will psychoanalysis fulfill its promise?

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Will psychoanalysis fulfill its promise? Robert S. Wallerstein 290 Beach Road, Belvedere, CA 94920, USA – [email protected] (Final version accepted 27 October 2011) Although Freud had aspirations of a university structure for psychoanalytic educa- tion the sociopolitical structure of the Austro-Hungarian empire precluded this, and psychoanalysis developed by default in the central European heartland within a part-time, private-practice educational structure. With its rapid spread in the post-World-War-II United States, and its ready penetration of American academic psychiatry, a counter educational structure arose in some quarters: the depart- ment-of-psychiatry-affiliated institute within the medical school. This article out- lines beyond these other, more ambitious, academic vistas (the David Shakow model, the Anna Freud model, the Menninger Foundation, Emory University (USA), AP de BA (Argentina)); conceptions even closer to the ideal (idealized) goal of full-time placement within the university, with strong links to medicine, to the behavioral sciences and to the humanities. The putative advantages of such a structure are presented. Keywords: autonomous institute within the university, independent psychoanalytic institute, department-of-psychiatry-affiliated institute, psychoanalytic research The psychoanalysis innovated almost singlehandedly by the genius of Sig- mund Freud, with the publication of his originating papers on hypnosis and suggestion and then Studies on Hysteria (1893–95) with his first co-worker Josef Breuer in the 1890s, is now well past its first century mark. It, along with the contributions of Charles Darwin on evolutionary theory, of Albert Einstein on the theory of physics, and of Karl Marx on social and political theory, shaped the intellectual world of the entire twentieth century in the natural sciences, the behavioral sciences and the humanities. I came to it at the beginning of the 1950s, a dozen years after the death of Freud, at a time of its seeming ever-increasing presence and influence, and have lived, with it and through it, somewhat more than half of its history to date. Now, in celebration of the 100 years of the International Psychoanalytical Association (IPA), the organization founded by Freud and his followers in 1910 to institutionalize the psychoanalytic idea and to preside over its grow- ing future – an organization in which I have been devotedly involved for close to a half-century – I want to render a very personal account of how I have seen psychoanalysis from my very first contact with it, and how I have felt it evolve over the years since, to what I see as its present very problem- atic place in the scheme of things and its present very uncertain future. At the time of my own change from a career in internal medicine to one in psychiatry and the lure of psychoanalysis in 1949, the ego psychology metapsychology paradigm, architected by Heinz Hartmann and his many Int J Psychoanal (2012) 93:377–399 doi: 10.1111/j.1745-8315.2011.00547.x Copyright ª 2012 Institute of Psychoanalysis Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA on behalf of the Institute of Psychoanalysis e International Journal of

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Page 1: Will psychoanalysis fulfill its promise?

Will psychoanalysis fulfill its promise?

Robert S. Wallerstein

290 Beach Road, Belvedere, CA 94920, USA – [email protected]

(Final version accepted 27 October 2011)

Although Freud had aspirations of a university structure for psychoanalytic educa-tion the sociopolitical structure of the Austro-Hungarian empire precluded this,and psychoanalysis developed by default in the central European heartland withina part-time, private-practice educational structure. With its rapid spread in thepost-World-War-II United States, and its ready penetration of American academicpsychiatry, a counter educational structure arose in some quarters: the depart-ment-of-psychiatry-affiliated institute within the medical school. This article out-lines beyond these other, more ambitious, academic vistas (the David Shakowmodel, the Anna Freud model, the Menninger Foundation, Emory University(USA), AP de BA (Argentina)); conceptions even closer to the ideal (idealized)goal of full-time placement within the university, with strong links to medicine, tothe behavioral sciences and to the humanities. The putative advantages of such astructure are presented.

Keywords: autonomous institute within the university, independent psychoanalyticinstitute, department-of-psychiatry-affiliated institute, psychoanalytic research

The psychoanalysis innovated almost singlehandedly by the genius of Sig-mund Freud, with the publication of his originating papers on hypnosis andsuggestion and then Studies on Hysteria (1893–95) with his first co-workerJosef Breuer in the 1890s, is now well past its first century mark. It, alongwith the contributions of Charles Darwin on evolutionary theory, of AlbertEinstein on the theory of physics, and of Karl Marx on social and politicaltheory, shaped the intellectual world of the entire twentieth century in thenatural sciences, the behavioral sciences and the humanities. I came to it atthe beginning of the 1950s, a dozen years after the death of Freud, at a timeof its seeming ever-increasing presence and influence, and have lived, with itand through it, somewhat more than half of its history to date.

Now, in celebration of the 100 years of the International PsychoanalyticalAssociation (IPA), the organization founded by Freud and his followers in1910 to institutionalize the psychoanalytic idea and to preside over its grow-ing future – an organization in which I have been devotedly involved forclose to a half-century – I want to render a very personal account of how Ihave seen psychoanalysis from my very first contact with it, and how I havefelt it evolve over the years since, to what I see as its present very problem-atic place in the scheme of things and its present very uncertain future.

At the time of my own change from a career in internal medicine to onein psychiatry and the lure of psychoanalysis in 1949, the ego psychologymetapsychology paradigm, architected by Heinz Hartmann and his many

Int J Psychoanal (2012) 93:377–399 doi: 10.1111/j.1745-8315.2011.00547.x

Copyright ª 2012 Institute of PsychoanalysisPublished by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and350 Main Street, Malden, MA 02148, USA on behalf of the Institute of Psychoanalysis

�e International Journal of

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collaborators and being systematized by David Rapaport, was the verydominant influence in (American) psychoanalysis. Many of Freud’s activecolleagues and students, having fled as Hitler refugees from the centralEuropean psychoanalytic strongholds, were then the central teachers in thespreading American psychoanalytic institutes. Psychoanalytic congresses –which, prior to World War II, had always been in Europe, with German asthe dominant language – were now being reconfigured by a new trans-Atlantic agreement, with the presidency of the IPA to be rotated betweenEurope and North America. With the new American membership majority,English became both the administrative language and the majority languageof the congress presentations. American psychoanalysts everywhere had fullanalytic practices – and often with substantial waiting lists.

Psychoanalysis had been popularized in America by Karl Menninger, theintellectual leader of The Menninger Foundation, which at the time was theforemost psychoanalytically based mental health treatment center in Amer-ica. His 1930 book, The Human Mind, a psychoanalytic exposition ofhuman mental functioning, was written in response to an earlier volume bya colleague at the Kansas University Medical School, Logan Clendening. In1927 Clendening had published the volume The Human Body, which wasdesigned to afford the educated reader an overview of anatomic, physiologi-cal and biochemical bodily functioning but had omitted – to Menninger’sdismay – the realm of mental functioning. And New Yorker cartoons werereplete with psychoanalytically themed humor, grist for the understandingand amusement of its sophisticated, psychoanalytically informed readership.

Before going to The Menninger School of Psychiatry in Topeka, Kansas,I had a half-year of psychiatric residency on the psychosomatic service atthe Mount Sinai Hospital in New York City. The only psychoanalytic bookthat I had actually dipped into prior to that was Otto Fenichel’s recentlypublished (1945) Psychoanalytic Theory of Neurosis. After starting in thatprogram, the first book I read was Psychotherapy in Medical Practice (1944)by the American analyst, Maurice Levine – followed very shortly by pre-Standard Edition translations of Freud’s papers and monographs. The psy-chosomatic service was staffed by both internal medical and psychiatrictrainees. The ward was occupied by severely medically ill, so-called‘psychosomatic’, patients – intractable duodenal ulcers, status asthmaticus,ulcerative colitis with bloody diarrhea and daily high-spiking fevers, etc –transferred there during that heyday of psychoanalytic attention to thesedisorders spearheaded by the new researches of psychoanalysts FlandersDunbar (1935, 1943) and Franz Alexander and his school (1948).

