Beyond the Medical Model

Many major changes in the requirements for admission to training in psychoanalysis and in the education of those admitted have occurred in the last fifty years. These changes have greatly increased both the number of members of the psychoanalytic profession and the opportunities available to them to practice.

It is a fact that becoming a psychoanalyst in the United States when I entered the profession meant that I was a medical doctor who was seeking advanced training in a subspecialty of psychiatry. We were learning how to do clinical psychoanalysis as a therapeutic tool to cure certain mental illnesses, mainly the psychoneuroses. We were expected to master the tools of our trade by undergoing a traditional analysis ourselves at a frequency of four or five times per week for at least three years. In addition, we were expected to take didactic courses and have supervision on our own cases where we applied the psychoanalytic method to neurotic patients. We were enrolled in a "trade school"—like those of other medical specialties—that would enable us to practice special skills. We were authorized to train other doctors in our area of expertise. This system can be described as analyzed neurotics training neurotics to treat neurotics. In addition, analysts trained non-doctors to do psychoanalytic psychotherapy, which was believed to require less specialized skills. Psychoanalysts unable to fill their practice with those eligible for and seeking psychoanalysis also did psychoanalytic psychotherapy.

In the sixties and seventies this closed system imploded for a variety of reasons. These include the "widening scope" of psychoanalysis in which the technique suitable for treating the classical neuroses was modified to accommodate an increasingly expanded range of diagnostic conditions such as character neuroses, narcissistic disorders, borderline personalities, depression, and selected psychoses. Some analysts considered this widening scope to be within the purview of the psychoanalytic method because the latter was greatly enlarged by the use of parameters—that is, departures from standard technique. Other analysts disagreed with one or another of these modifications. Because the changes in the method were not needed in work with the classical psychoneuroses, an unintended consequence of this "widening scope" was the blurring of the distinction between psychoanalysis and psychotherapy. At the same time psychoanalytic theories of the cause and cure of each new diagnostic category emerged that in turn legitimized this expansion in the range of diagnoses that could be treated. In short, one analyst's idea of analysis became another analyst's idea of psychoanalytic psychotherapy, leading to tensions and splits that were more or less contained by national and international organizations.

Other social changes dramatically impacted the field. The following is a short list: new psychological treatment methods such as cognitive therapy, behavior modification therapy, group therapy, etc. competed with psychoanalysis for patients. The sexual revolution occurred and women objected to Freudian concepts of gender and how the cure could be accomplished. Homosexuality was no longer considered a disease. Attitudes toward authority were strongly challenged, greatly affecting the willingness of patients to accept the rigors of psychoanalytic treatment. Psychoneurosis disappeared from the Diagnostic and Statistical Manual, undercutting some of the rationale for psychoanalysis. Non-MDs sued the American Psychoanalytic Association for the right to be trained as psychoanalysts, and won. Psychopharmacological therapy made exponential gains in the quality and quantity of drugs to alleviate the same symptoms previously treated by psychoanalysts.

All of these developments changed the profession by making it far more inclusive of different views, and they also changed psychoanalytic education so it could incorporate these enormous upheavals while retaining its core identity as a treatment method. One solution was the introduction of psychoanalytic educational centers that taught the traditional method along with its enlarged variations to some students, while offering to others courses in psychoanalytic psychotherapy, child development for parents, how to consult with adoption agencies, schools, businesses, forensic psychiatrists, agencies for the homeless, and so forth.

Meanwhile the large psychoanalytic organizations were embracing the idea that psychoanalysis is not only a treatment method for a special group of patients but also a body of knowledge that could be extended (applied) to a wide...