hours.

What is one to think of a therapy whose practitioners consider the best; candidate (the patient most likely to benefit from it) articulate, reasonably successful--and relatively healthy to begin with? What is one to make of a therapy that nowadays takes four or five years to complete (though Freud analyzed most of his own early patients in a year or less) 1and costs roughly $20,000? A psychology so pessimistic that it sees every human being as sick and labels even the seemingly normal person a "normopath"? That suspects any swiftly and dramatically successful analysis may be a "flight into health"-- an abandonment of illness out of fear of facing unacceptable truths about oneself?

• • •

All these contradictions and absurdities were bound to spell trouble for psychoanalysis when its honeymoon with American society was over. But even during its golden years in the 1950s, several other developments were getting under way that offered simpler explanations as to the source of mental illness and promised quicker, easier methods of treating it. One was the resurgence of vitality in the organic approach. It was in the mid-1950s that tranquilizers burst on the scene and began to revolutionize the treatment of hospitalized psychotics and to give symptomatic relief to anxious or overwrought neurotics. The organicists speculated that the drugs must inhibit certain kinds of excessive chemical activity within the brain cells and thereby reduce the intensity of the harmful thought processes; they began finding tantalizing clues of chemical imbalance in the urine and blood of schizophrenics and even of people with anxiety neuroses. Later, they sought and found drugs with an effect opposite to that of tranquilizers--the psychic energizers or mood elevators that alleviate depression. To those doctors who had always been hostile to psychoanalysis or disinclined to accept its complex explanations of human behavior, it seemed clear at last that psychoanalysis was inefficient and unnecessary, that faulty chemistry was the explanation of mental illness and that corrective chemistry was its cure.

Which is like saying that daily doses of Insulin constitute a cure of diabetes. Doctors still don't know how to cure diabetes; they do know how to keep the diabetic person alive. Similarly, psycho-pharmacology--the use of drugs to help the mentally ill--is no cure; it merely helps the patient live more or less normally. Logically speaking, there is no contradiction or conflict between psychoanalysis and psychopharmacology; as Dr. Donald Kenefick, director of research and professional affairs for the National Association for Mental Health, says:

It most probably takes both a biological substratum of weakness and an experiential stress to trigger mental illness. A person with faulty chemistry doesn't necessarily become sick, unless life experiences push him too hard; and a person with bad life experiences doesn't necessarily become sick, unless his chemistry isn't able to handle the stress. We need to know about both aspects of mental illness and to deal with the patient on both levels simultaneously. Unfortunately, the rivalry between the two approaches has always been so strong that even now, doctors seem to feel they have to belong to one camp or the other.

A second development has been the reemergence of behaviorism. This theory of psychology had been advanced by Ivan Pavlov, a Russian, early in this century and enthusiastically taken up by some Americans in the 1920s. As a theory, it dealt entirely with observable behavior, rather than with internal and unseen mental processes; as a method of research, it used only animals such as rats, cats and the like. On both grounds, it was thoroughly anti-analytic. Nonetheless, the behaviorists could produce symptoms in their animals that resembled those of neurosis in human beings. They could train an animal to expect food after a specific signal--a light, a bell, a symbol on a card--and then confuse him by giving him an electric shock instead; this produced alarm, agitation and wild behavior in the animal when he saw or heard the unreliable or bewildering signal. But the experimenters could also "extinguish" the neurotic response by providing only rewards in association with the signal until the animal had been retrained and restored to health.

All this was thoroughly overshadowed by Freudian psychology from the 1930s until about a decade ago, after B. F. Skinner of Harvard developed his teaching machines and his ideas of "operant conditioning" and Joseph Wolpe, a South African psychiatrist (now at Temple University in Philadelphia) worked out techniques of behavior therapy applicable to neurotic human beings.