As part of their treatment regime each in-patient was seen in daily psy-chotherapy, either while still bed-confined or, if ambulatory, in the resident’soffice. Each psychiatric resident, with four assigned patients, thus startedwith 20 hours of assigned psychotherapy from the first day on the ward –managed by excellent sustaining supervision. (The balance of the workingweek was filled with ward rounds, working up new patients, spending timein the adjacent out-patient clinic continuing the psychotherapy, usually on aonce-weekly basis, of former hospitalized patients who had been dischargedwhen their somatic well-being had been sufficiently restored, plus case

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conferences and reading seminars.) On my very first day in psychiatry,confronted with my list of four assigned patients who I was to see for dailytherapeutic sessions, I checked in my bewildered way with the chief resident,asking ‘what do I do?’. He looked at my list of four, nodded briefly andpointed to one of the names, saying ‘start with that one. She’s an awfulchatterbox and you’ll hardly have to say anything’.

The system worked, sustained by the intensive several-times-weekly super-vision given by the attending psychiatric staff, all practising clinical psycho-analysts. And it was what the residents wanted: in those days, the greatmajority of psychiatric residents looked forward to future out-patient careersas practitioner psychotherapists, most settling in the major urban centers,starting on the east coast – the Boston to Washington axis – but by 1949already spreading westward across the country, where they could then go onfor formal training in the newly growing psychoanalytic institutes. With theexception of the tiny handful who chose salaried positions in the country’snetwork of large state mental hospitals,1 many of them refugee physicianswho felt unable to pass the state licensure examinations (which would haveallowed independent practice), psychoanalysis seemed, in those days, theonly real career path in psychiatry. When, during the 1950s and 1960s, thegeneration of Adolf-Meyer-trained psychobiological psychiatrists2 werebeing replaced as chairs of the USA’s leading medical school departmentsof psychiatry by psychoanalysts or psychoanalytically sympathetic psychia-trists, there were academically ambitious psychiatrists, aspiring to universitycareers, who sought out psychoanalytic training – not because of interest ina psychoanalytic career path, but because it was seen as a prestigious cre-dential during those decades of avid pursuit of the psychoanalyticallyinformed by so many of the nation’s medical schools.

And it was at Mount Sinai Hospital that pioneering psychoanalyticresearch was being done, notably Charles Fisher’s exciting sleep-dreamresearch reported in the 1950s in early volumes of the Journal of the Ameri-can Psychoanalytic Association (Fisher, 1953a,b, 1954, 1956, 1957, 1959).Also, Sydney Margolin’s study correlated daily psychoanalytic hour themeswith ongoing studies of the stomach (motility, vascularity, acidity andresponse to drugs affecting gastric functioning) in a young woman with agastric fistula. The fistula was created after the woman attempted to commitsuicide by swallowing lye; this had caused a total esophageal stenosis, andled to her being hospitalized while she awaited an attempted surgical repara-tion that was designed to build a new alimentary pathway (PsychoanalQuart, 1951). In that setting, and with the intensity of the psychoanalytically

1I had occasion to visit the Dannemora State Hospital for several days in an isolated area of upstateNew York. Only four psychiatrists cared for a population of 4,000 chronically ill, overtly psychoticpatients, many of whom were there for life.2In those days, psychobiology referred to the Meyerian doctrine of attention to the study of the pressureof lifelong development and circumstance in the evolution of somatic and mental illness, but without thepsychoanalytic concepts of the unconscious or of transference. That meaning is today obsolete andpsychobiology now refers to understanding the neural science underpinning mental illness, with itsapplied biological psychiatry and psychopharmacology.

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based supervision, we all learned more and did better psychotherapy thanwe were, in fact, actually capable of.

When I left for the bulk of my psychiatric residency at the MenningerSchool of Psychiatry centered in the private Menninger Clinic and the affili-ated federal Winter Veterans Administration Hospital (WVAH), the ambi-ence was much the same. Psychoanalytic theory and the derivedpsychodynamic psychotherapy comprised the scene. Whether working on aclosed ward with the hospitalized psychotic or on open wards or out-patientclinics with the character-disordered and the neurotic, the central therapeu-tic was intensive psychotherapy – whatever else was also offered (on theclosed wards), like the then-active insulin coma, or electroconvulsive therapyor even the ill-starred lobotomy operation. The ideological center of theMenninger School universe was the Topeka Institute for Psychoanalysis, thefirst institute established west of Chicago. It was already monitoring formalpsychoanalytic beginnings in the far west, Los Angeles and San Francisco.

For those who assumed staff positions at the Menninger Clinic or theWVAH or at the newly joining (in the mid 1950s) Topeka State Hospital,the decisive goal was acceptance for concomitant psychoanalytic training atthe Topeka Institute. The first of my two analysts in Topeka, Robert Jokl,had come from Vienna, where he had trained at the Institute and been ana-lyzed by Freud. This made me a ‘grandson’; and in those days psychoana-lytic lineage seemed to be known everywhere, and to be importanteverywhere. On a number of occasions he would offer me one of Freud’sinterpretations: ‘At a time like this, the Professor would say to me…’. Some-times I thought it was apt, sometimes not.

While a psychoanalytic candidate, I began to attend the semi-annualweek-long meetings of the American Psychoanalytic Association at the vari-ous large urban centers across the country. I would meet old friends fromresidency days who had left Topeka after completing their residencies forcareers as therapists and candidacies in their local psychoanalytic institutesin, by then, at least a dozen major urban metropolises (and seemingly thisnumber was ever growing). The question I would be asked, pointedly, was‘when are you moving our way?’, while adding the particular virtues of NewYork or Washington or Los Angeles or San Francisco.

And to make the offer firm, something like the following would often beadded: ‘If you plan to come next summer, make a preliminary weekend visitsometime in May. We could schedule you with a dozen or so interviews withprospective patients, so that you could arrange to have a full therapy prac-tice waiting for you when you move to town.’ Everyone seemed to havewaiting lists, some of them quite long, and psychoanalysis seemed to be bur-geoning everywhere. Medical schools everywhere seemed to be looking foracademically qualified psychoanalysts to become the new department chairsin psychiatry, with the expected clustering of psychoanalysts in the depart-ment’s teaching and supervision posts. This would make them the kind ofpsychoanalytically oriented departments that would be more attractive toresidency applicants who, when accepted, would hope to be well regardedby their psychoanalytic mentors, and well recommended by them for thepsychoanalytic training offered at the local psychoanalytic institute.

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Everywhere psychoanalysis was thriving, and its future seemed limitless.Psychoanalytic treatment promised much – even too much – and had noready competitors. Rogerian client-centered therapy and the behavioral thera-pies were barely on the scene (at least not on the New Yorker readershipscene) in the country’s sophisticated intellectual and cultural centers. Thefirst of the more significant psychoactive medications, Thorazine, did notarrive until the mid-1950s, when it was brought from Switzerland to Canadaas Largactil and then by Smith, Kline and French to the USA. Everywhere,psychoanalysis seemed to be capturing psychiatry. Within American psycho-analysis there was an established hegemony of the ego-psychology paradigm,which was offered as the direct descendent of Freud’s structural theory. Thistheory was propounded in The Ego and the Id (1923) and Inhibitions, Symp-toms and Anxiety (1926a). It was then developed further by Anna Freud in1936 with The Ego and the Mechanisms of Defense, an elaboration of thedefensive functions of the ego (offered as a tribute on her father’s eightiethbirthday), and then by Heinz Hartmann in 1939 with Ego Psychology and theProblem of Adaptation, an elaboration of the adaptive functions of the ego.

What came to be the reigning American ego psychology was spearheadedin New York in the 1940s and 1950s by Hartmann and his many colleaguesand collaborators, including Kris, Loewenstein, Spitz, Mahler and Jacobson.Teaching in the American psychoanalytic institutes was uniformly in accord,with the partial exception of the Baltimore-Washington Institute (which wassomewhat influenced by the declared ‘deviant’ views of Harry Stack Sulli-van’s interpersonal psychiatry). Beyond Freud’s corpus and the supportingarticles of his early collaborators and followers, current reading was rigidlyproscribed: The Psychoanalytic Quarterly, The Journal of the American Psy-choanalytic Association (both American, thoroughly ego-psychological jour-nals); and for child and developmental issues, The Psychoanalytic Study ofthe Child, an Anglo-American monograph series with its British wing cen-tered in Anna Freud’s Hampstead Clinic (renamed after her death the AnnaFreud Centre), part of the same ego-psychological perspective.

