Betsy Alberty has entrepreneurial drive in her DNA. But she also has something else that has forced her to dig deep into her innovator’s bag of tricks: a predisposition to paralyzing depression.

Ms. Alberty, who is 52, was a bit of a late bloomer as an entrepreneur, holding research and marketing jobs for a string of biotechnology companies before starting a consulting firm in 1990 and, four years later, a biotechnology marketing and sales company.

The crash came in March 2001, set off by two events: the loss of two major clients and the evaporation of hundreds of thousands of dollars in unpaid fees and commissions, in a deal that fell apart.

“That threw me into a tailspin,” she said. She had fought depression a few years earlier, but this one, she said, knocked her out of commission for 15 months.

It started off with severe cramps. Before long, she was struggling to get through the day. “For a few months, I could neither laugh nor cry,” she said. “On some days, I didn’t have the motivation to brush my teeth. I split up with my boyfriend. I gained 70 pounds. There was no self to preserve, only dread of the anguish never ending. I went days without sleep, to the point where I was hallucinating. I realized it was change, or die.”

A psychiatrist put her on an antidepressant, “the magic bullet,” she said. That, combined with therapy, exercise and a better diet, started her on the road to recovery. “It was gradual,” she said. “I crawled out of my hole.”

In December 2002, she landed a job with an executive recruiting firm, and was soon chafing at the constraints of reporting to a boss. “I’m not the kind of person who can work at a desk in a cubicle under fluorescent lights near windows that don’t open,” she said.

She said she was also not the sort of person who was willing to make do with 45 percent of her fee rather than 100 percent. In May 2004, she started BioEquities Recruiting.

Two years later, she got a break that she thinks could help revolutionize the dietary habits of Americans. At a conference for the medical diagnostics industry, she said, she met the co-inventor of a technology that can quickly and inexpensively measure omega-3 and omega-6 fatty acids in serum or plasma, a process that normally takes 2 ½ days.

Maintaining a proper balance of those two fatty acids is crucial in the treatment of disorders ranging from diabetes and heart disease to Alzheimer’s and, yes, depression. A quick and inexpensive test would, she thought, have huge market potential.

Luckily for her, one of the symptoms of depression, a desire to escape the world, had lingered. “I get saturated quickly at these events and want to go hide,” she said. But when she saw a man “standing to one side of a room, by himself, sipping coffee,” she went up to him. He told her about his technology and asked, ‘Do you want to see my abstract?’ “

She read it during the next session, and was immediately excited. “I have a good gut feeling for what will be a successful product,” she said. “I’ve ushered enough of them to market. I knew this had huge potential.”

Within weeks, she started a second company, LipidX Technologies in Mill Valley, Calif., to develop the product. She said she has worked out arrangements to pay the man she met at the conference, Neil Purdie, the head of the chemistry department at Oklahoma State University, and his co-inventor.

At first, financers were lukewarm to her pitch. Then Ms. Alberty heard a commercial on her car radio for Smart Balance that promoted the omega-3 supplements in its butter, mayonnaise, eggs and other products.

“I said to myself, ‘We can test omega-3 in food as well as people,'” she recalled. “We broadened our pitch, because omega-3 is in everything.”

For now, she is focusing on using LipidX’s technology to develop faster and better tests of fatty acids in foods and in people at risk of heart attacks, especially for pregnant women and infants. But, she said, “the applications are everywhere, and the partnership, licensing and spin-off possibilities are endless.”

Investors are starting to show interest in her company, she said, and she hopes to raise up to $1.5 million this year to acquire enough data to go into clinical studies.

She said she made the transition from despairing recluse to enthusiastic promoter by drawing on all the reserves of her entrepreneurial personality, notably her determination to control her destiny, her stubbornness and her fearlessness, as when she left a company without a safety net.

“I was taking an entrepreneurial approach to depression,” she said. “Nothing stops me. At times I lost my motivation, but I had built my support system and fell back at that.”

That is true to form, says Kerry Sulkowicz, founder of the Boswell Group LLC, a New York consulting firm, who has agreed to comment on the ways entrepreneurs in this three-column series face up to personal adversity.

Despite their reputation as indefatigable optimists, he said, entrepreneurs are just as susceptible to bouts of severe melancholy as the general population – and maybe more so. “All of them are very emotionally vulnerable people,” he said, and many are probably borderline bipolar.