Wolpe and other behavior therapists start with a firm Pavlovian position: The unseen is unimportant and perhaps nonexistent--what counts is what you can actually observe and manipulate. A neurosis is not evidence of an unconscious conflict; it is nothing but a bad habit. The frigid woman's disorder is only a matter of faulty conditioning--she associates fear with the sexual act--and not the result of an inner conflict. So don't analyze her: Just make her relax, feel comfortable, and then have her envision the sex act (or some mild preliminary) until it is firmly associated with her relaxed state--until, indeed, like the retrained laboratory animal, she connects the stimulus with relaxation and pleasure. End of problem. As for the drug addict, it's even easier: Administer an electric shock to him each time he thinks of taking drugs, until the very thought of drugs gives him the willies. Have the homosexual think homosexual thoughts or look at pictures of nude males, then administer an emetic.

Does such simplistic therapy really work? Wolpe and his colleagues report extremely high cure rates and insist that no substitute symptoms pop up--thereby proving, in their minds, that there is no hidden underlying conflict. Skeptics say that there are many serious flaws in Wolpe's evidence; they also point out that every new psychotherapy introduced in the past 40 years has shown a very high cure rate at first, but not later. As Sir William Osier used to tell medical students, the time to use a therapy is when it's brand-new, because then--and only then--it cures nearly everyone.

For now, behavior therapy seems not only to work well in certain kinds of cases but to have immense appeal by virtue of its simplicity. Accordingly, a growing cadre of psychiatrists and psychologists is experimenting with it, advocating it and claiming that it disproves Freudian theory in toto. Wolpe often writes as if he has shown all of psychoanalytic theory to be a monumental fraud, leveled it to the ground and sowed salt where it flourished; while Eysenck says things like, "It has nothing to say to us, and there is nothing we can do for it except ensure a decent burial."

The third development has been an evolution within psychoanalysis itself--a shift of attention from the psychology of the id (the primitive, instinctual, unconscious processes) to the psychology of the ego (the adult, social, conscious self). Freud had originally seen the problems of neurosis largely in terms of conflicts buried in the unconscious and involving primitive instincts. But in his later years, he began to pay more attention to the ego, the adult self that is rational, conscious and controlled by the realities of living among other men.

Some of Freud's followers, spurred on by his interest and perhaps even more influenced by the expanding fields of anthropology and sociology and the stresses of the Depression and the War, began to examine the social and cultural aspects of neurosis. By the 1950s, many of the younger Freudians were paying as much or more attention to ego psychology as to id psychology. "Our critics still accuse us of doing the same thing we used to do in the Thirties," says Dr. Bernard Pacella, a spokesman for the American Psychoanalytic Association. "The fact is that there has been a significant shift in emphasis, among Freudians, from instinct analysis to ego analysis."

But by the time orthodox Freudians had come to this position, analytic heretics had long since reached it and gone beyond it. Harry Stack Sullivan had stressed "interpersonal" psychology to such an extent that by 1913, he, Erich Fromm and Clara Thompson had to start an institute of their own (the William Alanson White Institute), their ideas being too radical for the official organization. Karen Homey, another revisionist, went even further in die culturalist direction, making very little of instinctive drives and inner conflicts; she was thrust into the non-Freudian cold and had to form an institute of her own in 1941, which continues to this day to produce Horneyan analysts.

In the past decade or so, there has been a proliferation of schools of thought and therapeutic methods concerned with the conscious adult self and the realities of everyday living. William Glasser advocates his own brand, which he calls reality therapy; Albert Ellis teaches and practices his own brand, which he calls rational-emotive therapy; Bertram Pollens and others offer experiential therapy; Rollo May and others do existential therapy. All these, and a few dozen variants, concentrate on the practicalities of living among other people, rather than the problems of learning to be at peace within oneself.

In all of them, there is a shift away from rebuilding the past, using the therapist as a stand-in for parents, and toward the present, experiencing the therapist as a person in his own right. He faces the patient, acts like himself, reveals his tastes, his moods, his reactions to what the patient is saying or doing. He nods, smiles, cajoles, argues, frowns--yes, disapproves! (isn't that reality, isn't that experiential and existential?). Reality-oriented therapists--and even some Freudians--sometimes use touch therapy, sometimes kiss or embrace a patient as needed; a very few apply to selected patients what is unofficially called penis therapy; and a very few believe in letting themselves fall asleep during the sessions and then telling the patients their dreams.