The International Journal of Psychoanalysis, the official journal of the Brit-ish Society – and actually the first English-language psychoanalytic journal –was declared a minefield. There were articles that should be read. But therewere also Kleinian articles, all to be avoided like the plague. The Americanperspective on the Kleinians was captured in Rapaport’s dismissive footnotein his historical survey of psychoanalytic ego psychology: ‘‘the ‘theory’ ofobject relation evolved by Melanie Klein and her followers is not an egopsychology, but an id mythology’’ (Rapaport, 1959, p. 11). Of the manyMiddle-Group articles, two by Winnicott were deemed acceptable – ‘Hate inthe counter-transference’ (1949) and ‘Transitional objects and transitionalphenomena’ (1953) – but no others.

This was the American psychoanalytic world as I experienced it in mycandidacy days across the 1950s. It felt itself the carrier of the true Freudianheritage as now exemplified by ego psychology. It was centralized within therigidly hierarchical structure of the American Psychoanalytic Association,and attendance at its semi-annual meetings was a mark of professionalbelonging. Teaching in the American institutes was almost totally within the

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guiding ego-psychology paradigm – with the exception of one eight-sessioncourse in my institute (Topeka) entitled ‘deviant schools’, encompassingJung, Adler, Klein, the Middle Group and whatever else the instructor choseto include. (Lacan was not even mentioned.) And instruction in clinicaltechnique was confined within the dictates of Kurt Eissler’s 1953 paper onparameters, that relentless veridical interpretation of the transference (andnothing more) led inexorably – via working through – to insight and ulti-mately cure. Comprehensive cure was the expected result.

It was known that analytic groups were springing up outside the frame-work of the American Psychoanalytic Association, chiefly at first in NewYork and then in Los Angeles. This was an effort by non-physicians, psy-chologists and social workers, who at the time were denied ‘official’ trainingby the then-exclusionary policies of the American Psychoanalytic Associa-tion, to nonetheless be psychoanalytically trained; often, they did so withthe covert help of some prestigious members of the American Psychoana-lytic Association, who strongly opposed its dicta on this issue. Butthese efforts posed no competitive threat in the abundant psychoanalyticmarketplace. Although competitive psychotherapeutic ideologies – Rogerianclient-centered therapy and the beginnings of (stimulus–response) behavioraltherapies – were being promoted in university psychology departments, andto some extent in the public arena, again they attracted none of theeducated public’s fervor for psychoanalytic treatment.

Psychoanalytic treatment seemed to be encompassing an ever-wideningpsychological arena. In a much-noted paper in 1954, Leo Stone cast a cau-tiously skeptical view on what he called the ‘widening scope of indicationsfor psychoanalysis’:

One might say that in the last decade or two, at least in the United States, any ill-ness or problem which has a significant emotional component in its etiology hasbecome at least a possible indication for psychoanalysis…. Hopeless or grave realitysituations, lack of talent or ability (usually regarded as ‘inhibition’), lack of an ade-quate philosophy of life, or almost any chronic physical illness may be brought topsychoanalysis for cure.

(Stone, 1954, p.598)

Stone was warily receptive to this trend, albeit he was also skeptical. Hisown measured assessment of the issue was as follows:

The scope of psychoanalytic therapy has widened from the transference psychoneu-rosis, to include practically all psychogenic nosologic categories. The transferenceneuroses and character disorders of equivalent degree of psychopathology remainthe optimum general indications for the classical method. While the difficultiesincrease and the expectations of success diminish in a general way as the nosologicalperiphery is approached, there is no absolute barrier.

(Stone, 1954, p. 593)

Thus the sweeping triumph of psychoanalysis as the scientific understand-ing of human mental functioning in all its intellectual and cultural ramifica-tions, and as the scientific therapy for all the disorders of mental

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functioning in mid-twentieth-century America. The 100th anniversary, in1956, of the birth of Sigmund Freud, its founding genius, was marked by acelebratory address by Ernest Jones – perhaps the last survivor of Freud’sinner coterie of the seven ring-holders, and the former long-time presidentof the IPA – entitled ‘Our attitude toward greatness’. Jones’s opening sen-tence was: ‘‘One hundred years ago there came into life a being whose longyears of work and insight were to make such contributions to knowledge asprofoundly to influence the civilization of every country’’ (Jones, 1956,p. 626). The address ended with the words ‘‘I shall not look upon his likeagain’’ (p. 643). In the mid 1950s, psychoanalysis seemed to be enduring asa significant shaper of our worldwide intellectual life, and its future seemedlimitless as a central avenue in ameliorating humankind’s mental suffering.

Fast forward to 2012, a little over a half-century later. The picture at pres-ent is much more mixed. On the one hand the psychoanalytic idea seems tobe established securely as part of our general intellectual-cultural scene.Apropos here is a quip attributed to Freud counseling Ferenczi on one ofthe latter’s periodic visits to Freud in Vienna. Ferenczi was reportedly com-plaining to Freud about his intellectual isolation in his native Budapest,where his psychoanalytic doctrine was under constant severe attack; he waswondering whether to move to Vienna, where at least there was a group oflike-minded believers who could strengthen and comfort each other. Freud,wanting to maintain Ferenczi in his home in Budapest, was supposed tohave consoled him with a statement like: ‘Don’t worry so much about theseattacks. Our opponents may dismiss our theories during the day, but remem-ber: they dream according to them at night.’

For psychoanalysis is a pervasive idea everywhere today. In our language,where unconscious, rationalization, defense mechanism, Freudian slips, etc,are commonplace and widely understood terms, and in cultural expressionslike literary and artistic criticism. And in academic discourse: psychoanalyticperspectives are widely embedded in the social sciences, especially sociologyand anthropology, but also in the currently burgeoning field of behavioraleconomics; in the humanities as well, in philosophy, rhetoric, English andFrench departments. Organizationally, psychoanalysis has grown and spreadvery significantly. The IPA, which had between 2,000 and 3,000 memberswhen I first was able to join in 1960, today numbers between 11,000 and12,000. And the spread has been increasingly global. Originally it was aGerman-speaking European enterprise: American membership no more thantwenty percent in the days before Hitler’s takeover of Germany in 1933, andthere was practically nothing elsewhere. With the massive immigration ofrefugees fleeing Hitler across the Atlantic and the events of World War II –which left continental Europe psychoanalytically almost totally depleted – anew era of American majority was ushered in. When a functioning interna-tional association was reconstituted after World War II, it resulted from anumber of meetings in London between the IPA officers (then all British)and American officers. They effected a new compromised functioning, withthe presidency to alternate between America and Europe, the congresses tocontinue in Europe but English to replace German as the administrativelanguage and the language of the majority of scientific sessions. By 1977

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congresses spread out of Europe, first to New York. During my presidencyof the IPA (1985–89), Latin America – which by then had grown to consti-tute over twenty percent of the world membership – was added to the rota-tion of the presidency and was given an equality of vice-presidencies withEurope and North America. Beyond those three major regions, there wereat that time functioning psychoanalytic societies only in Israel, India, Japanand Australia.

With the fall of the Berlin Wall and the collapse of Soviet hegemony overEastern Europe, psychoanalysis began a steady march into Russia andalmost all of its former European Soviet satellite states. There was also aspread into South Korea, Turkey, even China, plus into hitherto psychoana-lytically empty areas in Latin America, like Paraguay. Psychoanalysis hasbecome a vibrant growth industry in major nations like Argentina, Brazil,Germany and Italy. In all these ways psychoanalysis – both as an idea, cen-tral to worldwide culture, and as institutionalized in the geographic reach ofthe societies and their training institutes – has been growing steadily overthe past half-century.

But there has also been a far darker side to this same period. Over time,psychoanalytic results have turned out to be more modest and more uncer-tain than the glowing optimism that the fervid 1950s had seemed to prom-ise. The behavioral therapies, which began to compete seriously in thetherapeutic marketplace at this time, did indeed promise faster symptomrelief and often seemingly equal restoration of psychic equilibrium for farless time and money, all backed up by increasingly empirical comparativeresearch studies. This research emphasis found favor in medical treatmentranks, which were increasingly responsive to the call for ‘evidence-based’treatment strategies. Meanwhile the increasing deployment of psychoactivemedications, first directed at the psychotically ill housed in in-patient men-tal-health facilities, was soon directed at the out-patient world. It reachedtowards the wide array of depressive and anxiety disorders that wereincreasingly dealt with by family physicians, and only those who provedrefractory to their medicines were referred on to mental-health practitioners.