What sets them apart is the alacrity with which they act, once they begin pulling themselves out of their rut. “It is because they are action-oriented, especially when the action is directed at a problem they want to solve,” he said. “In Betsy’s case, once she emerged from her crippling depression, she drew upon her entrepreneurial skills to prevent a relapse.”

Just as entrepreneurs, in general, view setbacks as opportunities rather than failures, Ms. Alberty said she views her struggle with despondency as a passage to success. “My depression led me to investigate the nutritional possibilities of this technology, to see how it might address the underlying causes of depression,” she said. “Otherwise, I might have just glanced at this guy’s abstract and done nothing.”

As his mother tells it, Cade Larson was a lively 15-month-old who loved playing peekaboo and chase with other children and was quickly adding to his vocabulary of more than 50 words, including “fish,” “bowl” and “shoe.”

But then, said his mother, Jennifer VanDerHorst-Larson, Cade got vaccinations for measles, mumps and rubella, influenza and chicken pox on Oct. 15, 2001. He wailed for a few moments, then slumped into a deep sleep that lasted 14 hours. When he woke up, she said, he was a different child.

“He stopped looking at me,” Ms. VanDerHorst-Larson said. “He had lost his speech.” She believes he had a huge seizure that resulted in brain damage.

In a heartbeat, her mission became healing her son. In that, she failed. On Valentine’s Day 2002, her school district told her that Cade had the severest case of autism it had ever seen. “This is my only child,” she said. “I can’t describe the pain.”

The idea that vaccines cause autism has been widely rejected by mainstream scientists, though some doctors are investigating it and many parents of autistic children remain convinced there is a link.

But Ms. VanDerHorst-Larson, 35, had a resource for fighting back that many parents do not: She was an entrepreneur. In 1996, she had opened a Pilates studio in Minneapolis. In 1998, she had started Vibrant Technologies, a buyer and seller of information technology hardware that now has 40 employees and expects revenue this year of $45 million, up from $37 million last year.

In the five and a half years since Cade’s condition was diagnosed, Ms. VanDerHorst-Larson has thrown herself into the challenge of giving meaning to his life with all of the classic weapons of the entrepreneurial personality: superhuman energy, bottomless self-confidence, bulldog tenacity, a compulsion to be in control and a knack for spotting opportunities in even the most disheartening reversals of fortune.

In effect, she has made caring for her son and for others like him her third business.

She shut her first one, the Pilates venture, to free up time. For two years, she traveled the country, attending seminars and taking Cade to neurologists, immunologists and other specialists, until, she said, she realized she would never find the cure she was seeking. As his mother tells it, Cade Larson was a lively 15-month-old who loved playing peekaboo and chase with other children and was quickly adding to his vocabulary of more than 50 words, including “fish,” “bowl” and “shoe.”

“By then, I was running a home program for him, nine people in all: a behavioral analyst, a speech therapist, an occupational therapist, a psychologist, a social worker, a special education teacher and three behavioral therapists,” Ms. VanDerHorst-Larson said.

She was also running Vibrant. She said she was getting just two hours of sleep a night. “It was not normal,” she said. “It was inhuman.”

“It was the same drive you have when you start a company,” she said. “My son was my investment. I was the manager.” Ms. VanDerHorst-Larson said that her husband, David Larson, a co-owner of Vibrant, was very supportive, but “this was who I am, not who he was.”

In April 2003, she started the nonprofit Holland Center in Excelsior, Minn., for children ages 2 to 8 who have autism, including Cade, whose face is on the Web site’s home page. The staff consists of a behavioral analyst, an occupational therapist, a speech therapist, a special education teacher, a music teacher, two psychologists, 15 behavioral therapists and Ms. VanDerHorst-Larson as the business manager. That comes to 23 people working with 17 children.

Six months after the Holland Center was created, she was back to more traditional entrepreneurship, starting St. Croix Solutions, a technology consulting firm and provider of computer hardware. She said that she wanted her son to sprout his wings and that she realized he could not do that if she was at the center all the time.

But it was more than that. “It’s in my nature,” she said. “I saw an opportunity. My husband says, ‘Don’t start anything else.’ But it’s like a drug.” Ms. VanDerHorst-Larson estimates that St. Croix’s revenue this year will be $26 million, up from $18 million last year.