This emphasis on the interpersonal and the real has also produced a tremendous growth in the popularity of group therapies in the past 15 years. A few practitioners, such as Dr. Louis R. Ormont of New York, keep group therapy genuinely analytic by dealing with the deep-lying and well-defended conflicts in each patient; but most group therapists are more concerned with stripping away social pretense, revealing real feelings, showing the patient how he has been behaving and getting him to test new ways of behaving in a social setting.

The further this gets from analysis, the more it stresses doing and acting, rather than talking and thinking, and the maximizing of feeling, rather than the repair of neurosis. It merges, finally, into the Human Potential Movement, most of whose enthusiasts think of themselves as repudiating or discarding psychoanalysis altogether, in place of that lonely and often downbeat procedure, they luxuriate in "joy therapy," encounter groups, sensory awareness workshops, "peak experience" seminars, weekend marathons, everybody-touch-everybody groups, all-take-off-our clothes-and-say-OM! groups--all of them supposed to get you to see yourself as others do, to show others how you feel about them, to teach you to relate, to be intimate, to be "authentic." [See next month's Playboy for a more detailed discussion of these and other Alternatives to Psychoanalysis, by Ernest Havemann--Ed.]

Does all this really work better than psychoanalysis? No one really knows. For, no matter what the anti-analysts claim, and no matter what the analysts claim, there are no reliable comparisons of effectiveness, no controlled studies of matched groups of neurotics, no before, during and after studies in depth. Indeed, there are no scientifically adequate studies within any one type of therapy, let alone comparative studies.

But it is not proved effectiveness nor the lack of it that accounts for the diminished status of psychoanalysis and the current enthusiasm for the newertherapies. There are more profound reasons for the shift. One of them is an inability of people today to deal with the society around them--a widespread feeling of impotence and disconnectedness. And this, according to Dr. Ormont, "results in a great interest in the how, not the why of behavior, and in the acquisition of skills in dealing with people rather than in exploring oneself."

Is television involved? Has it been so easy to push a button and have people at hand that young adults have never learned how to build real relationships? Is it revulsion with our intellectual, technological culture and the mess it has got us into that makes people turn against intellectuality and thinking in general and prefer feeling and doing? Either or both may importantly contribute to the need for the bought interaction and purchased relationships of the Living Theater, drug parties, love-ins, be-ins, campus sit-ins, the disruption of classes and meetings by shouting and heckling; either or both make an anti-intellectual Yippie leader preferable to an orderly, intellectual, fatherly, Freudlike psychoanalyst.

Finally, there is a significant shift in where people--especially young people--put the blame for their troubles. A generation or two ago, most people, conscience-directed, and individualistic, thought that they themselves were responsible for whatever had gone wrong with their lives and looked within themselves for cause and cure. Today, most radicals, and many who are not radical in the least, have decided that our military-industrial society is responsible for whatever problems they have and look for dropout or political answers. No wonder that many of these radicals, as Anna Freud has observed, consider psychoanalysis at best irrelevant, at worst a tool of the controlling powers, designed to get them to adjust and conform.

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Is it true, then, that psychoanalysis is dead, or at least in extremis? That its ranks are thinning, its practitioners switching to other therapies, its influence all but gone?

Not yet; not according to such statistics as one can rely on. In the past five years--the very period when psychoanalysis, especially the orthodox Freudian brand, has been getting hard knocks from all sides--membership in the American Psychoanalytic Association has grown 20 percent; and, while there are no official figures for the total number of analysts outside that organization, the indications are that they, too, have grown in number, perhaps by even more than that amount.