As enthusiasm for psychoanalysis as the immediate remedy for our neu-rotically ill declined, it was also losing its cherished place within Americanpsychiatry. Psychiatry has grown and diversified in significant ways, in itsteaching and in its practice, all at the expense of the emphasis and the timedevoted to psychodynamic psychotherapy – its central activity a half-cen-tury ago. This growth and diversification has had multiple aspects. First, ofcourse, is the literal explosion of biological knowledge, of brain–behaviorinter-relations within the domain of psychiatry. These are the advances ofneural science, of neurophysiology and neurochemistry, the underpinnings ofmodern-day biological psychiatry with the consequent development of thegrowing panoply of psychoactive drugs and their spreading deploymentwithin the psychopathological spectrum.

Secondly, psychoanalysis has had to share its place: it is no longer theunique psychology within psychiatry. It has been significantly challenged(and ⁄ or replaced) by the growth of two fundamentally different andcompeting psychological paradigms. The first is the learning–theory and

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stimulus–response model (partly classical, partly operant) with the behav-ior-modification technologies derived from it (cognitive-behavioral therapy(CBT), dialectical behavior therapy (DBT), etc). The second attacked bothpsychoanalysis and behavior modification for being mechanical and strippedof essential subjectivism and humanism; the so-called third force, the exis-tentialist-phenomenological tradition of European letters and philosophybrought to America as humanistic psychology with the associated encounterand human potential movements. Psychoanalysis no longer has its onceunquestioned place as the psychological basic science for clinical psychiatry.

The third major dimension of change in psychiatry is in the social scienceand social policy arena: the community psychiatry and community mentalhealth center movement and ideology inaugurated by the Kennedy legisla-tion of 1963. The new legislation led to the massive deinstitutionalization ofpatients who until then had been chronically housed in state mental hospi-tals. This was made possible, of course, by the advent of psychoactive drugs,with hospitalizations now for the most part only short and mainly for acuteand unmanageable life crises. This change has brought its own host of newproblems for psychiatry: from, at its best, dealing with the impact of chroni-cally psychotic patients, now living at home, upon the children they are try-ing to raise; to, at its worst, the patients who were once neglected andabused in the state hospitals now being neglected and abused in board andcare homes and cheap inner-city hotels. All this in response to the philo-sophic shift – putatively beneficial – from the therapeutic to the preventiveameliorative model, and from the idiosyncratically individual to the sociallycontrolled family and group and social-system concerns of the communitymental health movement.

All these new psychiatric emphases, psychobiology and psychoactive drugdeployment, geriatric psychiatry, forensic psychiatry, addiction psychiatry,consultation psychiatry, community mental health psychiatry, let alone thenew focus on clinical psychiatric research (especially trials of ever-newemerging medications) – necessary as they all are – have been at the expenseof the past central and unifying focus on psychodynamic psychotherapy, inclinical teaching and in practice. Whereas I in the 1950s did and learnedpsychotherapy twenty hours weekly, or more than 1,000 hours each year,through a three-year residency, today psychotherapy is one among manycomponents of the weekly schedule: in many programs it is down to sixhours a week for a year (300 hours), except for those who take it as an addi-tional elective in their third year.

This can represent a reduction of psychotherapy teaching time (and onlysome of that is ‘psychoanalytic’ or ‘psychodynamic’ teaching) from 3,000 to300 hours in three years in many academic psychiatric residency programs.This drastic shift has even led to panel discussions at some annual meetingsof the American Association of Psychiatric Training Directors entitled ‘Ispsychotherapy training essential for psychiatry, or should it be madeoptional, for those who intend to make it a crucial aspect of their own psy-chiatric careers?’. The argument in favor of the latter is that there is so muchelse to learn in modern-day psychiatry that is truly ‘medical’ and that, afterall, if formal psychotherapy is deemed to be indicated in a particular clinical

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instance, it can be referred to a non-medical therapist, psychologist or socialworker, or family therapist, who would indeed do it for a lesser hourly fee.The referring psychiatrist’s role could then be limited to the effort to ‘moni-tor’ or to ‘supervise’ the therapy, although it is hard to see that this couldbe welcomed, or carried out helpfully, if offered by someone who is not anexperienced therapist.

These changes in the nature of psychiatry have, of course, had theirimpact on psychoanalysis as a profession, despite the continuing active pres-ence in our culture of psychoanalysis as a theory of the mind and its func-tioning through academia in general. With so many new career paths withinpsychiatry, it can no longer be taken for granted that the best and thebrightest will opt for psychoanalytic thinking and for psychoanalytic psy-chotherapy as their chosen career path. Over the past half-century, despitethe enormous growth in the number of psychiatrists, there has been a steadyreduction in the proportion seeking psychoanalytic training: throughout the1970s and 1980s, candidate classes were progressively smaller at the USA’spsychoanalytic institutes, with numbers switching from having enough for anew class each year to a class every two years. Indeed, what maintained theviability of psychoanalytic training in the USA until today was the fullopening of clinical training to non-medical applicants consequent to theagreed settlement in late 1988 of the class-action lawsuit brought in early1985 against the American Psychoanalytic Association by four clinical psy-chologists on behalf of a class of several thousands, alleging restraint oftrade on Sherman Anti-Trust Law grounds.3

The receding place of psychoanalysis within psychiatric academia was alsomarked by the abrupt decline in the number of medical schools seeking psy-choanalyst psychiatrists as department chairs when vacancies arose. Whathad been a rapidly rising tide in the 1950s and 1960s had dwindled so farthat when I was recruited to chair the department at the University of Cali-fornia San Francisco School of Medicine in 1975, it was made clear to methat it was not because I was a psychoanalyst but despite that fact, becauseI had such other good credentials.

Thus, despite the worldwide geographic spread in the centers of psychoan-alytic activity, in the USA the total number of psychoanalytic graduateseach year has just about kept up with those leaving the ranks, despite theever-growing number of psychiatrists and the ever-increasing populationsize. Along with the declining number of candidates in each institute therehas been a similarly declining number of patients for each practitioner,including declining numbers of psychoanalytic clinic patients, suitable ascontrol cases. This is the much-heralded and worldwide ‘crisis in psycho-analysis’ that has become the focus of attention in the international arenaover the past decade and a half. Seemingly everywhere there are fewer candi-dates, fewer graduates and fewer patients than had once been the expectednorm. Many analysts have complained very unhappily, and this has been

3For full details on this lawsuit and the almost century-long (1910–88) contentious issue within theInternational Psychoanalytical Association over clinical psychoanalytic training for non-physicians, seemy book devoted to this story, Lay Analysis: Life Inside the Controversy (1998).

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reflected in many ‘psychoanalytic’ patients being seen less frequently – threetimes a week (justified only partly on conceptual grounds), in some caseseven less than that – and in growing percentages of time filled with avow-edly psychotherapy cases.

In part this decline in available patients has been part of the gradual disen-chantment with the results achieved after even lengthy analyses; in part overa rising fee structure in a persistently inflationary world; in part because ofcompetition with the growingly popular varieties of behavioral therapies,with their promise of far quicker results; in part due to the widening use ofpsychoactive medications for ever lesser severity of psychopathology; in partbecause of the increasing pressures of third-party reimbursement carriers, theincreasing call for ‘evidence-based’ treatments based on empirical research,findings of substantial symptom relief after separate or combined drug treat-ment and behavioral therapies offered by non-psychoanalytic psychiatristsor, even more widely, by general medical practitioners.