Dr. Kerry J. Sulkowicz, an M.D. who founded the Boswell Group, a New York consulting firm that specializes in business culture issues, says Ms. VanDerHorst-Larson’s approach to her son’s disability is a case study in “the uncanny ability of entrepreneurs to see obstacles as challenges and to jump over them instead of being stopped by them.”

“Many mothers might react to the discovery that their child has autism with depression,” Dr. Sulkowicz said. “Jennifer didn’t because she had pre-existing resources that she could call upon to seek a solution to the problem.”

Asked how he interpreted her statement that her son became her investment and she the manager, Dr. Sulkowicz said it was ” a depersonalization of something that is extremely personal.” He continued: “It’s kind of like saying, ‘On one level, I’m not going to think in terms of mother and son, I’m going to take a half step back and approach and deal with that as a business problem. Because that way, I will be more likely to find a solution.’ That approach, in turn, has probably made her a sturdier and more satisfied mother.”

Ms. VanDerHorst-Larson said she had not decided yet what to do next. She said she might create a chain of autism centers or a foundation to help children with autism. Or both.

Her ordeal, she agreed, had made her a better entrepreneur. “It changed my perspective on everything,” she said. “It gave me more drive in looking for opportunities and challenging myself more. It has led me to think harder, make smarter decisions.”

Successful entrepreneurs do not agonize over problems. They jump in and solve them, often in ways they could never have foreseen. Ms. VanDerHorst-Larson was unable to find a quick fix to Cade’s autism. But she found a remedy.

“Today, he does speak,” she said. “He says, ‘Sit, mommy,’ and ‘Blue crayon,’ and ‘Red shirt.’ He’s not in pain anymore. He’s a social person. He makes eye contact. He’s happy.”

Written by Brent Bowers

”BY his word he could kill them, have them tortured, have them rescued again, have them rewarded. Life and death depended on his whim.”

The psychoanalyst Erich Fromm used these words to describe the ”refined sadism” of Josef Stalin, who took delight in playing with the minds of his victims before he ordered the destruction of their bodies.

But the revelations of recent weeks suggest that they might as easily be applied to another former dictator, Saddam Hussein.

The objects unearthed at Iraqi prisons, palaces and safe houses speak of brutality and indulgence. A gold machine gun. A cable used to deliver electric shocks to ears and genitals. Fantasy paintings of snakes, monsters and unclad women. A red wire cage with a cement channel in the floor for human excrement.

The stories behind the objects tell of paranoia and caprice — arbitrary imprisonment and equally arbitrary release, opulently furnished rooms never inhabited. And behind it all is a man who acted out his fantasies of omnipotence using a nation as his theater and its citizens as his props.

Psychoanalyzing political leaders is a dicey business, and psychiatrists are quick to caution that without extensive research or personal contact with Mr. Hussein, nothing can be said with certainty about his psychological makeup. But what is already known about Mr. Hussein is suggestive, the psychiatrists say.

Like Stalin and Hitler, Mr. Hussein has sometimes been referred to as a madman, in part because people are reluctant to accept such ruthlessness and cruelty as the product of anything but insanity.

But bad does not equal mad. Most historical analysts have rejected the notion that mental illness could explain the actions of either Stalin or Hitler. Experts familiar with Mr. Hussein’s upbringing and years in power said that there was no evidence that he suffered from psychosis or any severe mental illness. The very fact that he was able to stay in charge for so long and exert such complete control argues against insanity, the experts said.

Two researchers, Jerrold M. Post and Amatzia Baram, concluded in a psychological profile of Mr. Hussein that he was more accurately described as a malignant narcissist, a label that has also been applied to Stalin and Hitler. Dr. Post, a psychiatrist at George Washington University, and Dr. Baram, an expert on Iraq at the University of Haifa in Israel, wrote the profile for the United States Air Force Counterproliferation Center. Dr. Post was also the founding director of the Central Intelligence Agency’s political profiling program.

Malignant narcissism, as defined by psychiatrists, is a severe form of narcissistic personality disorder. Like classic narcissists, malignant narcissists are grandiose, self-centered, oversensitive to criticism and unable to feel empathy for others. They cover over deep insecurities with an inflated self-image.

But malignant narcissists also tend to paranoia and aggression, and share some features of the antisocial personality, including the absence of moral or ethical judgment, said Dr. Otto Kernberg, a psychiatry professor at Cornell University and an expert on personality disorders.