The statement is often made, however, that even if the total number of psychoanalysts is growing, it is doing so more slowly than the mental-health field and thus, in effect, is suffering a relative reduction. This, too, is false, judging by the data in Psychiatric Services, Systems Analysis and Manpower Utilization, a nationwide survey published by the American Psychiatric Association. It shows that between 1965 and 1968, there was no decrease--indeed, there was even a tiny increase--in the percentage of psychiatrists who are psychoanalysts (it now stands at ten percent). Nor is it true, as often said nowadays, that analysts are leaving private practice in droves and seeking shelter in clinics, hospitals and universities; the study shows only a two percent decline in private practice over the three-year period.

What psychoanalysis has suffered is something that cannot be precisely measured: a loss of status. On this score, though there are no statistics, even dedicated psychoanalysts are more or less in agreement with their enemies. Says Dr. David Kairys, president of the orthodox Freudian New York Psychoanalytic Institute, "The data don't show a decline in our numbers, but there's a distinct feeling in many quarters that we've lost prestige both in the medical community and among the public." Leo Rangell speaks of the "emotional and intellectual backlash" growing out of the public's overexpectations of analysis and its subsequent disenchantment. Donald Kenefick says there is a "shift of conceptual fascination to other forms of therapy. Even those of us who still find psycho-analysis the most valuable existing system of psychological thought feel about it rather the way you feel about an old girlfriend--you still love her in the depth of your heart, but the joie de vivre, the excitement, isn't there any longer."

Though this loss of prestige has not, yet been reflected in the statistics, it may well be in the near future. For one thing, fewer psychiatric residents seem to be hell-bent on becoming analysts today than used to be the case: There were 16 percent fewer applications for training in the 20 institutes of the American Psychoanalytic Association last year than there were a decade ago; and the 1967--1968 entering class (at all the institutes combined) totaled a little less than it did a decade ago, although, to keep pace with the growth of psychiatry over that same period, it should have been twice as large. Dr. Pacella explains: "With the tremendous growth of community psychiatry, there are good jobs immediately available for every man finishing psychiatric residency, without his having to go on to three or four more years of training and spend another $25,000 to $40,000. Today's residents are different from the men a generation ago--they aren't interested in working all that hard or waiting that long. They want to start earning money and enjoying their leisure. And even if private practice appeals to them more than community psychiatry, they get so much more exposure to psychoanalytic thought in medical schools nowadays that they feel ready to practice therapy, if not analysis, without further training."

Outside the American Psychoanalytic Association, both the institutes of dissenting medical sects and those that train psychologists and other nonmedical people seem to be taking in slightly larger classes than formerly. Yet they, too, are getting fewer applications than they used to; and if this trend continues, it will surely reduce the number of accepted trainees in the near future. In sum, the much-heralded disappearance of psychoanalysis is by no means imminent, but there is reason to suppose that psychoanalysis as a specialty--especially among psychiatrists--may show a gradual decline in numbers.

Perhaps the most significant indication of the future fate of psychoanalysis would be evidence that people in need of therapy are beginning to avoid it and to seek other forms of help instead. But no one has any data on this; there are only hints, rumors and vague impressions. Some psychoanalysts, interviewed for this article, said there has been no change, but more of them said that the waiting lists of patients seem to be shorter than formerly. A few said they'd heard that some of their colleagues even had empty time, though they themselves were as busy as ever. Dr. Bertram Pollens said, for instance, that he himself has a three month waiting list, but that recently he has been hearing, from some of his classically oriented colleagues, that they have free time available and would welcome referrals. A spokesman for the orthodox Freudians, who declined to be named, said that the number of people in classical Freudian analysis does seem to be smaller these days, but he added that he knew of no competent psychoanalyst who couldn't easily fill up his time by accepting patients for psychotherapy as well as for psychoanalysis.