All of this has been particularly marked in the case of child analysis, withparents far less willing today than in the psychoanalytic heyday a half-centuryago to invest the money and the time – three hours a day for the adult bring-ing the child, waiting for the child, and returning home with the child eachday – for a traditional child analytic treatment. The trend is accelerated bythe fact that compared with previous generations, so many more mothers arein the workplace today. (This is partly the consequence of the successes ofthe feminist movement, and partly out of increasing economic necessityamong the less affluent). Therefore, many simply no longer have the time toferry children for daily treatment. Even among the more affluent, there arethe competing pressures of music lessons, of fitness classes, of Little Leagueand soccer games, of ‘play dates’ with school chums, all pulling on caretakertime. Given these combined circumstances, it is no wonder – aside fromquestions in many minds about the need for, or the reliable efficacy of, childanalysis – that there are a substantial number of certified child analyststoday who do not have a single child in a full traditional psychoanalysis.

This sharp decline in the search for psychoanalytically based remedies formental and emotional disorders today compared with a half-century ago hasbeen characterized aptly by Robert Michels, from the prospective patient’spoint of view, as follows:

It often seems as if psychoanalysis isn’t even designed to help them. Patients wantanswers, whereas psychoanalysts ask questions. Patients want advice, but psychoan-alysts are trained not to give advice. Patients want support and love. Psychoanalystsoffer interpretations and insight. Patients want to feel better; analysts talk aboutcharacter change.

(p. 33)4

Let us compare today’s situation with the unbridled growth and optimismof a half-century ago, when I was growing into the field. Our institutes are

4Quoted in a New York Times article by Daphne Merklin (2010) describing her own long career as asophisticated long-term patient in this changing psychotherapy world.

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struggling to maintain their recruiting and teaching activities, patient receptiv-ity is diminishing, the curative aspirations of our current practitioners are farmore modest, and increasing psychotherapy research (which thus far has notbeen able to demonstrate convincingly the special efficacy that psychoanalysispurportedly offers over the competitive drug and behavioral therapies) isever-growing in methodological sophistication. How do all these portents ofpsychoanalytic decline today relate to our possible future as both an aspiringscience and a practitioner profession? Or, put somewhat differently, how canpsychoanalysis rescue itself and reverse the currently stagnating trends?

Any number of us are seriously concerned by these issues and givingthought to variously conceptualized paths of reversal, framed with differingemphases according to our varying conceptions of the fundamental natureof psychoanalysis as a human activity and what its place in the worldshould be – and, hopefully, can be. My own lifelong commitments havebeen – in accord with those of Freud – of psychoanalysis as an aspiring sci-entific psychology, a science of the mind. Of course, these are linked to myconception that sciences accrue new knowledge, and add to their establishedknowledge base, through systematic incremental research, methodologicallygeared to the nature of their data and the possibilities and constraints thatthe data pose for the testing of their guiding assumptions.

Strangely though, Freud never linked his declared belief in the nature ofpsychoanalysis as a science to any need (or requirement) for the formal sys-tematic research by which a science necessarily can claim to grow. The onlybearing of empirical research on psychoanalytic concepts that Freud evermentioned (and he did so approvingly) was a footnote in The Interpretationof Dreams (1900) (footnote added in 1919, pp.181–2) referring to OttoPçtzl’s experimental studies of subliminal perception (Pçtzl, 1917). Whenthe American psychologist Saul Rosenzweig wrote to Freud in 1934, describ-ing his laboratory support for some of Freud’s central psychoanalytic con-cepts, Freud responded tersely and dismissively, stating that suchconfirmatory evidence was not needed because psychoanalysis rested onsuch a wealth of positive clinical experience. Freud ended acerbically with:‘‘still it can do no harm’’ (Shakow and Rapaport, 1964, p.129). Actually, thisnegative view by Freud of the value of empirical research to the growth ofpsychoanalysis has added weight to the hermeneutic movement, whichclaims that psychoanalysis is not a science but a humanistic discipline, thatit grows by continuing clinical discovery and theoretical reasoning – a vigor-ous counterinfluence within psychoanalytic discourse. (See Andr� Green,2000, for an exposition of that viewpoint.)

But as a science, like all disciplines that claim such status, the logicalhome for psychoanalysis would be academia, with all the necessary missionand resources (full-time faculty positions, an organized and supportiveresearch infrastructure, degree-seeking graduate students) to promote disci-plinary scholarship for the social good, both educationally (the transmissionof the knowledge base to new cadres of aspirants) and in terms of research(to fortify, and increase, that knowledge). Unfortunately, the early develop-ment of psychoanalysis precluded the possibility of an academic base.Because of the severe revulsion within the medical and intellectual world of

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Freud’s Victorian-era Vienna against the scandalous childhood sexualdoctrines propounded by this new psychoanalysis, as well as the more-or-less official anti-Semitism of the Austro-Hungarian Empire, Freud neverwon the university position to which he aspired throughout his life, norcould his psychoanalysis find a proper university home.

Instead, psychoanalysis had to begin and grow as a private evening nightschool, with its students having to make their living and to support theirtraining through their daytime clinical activities. Likewise, the faculty sup-ported themselves in their clinical practice, and did much of their eveningteaching as tired volunteers. This is how Max Eitingon and his colleaguesorganized the first formal psychoanalytic training institute in Berlin in 1920,and how it spread across Europe, first into central Europe (Vienna, Zurichand Budapest) and then spreading beyond this periphery in the pre-WorldWar II years.

From the start Freud had envisioned a different approach to psychoana-lytic education, looking clearly to a university placement as its desired home.He made this clear in his 1919 paper ‘On the teaching of psycho-analysis inuniversities’, where he expounded all its advantages as a psychology for theteaching of medical students about mental illness and its treatment – andtherefore the place (and the influence) of psychoanalysis in the wider world.Moreover, he stated that ‘‘the inclusion of psycho-analysis in the universitycurriculum would no doubt be regarded with satisfaction by every psycho-analyst’’ (Freud, 1919, p. 171). Unhappily, Freud’s vision on this issue wasone-sided. At that time he did not appreciate the enduring benefits in thereverse direction, to psychoanalysis for its education, and the accompanyingpsychoanalytic research for which the history of psychoanalysis over the suc-ceeding century would so clearly evidence the need. Of these vistas, Freudsaid dismissively, ‘‘at the same time it is clear that the psycho-analyst can dis-pense entirely with the university without any loss to himself’’ (ibid.).

That Freud did come to a wider vision can easily be read into what is seenwidely as his most encompassing statement about psychoanalytic education,The Question of Lay Analysis (Freud, 1926b), which was written in the con-text of his spirited defense of the psychoanalytic bona fides and the impres-sive credentials of a favorite non-medical adherent, Theodor Reik. ThereFreud ventured his ideal prescription for training in the discipline of psycho-analysis as follows:

If – which may sound fantastic today – one had to found a college of psychoanaly-sis, much would have to be taught in it, which is also taught by the medical faculty:alongside of depth psychology which would always remain the principal subject,there would be an introduction to biology, as much as possible of the science of sex-ual life, and familiarity with the symptomatology of psychiatry. On the other hand,analytic instruction would include branches of knowledge which are remote frommedicine, and which the doctor does not come across in his practice: the history ofcivilization, mythology, the psychology of religion and the science of literature.Unless he is well at home in these subjects, an analyst can make nothing of a largeamount of his material. By way of compensation, the great mass of what is taughtin medical schools is of no use to him for his purposes.

(Freud, 1926b, p. 246, emphasis added)

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Embedded in this statement, as well as in a more terse comparable state-ment a few pages further on (p. 252), is Freud’s implicit acknowledgementof the insufficiency of the already established part-time and private-practicepsychoanalytic institute structure created just a half-decade earlier by MaxEitingon and his colleagues, first in Berlin and, by the time of Freud’s writ-ing, already spreading across the Central European heartland. Freud’sacknowledgement of this insufficiency is evident in his statement that ‘‘ascheme for training for analysts has still to be created’’ (ibid.).

