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fter more than a century mining the unconscious, psychoanalysis is really showing its age.

Only 15 percent of members in the American Psychoanalytic Association are under 50. And traditional Freudian analysis — lying on a couch, talking about your childhood, day after day for years — is widely seen as a musty relic, far too expensive and intensive to fit into modern life.

But analysts aren’t ready to give up on Sigmund yet.

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Determined to reinvigorate their profession, they’re seeking to train a new and more diverse generation of therapists. They’re introducing the concepts underlying analysis to schoolkids. They’re holding public talks, including recent ones taking an analytical view of President Trump. They’re opening their field to more rigorous research, sometimes in collaboration with neuroscientists.

And they’re working to persuade a skeptical public that psychoanalysis is relevant. Yes, busts of Sigmund Freud stare down anyone who enters the New York Psychoanalytic Society & Institute, the oldest training center in the United States. But analysts say they’re not unduly fixated on his stages of psychosexual development or his ideas on the id, ego, and superego.

“People say, ‘Oh, does that mean you’re Freudian?’” said Adele Tutter, a psychoanalyst in Manhattan. “That’s kind of like asking a modern-day nuclear physicist whether he’s Copernican. Much of what Copernicus said was not true, but it helped. It was the foundation.”

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The foundation for psychoanalysis starts with the unconscious. Freud theorized that humans act in order to satisfy needs they don’t know exist. If patients in therapy could speak whatever came to mind — a concept known as “free association” — he thought they’d eventually push to the surface subconscious feelings that can lead to self-destructive behavior.

Now, practitioners are trying to make the case that such ideas have power beyond the analyst’s couch.

“We’ve started applying psychoanalytic ideas outside of our offices — in schools, in agencies, in business,” said Mark Smaller, the immediate past president of the American Psychoanalytic Association. “We’ve made social issues much more on the minds of our membership.”

Smaller, for instance, has been bringing psychoanalysis to at-risk teenagers at Morton Alternative School in Cicero, Ill. Now in its 12th year, Project Realize has treated more than 400 students who were expelled from regular high school for aggressive and dysfunctional behavior. Smaller said the program has helped lower violence and improve graduation rates.

“People say, ‘Oh, does that mean you’re Freudian?’ That’s kind of like asking a modern-day nuclear physicist whether he’s Copernican.”

Adele Tutter, psychoanalyst

Another form of public engagement comes from an experimental psychoanalytic group called Das Unbehagen. It holds public readings and performances — often on edgy topics — in hopes of drawing an audience that may be receptive to Freudian ideas.

“Talking about the arts or the occult is helpful,” said Vanessa Sinclair, a clinical psychologist and psychoanalyst in New York and a cofounder of the group. “I get younger people who are interested, and then I can throw psychoanalysis at them. It makes sense intuitively to a lot of people.”

The struggle to get more patients on the couch

Is the outreach working?

Perhaps, if the goal is public awareness. In January, the Library of Congress unveiled a digitized archive of Freud’s psychoanalytic and personal papers. Two new books on Freud — one a study, the other a biography — have been published within the past six months. Essays claiming to “psychoanalyze” figures like Kanye West and Donald Trump are routinely shared across social media.

But analysts acknowledge it will be an uphill battle to get more patients on their couches. Approximately 1 in 5 adults in the US will experience mental health issues, yet psychoanalysis is rarely covered by insurance — or considered a viable treatment option.

“There’s much more emphasis on medication,” said Lisa Deutscher, vice president of the 106-year-old New York Psychoanalytic Society & Institute. “Even in a rather privileged stratum of society, there are shifts away from the idea that it would be useful to spend your time doing therapy. There are greater pressures, like the fact people are on call for their jobs 24/7. It makes other commitments in life that much harder.”

It can even be hard for would-be analysts to find the time to train. They can’t start until they’ve earned an MD, a PhD, or a license to practice clinical social work. After that, they must complete four years of coursework in psychoanalysis and 200 hours of clinical training.

On top of all that, they have to undergo analysis for at least two years — for at least four sessions per week.

“They’re requirements that fit the 1950s, when every psychologist wanted to be an analyst,” said Jamieson Webster, a psychoanalyst with a private practice in downtown Manhattan. “If you’re doing a MD or a PhD or an LCSW, the conditions of starting a private practice and having a job don’t fit with analytic training anymore. Candidates find their analytic voice at 50. That’s nuts.”

“Talking about the arts or the occult is helpful. I get younger people who are interested, and then I can throw psychoanalysis at them.”

Vanessa Sinclair, psychoanalyst

It may also help explain why 52 percent of members in the American Psychoanalytic Association are between 60 and 80 years old.

“We are an aging organization,” said Smaller, who runs the school program in Illinois. “When I became president-elect at age 62, it was scary that I might have been considered a Young Turk.”

To bring in a new generation of analysts, training centers have embraced a mode of treatment called “psychoanalytic psychotherapy.” It incorporates Freudian ideas about motivation and the unconscious, yet requires only two years to learn, making it an easier and cheaper route for new candidates to join the profession.

And last year for the first time, the American Psychoanalytic Association offered two “diversity grants” to help training institutes develop programs to encourage diversity among their students. (The grants, however, were tiny: Just $2,500 each to the St. Louis Psychoanalytic Institute and the Psychoanalysis Institute at Emory University.)

A tentative embrace of neuroscience

Perhaps the most radical move for psychoanalysis is to actively embrace scientific research in a quest to see how applying Freud’s theory of the mind affects the physical brain.

Analysis “needs to open these concepts up to new evidence, to new terminologies, to new methods,” said Mark Solms, chair of neuropsychology at the University of Cape Town and research chair of the International Psychoanalytical Association. Blending analysis with neuroscience, he said, “is the way forward.”