Even if the number of patients in analysis is dwindling, even if analysis should find themselves compelled to spend some of their time doing other forms of therapy, psychoanalysis itself is unlikely to die out, either as a theory or as an influence on other forms of therapy. Rather, it will be absorbed, digested and amalgamated with other theories and therapies. As Dr. Pacella points out, far more psychoanalytic theory is now incorporated into medical-school curricula and psychiatric residency training than ever before--so much so that some deans of medical schools believe that the institutes of analysis, and even analysis itself as a separate specialty--will soon become unnecessary; both will wither away, although psychoanalysis will live on within tine body of psychiatry.

What will happen to the institutes that train nonmedical people in analysis is anybody's guess; but even if they, too, wither away, psychoanalysis will also continue to live on within the body of American psychology. Despite the present revival of behaviorism, psychodynamics could no more be extracted and cast out of psychology than could Newtonian mechanics be extracted and cast out of contemporary physics. For even in the era of relativity theory, Newtonian mechanics is still "true"--it is merely incomplete and imprecise. Similarly, behaviorism, chemotherapy and ego psychology do not disprove or replace psychoanalysis; they merely add to it and make possible more complete and precise explanations of human behavior. As Dr. Abraham Maslow of Brandeis University, one of the country's most distinguished psychologists and the founder of the Human Potential Movement, puts it, "The successor to Freud will not offer a repudiation of Freud but an elaboration of his work. My friends and I are 'epi-Freudians,' trying to build an adequate superstructure on the foundation he laid down."

Already, a number of eclectics are trying to fit the pieces together. At the therapeutic level, for instance, Dr. Nathan Kline, a pioneer in the use of tranquilizers and other drugs, says he finds no conflict between psychoanalysis and chemotherapy; in his private practice, many of die patients he aids with drugs need psychotherapy or psychoanalysis at the same time--and make far better psychotherapeutic progress as a result of the relief the drugs give them. Dr. Lewis R. Wolberg, director of the Postgraduate Center for Mental Health, uses everything from classical analysis to drugs, behavior therapy and even electric-shock therapy, according to each patient's needs and capabilities. Even among the orthodox Freudians, one out of lour psychoanalysts has recently been prescribing drugs for some of his patients, according to Dr. Mortimer Ostow in a recent address to the American Psychoanalytic Association. Maslow and other epi-Freudians are struggling to work out a larger theoretical framework, and even behaviorists have suggested that behaviorism and psychoanalysis are not opposed but complementary, and can be combined.

Even were the most implacable foes of psychoanalysis to sweep the field and to exclude psychoanalytic thinking from the training of psychiatrists and psychologists, it would not stay excluded. We have become too sophisticated to be content with simplistic explanations; we have accumulated too much knowledge of human behavior to be able to make sense of it without psychodynamic psychology. Both biochemistry and behaviorism increase our understanding of the external aspects of human behavior, but not its meaning. If one wants to know what a great painting is about, he needs much more than data on the composition of the oil and pigments, or a description of the way in which the painter mixed and applied them to the canvas. To comprehend love and hate, hope and despair, poetry and politics, we need to know more than the chemical events occurring in the synapses, or the ways in which stimuli become associated with responses and disassociated from them.

Finally, what of psychoanalysis as a therapy? Will anyone be practicing psychoanalysis on anyone else 25 or 50 years from now, or will it have passed into therapeutic history, along with cupping and blistering? A few enthusiasts profess to see a greater future for analysis than ever; most psychoanalysts, however, expect it to be even less used than it is today but to remain a permanent and important weapon in the armamentarium of therapies. Although it is the most costly, lengthy and arduous of them all, it is also the only one that does what it does. "At the most," says Dr. Wolberg, "classical psychoanalysis is suitable for perhaps five percent of the patients who seek psychotherapeutic help--But for them, it is the treatment of choice. They have conflicts so deeply buried that it takes the atom bomb of transference neurosis to expose them. The other 95 percent don't need it, or can't afford it, or aren't verbal enough to be able to use it."