However clear this vision was, and however much it was shared by manyof us who have followed Freud, after the first century of psychoanalysis ithas still not been realized. The first moves in that direction came in post-World War II America, where the influx of large numbers of psychoanalystHitler refugees had added enormously in numbers and in prestige to theAmerican psychoanalytic community. Whereas the main psychoanalyticinstitutes in America had been spread along the Atlantic seaboard – fromBoston to Washington – in the pre-war years,5 after the war psychoanalystswere able to launch a rapidly successful campaign over a two-decade perioduntil the mid-1960s to capture academic psychiatry for the psychoanalyticidea. Medical-school departments of psychiatry were replacing retiringdepartment chairs with trained psychoanalysts or psychoanalytically sympa-thetic psychiatrists. These new department chairs were expected to installpsychoanalytic teachers who would make psychoanalysis the clear psychol-ogy for psychiatry; the derived psychoanalytic psychotherapy, geared to theneeds of the psychiatric patient population deemed not amenable to properpsychoanalysis, was to be made the central therapeutic instrument taught toneophyte psychiatrists.

Alongside this spreading influence of the psychoanalytic idea withinAmerican (academic) psychiatry was the creation, in some receptive aca-demic centers,6 of a university-based psychoanalytic institute as an adminis-trative division: autonomously governed, within the department ofpsychiatry, with at least some of its psychoanalytic teachers part of the full-time faculty of the medical school’s department of psychiatry. Of course,only a portion of their time would be available for institute activities,because they also (properly) had major commitments to their psychoanalyti-cally guided wider teaching and their scholarly research activities within thehost department that underwrote their salaries. But limited as it was, thiswas seen as the beginning of the university placement of the psychoanalyticteaching enterprise. Impressively, four of the six have survived to the presentday, with three of them (Columbia, Denver and Emory) becoming centersof significant psychoanalytic research.7

5With the exception of Chicago.6Six, actually.7For a fuller description of this functioning (the advantages and also the limitations) of the medical-school-based psychoanalytic institute as an administrative unit within the department of psychiatry aswell as the circumstances under which two of the original cohort (Pittsburgh and Cleveland) separatedfrom the parent department, see Wallerstein (2011).

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Originally hailed as a first important step, perhaps the harbinger of amore comprehensive university entr�e – with (at least partially) the puta-tive advantages of a university home, at least some full-time faculty, accessto department of psychiatry resources for psychoanalytic research support,and opportunities for cross-disciplinary contact within the medical schooland, to a variable extent, within the wider university community – at itsbest the overall model still left psychoanalysis as the only serious disciplinethat thinks of itself as a growing science and profession, that has an edu-cational enterprise that is only part-time, and that rests, for the most part,on a volunteer, and essentially unpaid, teaching staff. For whateverreasons, although American psychoanalytic institutes have continued toproliferate widely over all the decades since World War II, only one uni-versity-based institute has come into being (at Emory, originally sponsoredby the one at Columbia) in the years since the original cluster of five wereestablished in the explosive growth period immediately after World War II.Although it has generated some significant psychoanalytic research, this(partial) university placement has fallen far short of the potential inherentin the full-time university placement of the totality of the psychoanalyticeducational structure.8

Over this same past half-century since World War II, other (different)models have been advanced for full-time psychoanalytic training within theuniversity structure and a number of experiments pointing in that directionhave been tried. Two such models have been proposed and have beendescribed by me in considerable detail in prior articles (Wallerstein, 2007,2009b, 2011). The first, proposed by David Shakow in 1962, called for anindependent psychoanalytic institute within the university, with linkages andjoint appointments with the biological sciences, medicine and psychiatry,and equally with the social and behavioral sciences and the humanities inthe university graduate schools. Shakow’s explicit focus was on training forresearch, which he felt to be woefully underdeveloped within psychoanalysis;he thought it could be made possible by autonomous university placementand the ties to cognate disciplines of human intelligence. (Philip Holzman(1976, 1985) made very comparable statements to Shakow’s about ideal psy-choanalytic training possibilities within the university; similarly, they weregeared towards the psychoanalytic research potential.) The other major pro-posal, made by Anna Freud in 1971, for the ‘ideal psychoanalytic institute’was for full-time psychoanalytic institute training, with an explicit clinical

8In post-World War II Europe, psychoanalysis also became embedded to some extent in medical schoolsin various other countries, first quite substantially in Germany: not in departments of psychiatry (whichcontinued in the Kraepelinian tradition, focusing on the sicker psychotic patients) but in newlyestablished departments of psychotherapy and psychosomatic medicine. Various medical disciplines(especially obstetrics, gynecology and pediatrics) were involved along with psychoanalysts; all focused onpsychosomatic issues with neurotic patients who were deemed amenable to psychoanalytic psychotherapy.Psychoanalysts have since also obtained professorships in other European nations, and also in LatinAmerica, in departments of either psychology or psychiatry. Although this entire article has, of course,been based primarily on my own half-century career and study within North American psychoanalysis, Ifeel that my own longstanding involvement in psychoanalysis internationally gives support to myperspective that the same issues, trends and possibilities exist comparably across worldwidepsychoanalysis (although with some time lag behind the described American events in many places).

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focus. This need not necessarily be situated in the university, but was pro-posed as the essential remedy for the deficiencies of our present part-timetraining model with volunteer faculty.

Three enterprises did flourish for periods over those years; all pointed inthe direction of full-time psychoanalytic training, although none achievedit. One was the famed Menninger Foundation, where I worked for seven-teen years (1949–66). For the eight decades of its existence in Topeka,Kansas (mid 1920s into the beginning of the 2000s), the Menninger Foun-dation was an independent full-time group practice with psychiatric hospi-tals for adults and children, a day hospital and an out-patient clinic,training programs in all the mental health disciplines including a psycho-analytic institute, and an active psychoanalytic research enterprise. It hadeverything but a formal university affiliation, and therefore was withoutofficial medical school and university graduate school colleagueship. Thesecond was Anna Freud’s, also full-time, training program over the post-World War II years at her Hampstead Clinic. However, this program waslimited to child analysis, and was only marginally covered by the psycho-analytic world. The third was the thirteen-year-long (1973–86) Doctorateof Mental Health (DMH) program started by me and my collaborators(Wallerstein, 1991). We founded the DMH in an effort to create a full-time, psychoanalytically based mental health doctorate program at theUniversity of California San Francisco School of Medicine. It was anamalgam of the most relevant mental health training experiences from psy-chiatry, clinical psychology and psychiatric social work. Our hope was thatthe DMH graduates might go on to full psychoanalytic institute clinicaltraining, and a fair number of them did. Although all three programsembraced the full-time desideratum, none brought it as far as training forfull clinical psychoanalysis itself.

Such is the state of the quest for the full-time university placement of psy-choanalysis, with all of its clinical requirements and its research needs, atthis time. Such placement seems nowhere to be immediately feasible: cur-rently, academia is reluctant to acknowledge psychoanalysis as an indepen-dent discipline warranting placement as an autonomous university entity(with appropriate ties to cognate avenues of intelligence of human mentalfunctioning); meanwhile, much of organized psychoanalysis is reluctant toabridge its vaunted total independence and to accept the monitoring con-straints of the higher university authority. And this is not to speak of thefinancial issues of the material support that universities provide to the mem-bers of the academic canon, beyond the tuition and other expenses expectedof the student body –especially in the present worldwide climate of curtail-ing the public resources being expended for the public good.

Nevertheless, this is my central conviction: that the psychoanalysis thatexpanded so spectacularly during its first half-century, even within theseverely constrained possibilities of its then private practice and very part-time training and research-growth institutional structure, would inevitablyfalter – as it has so severely in its second half-century. It has faltered for avariety of reasons inherent to the changing Zeitgeist of this second periodand, conspicuously, because of the inherent insufficiencies of our training

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structure and our growth-promoting structure that have become increasinglyevident over this time.

My own conviction has deepened over time that the ultimate redemptionof psychoanalysis – in terms of both (re)gaining its appropriate place as agrowing discipline intellectually, as a sought-after therapy for those who canmost profit from it (and who could profit beyond what other competitivetherapeutic approaches, psychosocial and ⁄ or biological-medical can offer),and its need to continuously renew and enlarge its agreed knowledge base –will only come when full academic-university placement is achieved. Distantand Utopian as that vision may seem today, a comparative historical noteallows a somewhat more positive long-term perspective.