The concept sparked considerable resistance when Solms first proposed it in the mid-’80s. Now, though, it’s gaining acceptance.

“Psychoanalysis, as I see it over the last few years, is right back at the table of science,” said Smaller.

A 2010 meta-analysis assessing the recent body of research found that psychoanalysis is more powerful for some patients than medication and about as effective as cognitive behavior therapy, a short-term course of therapy that seeks to give patients practical tools to control conditions such as anxiety. But analysts say more rigorous research is needed.

“We have to be open to the fact that undoubtedly some of things we think work don’t work,” Deutscher said. “We have to know that if we’re testing our ideas, some will be proven and some will be disproven.”

One key side effect of research: banishing a reputation that analysts are arrogant and aloof — and not willing to partner with other health care professionals.

“It’s only in recent years that psychoanalysts started being willing to do randomized control trials and actually measure the outcomes of their treatments,” Solms said. “As that information is accumulating, it’s up to us to advertise. You must remember what we’re up against. The pharmaceutical industry is enormous and has enormous resources. It’s going to be an uphill battle, but the evidence speaks for itself.”

Correction: A previous version of this story misstated the goal of the diversity grants offered by the American Psychoanalytic Association.

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  • I was fortunate , or unfortunate, enough to have had a psychotic patient as a training case at the British Institute in 1963. What saved the patient and myself was that I had Donald Winnicott as a supervisor.
    He suggested, since I was becoming as confused and incoherent as my patient, that I stop talking and listen.
    This I did for several sessions until I began to be able to understand him.
    This gradually led to him learning to communicate with a fellow human and to being able to feel human himself.
    In order to make a living I ran psychiatric units and taught at a university for 15 years, but since drugs seemed cheaper and more scientific no one was interested. So I went into private practice and treated any patient who would come.
    Luckily my background with psychosis saved the day and allowed me to save many patients who had been abused with drugs ECT and repeated hospitalizations, sometimes for decades.
    Unfortunately this alienated me from the psychoanalytic and psychiatric societies to which I belonged, so I , to avoid pain, quit them and focused on my patients who were working extremely hard to become well.
    This was also very hard on my wife and children because we had to move to four cities to make a living.
    Sometimes I think Michel Fouchault was right: in the age of reason we need the mentally ill to be the untouchable lepers of our society.
    It’s very uncommon for the mentally ill to talk about their disorders and recovery, but I am pleased that this is happening on the Mad in America website today.
    Maybe there is hope.

  • The profession is in denial and still overly attached to their “mother” (psychoanalytic training). Time to let the field age out and focus our limited resources on therapy and interventions that have solid evidence of efficacy.

  • I am certain that mindfulness meditation is the future of mental health care. Freudian therapy is about speaking whatever came to mind. Mindfulness practice is about being aware of whatever come to mind (and so much more than that as well).

  • As a technically trained non-physician advocate for chronic pain patients, I have long been active in critical commentary concerning both drug and non-drug therapies for people struggling with emotional issues. In my view, the entire field of so-called “psychosomatic” medicine and its DSM-5 diagnostic hierarchy is an unfounded mythology preached by financially self-interested psychiatrists. And when applied to chronic pain patients, this field is almost uniformly damaging of the welfare of the patient.

    The fundamental issue in Freudian work is that for most people most of the time, talking therapy is no more effective in cognitive or emotional difficulties that being afforded a quiet safe space and left alone, or being placed on an waiting list for in-facility treatment for six months. This has been known since the 1950s. [See, for instance, multiple references included in “The Psychological Society – The impact and failure of psychiatry, psychotherapy, psychoanalysis and the psychological revolution,” by Martin L. Gross, Random House NY 1978.]

    Drug therapies entail even more critical issues. Apart from the ethical issues in forcible administration of psychoactive drugs, there is ample evidence that Americans are greatly over-medicated with anti-depressent drugs that are no more effective than placebos in mild to moderate clinical depression. The use of stimulants in ADHD is of doubtful benefit over the long term and entails significant side effects in arrested development of kids. Antipsychotic drugs used for long periods are associated with significant decreases in life expectancy and disabling side effects including tardive dyskenesia.

    Psychiatry as a field is arguably and deservedly weathering a crisis in public confidence. Despite prominent claims of psychiatric advocates, there is little evidence that the brain disorder model for cognitive or emotional crisis offers us any measurable improvement over Freud and his imagined complexes.

  • I don’t know why some of my colleagues hold on so much to Freudian ideas as they were formulated at the beginning . Psychodynamic thinking has evolved a lot since Freud. There is, in New York, a modern school already integrating neuroscience in the their psychodynamic thinking. I am surprised it was not mentioned in this article. Otto Kernberg’s team in New York and international colleagues have conducted solid empirical research on TFP (Transference Focusted psychotherapy). If you are interested, you can read more on these tree websites: http://www.borderlinedisorders.com, http://www.istfp.org, http://www.tfp-quebec.org (here you can find research paper and publications in pdf format). Cheers!

  • I think more people would be interested in psychoanalysis if they had properly trained psychoanalysts…. patient must be told they are a training case…. and hours are being used toward analyst certification! It is such Betrayal to find out after the fact! And to learn a candidate in training wrote and presented a paper using a patient as their subject without permission is the most harmful form of Betrayal !!!!

  • I’ve trained as a psychoanalytic psychotherapist, and the training was a 4 year MSc and Clinical Diploma. The only difference between psychoanalysis and psychotherapy is the frequency of tgereapy…. 1-3 times per week rather than 5.

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