Besides serving this limited group of cases, there is an even more limited--but more important--function it will perform for a very small, special group of patients whose primary need is thorough self-knowledge. Therapists themselves are one such group. Dr. G. David Weinick, a New York psychologist and psycho-analyst, says, "Classical psychoanalysis will probably become very esoteric--a specialized form of education, mostly for people who are doing various forms of therapy or studying human behavior and for whom it is extremely important to be able to keep their own problems separate from those of the people they're dealing with." And for much the same reason, say others, psychoanalysis will continue to be valuable, even virtually irreplaceable, for teachers, communicators, judges and leaders of society--a kind of intellectual elite who, more than most people, need to fully understand themselves and their fellow men.

This is a very different thing from therapy in the usual sense. Freud began using psychoanalysis with the limited aim of alleviating his patients' hysterical symptoms, but gradually the goals of psychoanalysis broadened and became the freeing of the individual from unnecessary self-imposed limitations and the achieving of his full potential in work and in his relationships. And though it attains these lofty goals in full in only a limited number of cases--about one out of five, according to some estimates--nothing else does so.

Psychoanalysis--as even psychoanalysts agree--has not proved a highly efficient way of getting rid of symptoms; suggestion, direction, drugs and behavior therapy may all be better at that--and yet what analysis does do turns out to be far more valuable. "I have patients all the time who come to me to get rid of certain symptoms," says Bertram Pollens, "and who get so involved in seeking larger changes that the symptoms become unimportant." Or, as Donald Kenefick puts it, "You come in with symptoms and even though they never fully disappear, they're never the same afterward--they cease to be crushing; you have a framework to place them in. You have a comforting, meaningful way of seeing yourself and the world. You have a view of the universe that you can live with."

Psychoanalysis is unequaled as a treatment--not of symptoms but of ignorance about oneself; in the end, it does minimize symptoms; but, what is far more important, it permits one to free himself from the self-imposed limitations and the faulty strategies of life that his ignorance sustained. No one has said it better than Dr. Karl Menninger, one of the grand old men of psychoanalysis:

I once regarded psychoanalysis not only as a great educational experience but also as a therapeutic program par excellence. True, Freud warned us against the emphasis on the therapeutic effect. Now I know he was right; therapeutic effect it does have; but, in my opinion, were this its chief or only value, psychoanalysis would be doomed. Surely the continued development, of our knowledge will help us find quicker and less expensive ways of relieving symptoms and rerouting misdirected travelers. Psychoanalysis assays to change the structure of a patient's mind, to change his view of things, to change his motivations, to strengthen his sincerity; it strives not just to diminish his sufferings but to enable him to learn from them.

Instead of being free from guilt feelings and anxiety feelings, the psychoanalyzed person may have even more of both than the unanalyzed person, but he will know where they came from and what to do about them instead of developing symptoms. He will know whether or not restitution can be made, whether or not penance is in order, whether or not easement can be found. And if they are not, then he must have the courage to bear them cheerfully.

Philip Rieff put it in a single pungent epigram: "Psychoanalysis does not cure; it merely reconciles." Merely? But it has long been the noblest aim of philosophy to reconcile us to our own limitations and to those of our fellow men, to reconcile us both to the unavoidable imperfections of life and to its brevity.

If psychoanalysis can do this, it is not just therapy but education, not just education but philosophy; and not just philosophy but a cure, after all--a cure for what someone has glumly termed "this long and cruel malady called life." If so, psychoanalysis will surely survive its present crisis and seeming decline. Until a better philosophy appears, it will continue to be sought by the special few who have the perception, die intelligence and the motivation to see it through.

Concise Glossary of Psychoanalytic Terms

Anal Character: A pattern of character traits arising in individuals for whom the anal stage of psychosexual development--marked primarily by the acquisition of voluntary sphincter control--has had exaggerated significance. Orderliness, stubbornness and miserliness are features of this character; but when defenses against instinctual drives are weak, die personality may be ambivalent, untidy, defiant and sadomasochistic.

Defense Mechanisms: Unconscious methods of preventing repressed wishes associated with some real or imagined threat from rising into consciousness, often by denying or distorting some aspect of reality.