This was provided in the opening address by the Emory University presi-dent, James Wagner (2009) – an engineer by discipline – at a conference atEmory on the present and the future of psychoanalysis in the university.Wagner’s point was that however and wherever a discipline requiring schol-arly knowledge and application arises, it must sooner or later be encom-passed within the university for its proper maintenance and its continuinggrowth. He used his own discipline of engineering as his case illustration: itgrew out of practical necessity, and under military auspices, when theexpanding Roman empire required an extensive network of good roads andbridges for its warrior legions and their military equipment. Initially therewas just military engineering and civil engineering. Over time, as humanknowledge and human needs increased so impressively, engineering finallyhad to be admitted to academia, with all its multiple specialized compo-nents today. (The university was, of course, concomitantly necessarilyexpanding beyond its own originating disciplines of law and medicine, theol-ogy and philosophy.) That this is the acknowledged function of the univer-sity today – as the responsible repository of human knowledge and both itstransmission and its enhancement – Wagner stated at the end as follows:‘‘posing the questions and working to form the ‘public sphere’ for discoursethat has overcome traditional academic biases in the past and has insertedand preserved valid fields into the list of the academic canon’’ (Wagner,2009, p. 1100). This, then, is the future that Wagner was predicting confi-dently for psychoanalysis, which as an intellectual discourse and a clinicalpractice had already acquired a place at his university that was substantialbut was still very far from what he envisioned for it. For a psychoanalystwith my commitments, this was a very heartening message.

To work towards and ultimately reach that goal would require, I think,three major attitudinal shifts in the concerns of organized psychoanalysis.One is in the direction of the intellectual preoccupations in our literatureand in our congresses. Over the past decades, there has been what I call aturn inward. Our focus has been internal: our theoretical refinements,whether the interplay of our varying theoretical perspectives (our theoreticalpluralism) – in their similarities and differences, in their competitive strug-gles for our conceptual allegiances, or in their possibilities of existing sideby side as called upon by our clinical exigencies – or the scientific need toseek a unifying theoretical common ground; or whether our differing cul-tural and linguistic variants, our more empirical Anglophone tradition with

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its roots in formal science or our more linguistically and philosophicallyrooted Francophone traditions; or the training advantages and disadvan-tages of our now three different training models (Eitingon, French andUruguayan) in all their divergences and concordances. Important as theseissues and debates have been to our intellectual searching, it has been at theexpense (with, of course, notable individual exceptions) of the intellectualturn outward; at the expense of reaching towards the major social issues thatconfront society today, about which analysis should have something helpfulto say – and, if pursued usefully by us, could help restore analysis to theposition of public prestige it once held in our social-intellectual world. Irefer here to issues of crime and violence, to the impact of severe early orcurrent life trauma, to school dysfunction – whether matters of optimaleducational policy at all levels or particular dysfunctions across schoolyears, like bullying, drug and alcohol abuse, suicidal trends, etc – to the cur-rent vast increase in broken homes, to easy recourse to divorce for troubledmarriages, to remarriage with complexly reconstituted families, and to newlyacceptable family arrangements (lesbian and gay marriages, single-parentfamilies, etc). All these are problems or have their problems, and psychoana-lytic attention to them and to their clinical implications has been far lessthan it could, or should, be. Our turn outward – towards society’s ills –should at least equal our inner preoccupations and should, of course, makeour placement within academia both more important and more likely togenerate wider societal support.

The second major attitudinal shift that I feel necessary has to do with ourperspectives on our training structure and the contents of our educationalprograms. In its origins, psychoanalysis was properly seen as a revolutionaryunderstanding of human mental functioning and its aberrations, which trou-bled the up-to-then established convictions about how people worked outtheir place in their human and social surroundings. The theory that waspropounded and the therapeutic techniques elaborated from it came to bewidely accepted as proper understanding and proper treatment over the firsthalf-century of the spread of the psychoanalytic idea. But the world hasindeed changed in its sociocultural (and its derivative psychological) con-cerns over the second half-century of psychoanalysis, and analytic doctrinesand therapies have not been seen by the surrounding world to have changedand adjusted to the changing times and changing pressures. Instead theyhave been experienced increasingly as rigidly conservative and pass�, andmore and more articles have appeared in our intellectual exchanges declar-ing the ‘death of psychoanalysis’.

Whatever the degree of truth in these altered perceptions of us, itbehooves us to look seriously not just at the profound accomplishments ofour theory and our therapy but also at our failures: our failures to live upto all the transformative and curative aspirations that funneled the enthusi-asm with which the potential of psychoanalytic therapy was hailed in itspublic heyday, in the period in which I was drawn to it. The tenets of psy-choanalytic treatment had evolved – and had their greatest success – aroundan initial cadre of psychoneurotic patients seen in the out-patient offices ofneurologists in Freud’s Vienna: the symptomatic hysterics and obsessionals

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and the related character-disordered, with all their attendant anxieties. Overthe years since, many significant modifications have indeed been made: fromthe development of psychoanalytic psychotherapy to encompass the widerarray of psychiatric disorders deemed not amenable to the traditional (clas-sical) psychoanalytic structure (the sicker patients found in psychiatric clin-ics) to the technical shifts introduced by our expanding theoreticalperspectives – Kleinian, Bionian, Lacanian, object-relational, self-pyscholog-ical (Kohutian), relational, intersubjective, social-constructivist, etc. But withall this, we have still too many therapeutic efforts that are incomplete, thatfail to reach their hoped-for objectives, plus a more hectic world today inwhich fewer people among the psychologically troubled seem to have thetime, the money or the willingness to settle into our traditional frame –coming daily, multiple times a week, for an indefinite duration, to our con-sulting-room couches.

It is this combination of unsatisfying results from our usual treatmentarrangement and a world less willing (or able) to abide those arrangementsthat to me represents the great challenge to our educational and therapeuticenterprise. Can we ask: what psychological ailments, of what severity, bothrequire and will maximally profit from our usual accoutrements (the couch,the absence of eye contact, the daily session for an indefinite period)? Whencan (should) our therapeutic efforts be better directed towards immediatelypressing symptomatic and behavioral difficulties that are responsive to socialand economic circumstance, but are not necessarily linked strongly to char-acter dispositions growing out of lifetime development? And to what extentdoes that warrant (or require) changes in recumbency, visual contact, fre-quency and ⁄ or duration? Can we adapt more to clinical need and circum-stance, and forego the predilection that, whenever feasible and possible, aneffort at conventional psychoanalysis would serve the patient best? Can wedo all this psychoanalytically, in the sense that our treatment strategy isguided by what our psychoanalytic understanding would establish as mostlikely to bring our patient to the psychological redress he or she is seeking?Obviously, all of this searching could be done best within a university con-text with its endless opportunities for cross-disciplinary fertilization with theother human sciences. But we could be thinking and planning in that direc-tion now, and relinquish the idea that wherever possible full traditional psy-choanalysis, as we have known it, is best for everyone.

A third required shift is in our collective attitude towards psychoanalyticresearch: in terms of both our need for it and a shift to a more whole-hearted sponsorship of it. Formal psychoanalytic research has had a check-ered history going as far back as Freud, as I indicated earlier in this article.Yet every discipline that claims to be a science lives and grows by research,as is quite commonly understood and acknowledged. The problem here isthat psychoanalysis is not universally seen as a science, and that those whosee it as a humanistic or hermeneutic enterprise see formal, especially empir-ical, research as detrimental to the psychoanalytic idea – as being counterto the true psychoanalytic progression. In my opinion, the seemingly irrec-oncilable intellectual dilemma here is the result of needlessly different con-ceptions within our ranks of what research actually connotes.

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Those who see research as antithetic to the idiosyncratic nature of psycho-analytic data and the subjective dialogue that generates that data have, Ifeel, an unnecessarily constricted conception of the nature of research, need-lessly confining it to formal (empirical and statistical) methods applied tolarge datasets gathered in declaredly objective ways. My own conception issignificantly broader, embracing the entire spectrum from the most quantita-tive (objective) to the most qualitative (and highly subjective) as long as it isgeared to the systematic study of the research questions posed, and as longas it creates safeguards that the findings and interpretations arrived at aremore likely to be the case than any plausible alternatives. (See Wallerstein,2009a, for a detailed exposition of my perspectives on the scope of psycho-analytic research.) This does not mean, as some analysts have claimed(Ramzy, 1963), that every analysis in its creative search for new understand-ings is therefore properly a species of research. Indeed, search – imaginativesearch and under proper conditions (which clinical case reports are typicallynot designed to meet) – can become proper (single-case) real research. (SeeEdelson, 1984, for a full statement of the requirements and the methods thatwould render an appropriately studied clinical case report a properresearch.)