Ego: A group of functions in the psychic apparatus that includes operation of conscious thought processes, integration of the personality, control of speech, regulation of drives and adaptation to reality and other people.

Hysteria: A neurosis characterized by physical symptoms--such as pains, paralyses, tremors, deafness, blindness vomiting--that have no physical cause but were developed to relieve emotional tension caused by an inner conflict.

ID: A part of the psychic apparatus that is totally unconscious, in touch with the body and consists of wishes arising from the individual's physiological needs, which are represented in the mind as instinctual drives.

Infantile Sexuality: The universal appearance of the sexual drive in the infant and young child, which is gratified through pleasurable sensations accompanying the satisfaction of basic bodily needs, such as eating and excreting. It matures through a series of phases known as oral, anal and phallic.

Instinctual Drives: The motivational forces in human behavior deriving from physical needs. This term has replaced instinct in modern psychoanalytic usage because of disagreement among scientists over the meaning of the latter term.

Libido: A quantitative measure of the energy of the sexual drive.

Neurosis: A condition characterized by mental conflicts that result in such symptoms as excessive anxiety, depression, guilt or irritability. The conflicts take place between the sexual and aggressive drives and those forces of the ego that restrict expression of the drives. Growth and maturing of the personality is constricted, but the individual is able to function in society.

Oedipus Complex: A crucial point in the phallic phase of infantile sexuality during which the child desires, within the limits of his knowledge and capacity, sexual union with the parent of the opposite sex and wishes for the death or disappearance of the parent of the same sex. The child fears damage to his sexual organs in retaliation for these wishes. This usually occurs between the ages of three and six and the resolution of this problem contributes to the development of the superego; problems arising in its resolution form the nucleus of some future neuroses.

Oral Character: A pattern of character traits arising in individuals during the oral stage of psychosexual development, when the process of nursing is of primary concern to the individual. Excessive indulgence or severe deprivation at this stage may lead to the dominance in the character of inappropriate optimism or pessimism, greed, demandingness, undue generosity or frugality, dependency, restlessness, impatience or excessive curiosity.

Paranoia: A psychosis characterized by delusions of persecution and/or grandeur. The paranoid's thought processes and ego functions are usually well preserved and he is often able to defend his beliefs with the appearance of logic.

Phobia: A persistent, excessive fear of some particular objector situation that is without rational grounds.

Psychosexual Development: The regular series of stages through which die individual's sexuality matures between infancy and adulthood. The oral, anal and phallic phases culminate around the age of six with the development of the Oedipus complex, after which there is a phase of sexual latency until the onset of puberty. Psychosexual development resumes at puberty and reaches a successful conclusion when the genital phase is attained.

Psychosis: A mental disorder marked by extreme regression of the ego and the libido, often preventing the individual from functioning as an acceptable member of society.

Regression: A retreat to childlike levels of instinctual organization or modes of ego functioning.

Repression: The exclusion of ideas or feelings that are undesirable or threatening from the conscious mind by a process of which the individual is not directly aware. Repressed ideas and feelings remain active influences in the personality.

Schizophrenia: A group of psychotic reactions characterized by severe emotional, intellectual and behavioral disturbance stemming from a view of the world that is apparently unrelated to the realities of the individual's situation and is determined by regressive functioning of the psychic apparatus.

Sublimation: Refining or diverting an instinctual drive from its primitive goal to an aim more acceptable to the ego and superego, allowing for use of the energy and partial satisfaction of the drive within the bounds of constructive activity.

Superego: A group of psychic functions that represent moral attitudes and behavioral standards imposed from without but accepted by the individual as his own. The superego operates positively to set up ideals and values and negatively to impose guilt feelings for breaches of die internalized code.

Transference: Displacement of feelings and attitudes originally having an important figure in childhood as their object to individuals in one's present relationships. When a neurotic patient displaces onto his analyst the feelings and attitudes he had toward his parents or other significant childhood figures, this is called a transference neurosis, and its development and resolution is a key element in the process of psychoanalysis.