Within this broader context, real psychoanalytic research has developedsignificantly over the first century of our discipline, but all too slowly and inthe face of many obstacles – both internally, within our organizationalstructure, and externally in the contextual academic surroundings (Engel,1968). It has had to slowly win acceptance and support within the organizedpsychoanalytic community, and still has to contend with strong countervoic-es that espouse different intellectual and material priorities for our limitedresources. Moreover, the research has flourished best when carried out bypsychoanalytic researchers with academic positions within university depart-ments of psychology or medical-school departments of psychiatry, whocould readily seek out such positions in the 1950s and 1960s when academiawas much more receptive to psychoanalytic influence. Such appointmentsare far less frequent today.

It is clear that only the university, with its mission to transmit and toever-increase the human store of knowledge within all its many directions,provides the institutional context and scholarly infrastructure that centrallysupports and promotes formal research – even requires it – and thereforewill best ensure its proper growth. What psychoanalysis itself can best con-tribute to the achievement of this shared goal is to (morally and materially)support its own research turnings more wholeheartedly, including the turn-ing of a quantum of its own adherents towards the importance and neces-sity of research activity for the formal advancement of psychoanalysis as adiscipline – and as a healing profession.9

9This may, of course, sound like (and perhaps is) an idealization of the role of the university in theadvancement of the human condition. I do not mention the university’s many well-known shortcomingsin its functioning: its politics, its financial exigencies, its space wars, its contested research priorities, itsuncertain and shifting promotion criteria, its altering intellectual prejudices, etc. yet, given all theseinevitable frailties, the university is still the only societal institution that can qualify for the accoladeaccorded it by the sage Walter Lippman (1966): ‘‘that ancient and universal company of scholars’’.

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Hopefully, all of this – psychoanalysis turning more attention to its sur-roundings, to social challenges stemming from our societal pressures that wemust try to help meet, to the concomitant need to constantly fit our educa-tional structure and contents to the changing needs of our evolving worldand to our prospective patients, and to the research that will help improvethe ways of dealing with those shifting social and individual issues – might(or should) help in psychoanalysis ultimately gaining the full academicaccess on which its future, I feel, so much depends. I would like to antici-pate that future as optimistically as president Wagner indicated in hisEmory University address in 2007. Otherwise, I fear for our increasing mar-ginalization as a recondite and precious activity with ever less relevance andinfluence on the world in which we live.

Translations of summary

Wird die Psychoanalyse ihr Versprechen einlosen? Auch wenn Freud nach einer universit�renStruktur f�r die psychoanalytische Ausbildung strebte, schloss die soziopolitische Struktur des çsterrei-chisch-ungarischen Kaiserreichs dies aus, und die Psychoanalyse entwickelte sich im Herzen Zentraleuropasmangels einer universit�ren Struktur standardm�ßig mit einer teilzeitigen, in privater Praxis organisiertenAusbildungsstruktur. Mit ihrer raschen Ausbreitung in den USA nach dem Zweiten Weltkrieg und ihrerprompten Durchdringung der akademischen Psychiatrie Amerikas kam in einigen Gegenden eine ge-genl�ufige Ausbildungsstruktur auf, eine Abteilung mit einem an die Psychiatrie angeschlossenen Institutinnerhalb der medizinischen Fakult�t. Dieser Artikel erl�utert �ber diese hinaus weitere, anspruchsvollereakademische Perspektiven (das Modell von David Shakow, das Modell von Anna Freud, die MenningerFoundation, das Emory University Psychoanalytic Institute (USA), PA de BA (Argentinien)), Konzeptio-nen, die noch n�her an dem idealen (idealisierten) Ziel einer innerhalb der Universit�t untergebrachtenVollzeit-Ausbildung dran sind, mit starken Verbindungen zur Medizin, zu den Verhaltens- und Geisteswis-senschaften. Die mutmaßlichen Vorteile einer solchen Struktur werden dargestellt.

¿Podra el psicoanalisis hacer realidad su promesa? Si bien Freud aspiraba a que la educaci�n psi-coanal�tica estuviera montada sobre una estructura universitaria, la realidad sociopol�tica del imperioaustro-hfflngaro impidi� que esto sucediera. En consecuencia, el psicoan�lisis se desarroll�, por defecto,en el coraz�n de Europa Central, con una modalidad educativa de media jornada y pr�ctica privada. Lar�pida diseminaci�n de esta disciplina en los Estados Unidos de la segunda posguerra, y su penetraci�nen la psiquiatr�a acad�mica de ese pa�s, llevaron a la aparici�n de una estructura educativa contraria a lainicial en algunos �mbitos: el instituto afiliado al departamento de psiquiatr�a en la facultad de medicina.Este trabajo describe brevemente otros panoramas acad�micos m�s ambiciosos (el modelo de David Sha-kow, el de Anna Freud, el de The Menninger Foundation (Fundaci�n Menninger), el de la Universidadde Emory (EE UU) y el de APdeBA (Argentina)). Estas concepciones est�n affln m�s cerca del objetivo(idealizado) de alcanzar una inserci�n de jornada completa dentro de la universidad que tenga conexi-ones fuertes con la medicina, las ciencias de la conducta y las humanidades. Se presentan las ventajaspotenciales de una estructura como �sta.

La psychanalyse tiendra-t-elle sa promesse? Bien que Freud ait aspir� inscrire l’enseignement dela psychanalyse dans un cadre universitaire, le contexte social et politique de l’empire austro-hongroisl’en empÞcha et, par d�faut, la psychanalyse et son enseignement se d�velopprent en Europe centraledans le cadre d’une pratique priv�e et temps partiel. En raison de la diffusion rapide de la psychanalyseaux �tats-Unis, au lendemain de la Seconde guerre mondiale, et de sa p�n�tration facile dans les milieuxpsychiatriques universitaires am�ricains, l’on assista la naissance d’une contre-structure d’enseignementau sein des d�partements des instituts de psychiatrie affili�s aux facult�s de m�decine. Outre ces modles,l’auteur de cet article passe �galement en revue d’autres modles universitaires plus ambitieux (le modleDavid Shakow, le modle Anna Freud, la Fondation Menninger, l’Universit� Emory (�tats-Unis), l’APde-BA (Argentine)), conceptions qui se rapprochent davantage encore de l’objectif id�al (id�alis�) et qui vi-sent accorder la psychanalyse une place part entire au sein de l’universit� qui soit fortement li�e la m�decine, aux sciences du comportement et aux humanit�s. L’auteur pr�sente les avantages pr�sum�sd’une telle structure.

Manterra la psicoanalisi la sua promessa? Sebbene Freud aspirasse all’ambito universitario comeambiente ideale per l’insegnamento e il tirocinio della psicoanalisi, questa sua ambizione non pot�

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realizzarsi, per questioni sociopolitiche inerenti alla struttura dell’Impero austro-ungarico. La psicoanalisisi svilupp� cos in Europa Centrale come disciplina insegnata, part-time, all’interno di strutture private. Ilfatto che la psicoanalisi, dopo la Seconda Guerra Mondiale, si sia rapidamente diffusa nella psichiatriaaccademica statunitense, ha permesso che emergesse una struttura didattica alternativa con il dipartimen-to dell’Istituto psicoanalitco affiliato alla Psichiatria in seno alle scuole di medicina statunitensi. Il lavoroqui proposto descrive progetti simili a questo (David Shakow, Anna Freud, The Menninger Foundation,Emory University (US), APdeBA (Argentina)), che condividono lo stesso obiettivo ideale (o idealizzato)di una formazione psicoanalitca a tempo pieno all’interno delle universit, che sia strettamente connessaalla medicina, alle scienze del comportamento e all’umanistica. Vengono anche spiegati quali sarebberogli eventuali vantaggi di tale struttura.

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