Far from being psychotic, malignant narcissists are adept at charming and manipulating those around them. Political leaders with this personality, Dr. Kernberg said, are able to take control ”because their inordinate narcissism is expressed in grandiosity, a confidence in themselves and the assurance that they know what the world needs.”

At the same time, he said, ”They express their aggression in cruel and sadistic behavior against their enemies: whoever does not submit to them or love them.”

Dr. Kernberg added that while he had studied Hitler and Stalin, and would categorize them as malignant narcissists, he knew little about Mr. Hussein and could not comment directly about him.

Dr. Post, however, said that the concept of malignant narcissism fit Mr. Hussein quite nicely.

”The overarching theme is the centrality of the self — that he is Iraq,” Dr. Post said. This self-glorification, he said, was combined with ”a deep-seated need to reassure himself through public adulation of how magnificent he is.”

Dr. Post added that the bunker built beneath one of Mr. Hussein’s palaces was a perfect metaphor for his personality. ”Here, under this grandiose palace with its inlaid woods and fine marbles, is this underground bunker with reinforced concrete and steel,” Dr. Post said. ”That’s his psychology: a grandiose facade and under it a siege state, ready to be betrayed, to be attacked, to strike back.”

In their profile of Mr. Hussein, compiled from news accounts and interviews, Dr. Post and Dr. Baram attributed much of the Iraqi leader’s psychopathology to his early childhood.

They described how Mr. Hussein’s mother suffered the death of both her husband and an elder son while she was pregnant with him. She tried to commit suicide and to abort her son, but was prevented in each case by members of a Jewish family who became her benefactors. When Saddam Hussein was born, the researchers wrote, his mother refused to look at him or take him in her arms.

Saddam went to live with a maternal uncle, Khairallah Tulfah, who imbued him with dreams of becoming a great Arab leader, like Saladin and Gamal Abdel Nasser. At 3, he returned to live with his mother for several years, but was psychologically and physically abused by her new husband, according to the profile.

”One course in the face of such traumatizing experiences is to sink into despair, passivity and hopelessness,” Dr. Post and Dr. Baram wrote. ”But another is to etch a psychological template of compensatory grandiosity, as if to vow, ‘Never again, never again shall I submit to superior force.’ This was the developmental path Saddam followed.”

Other psychiatrists, however, cautioned that it was difficult to draw conclusions about psychological development from sketchy information about a leader’s childhood, particularly when another culture was involved. ”Certainly, childhood experiences are very important,” Dr. Kernberg said, ”but very often that’s what we know least about, and what is most easily distorted by fancy speculation.”

What is not speculative is the adult that Mr. Hussein became, a man obsessed with molding the world into a reflection of his own power.

Malignant narcissism is not the exclusive province of dictators. In another country, at another time, with a different set of dice, some psychiatrists say, Mr. Hussein might instead have become a corporate executive, a lawyer, a cult leader or a politician. His ambition, paranoia and violence might then have been modulated by legal codes and tempered by the checks and balances of a free society.

Unfortunately, this was not the case. ”The best way to understand this,” said Dr. Kerry J. Sulkowicz, a psychoanalyst in private practice in Manhattan, ”is that occasionally in history there is a confluence of events, in which the severe psychopathology of a leader is allowed to flourish.’

Written by Erica Goode

Four days a week, Rachel H. takes the subway uptown, waves to the doorman in the large prewar apartment building where her psychoanalyst keeps his office, lies down on a burgundy leather couch and begins to talk. 

Ms. H., a 33-year-old graduate student, has heard all the jokes. She has listened patiently to friends who tell her she would be better off taking Prozac or trying yoga or leaving New York altogether to escape her obvious ”dependency” on her analyst. She has endured teasing and incredulity. ”Don’t you think that’s so last century?” asked one woman. 

Yet Ms. H. is not bothered by this lack of enthusiasm. 

After spending six years and about $60,000 on analysis, she says, she is less self-destructive, more responsible, more productive and more successful in her work. She has more compassion for others. She understands, in ways that have grown more layered and complex, her own strengths and limits and those of the people close to her. 

In the last quarter century, psychoanalysis has been declared dead many times over. Psychoanalysts, once dominant in psychiatry, now stand on the sidelines of a field where drug treatments and brief forms of talk therapy are the rule. Thanks in large part to Woody Allen, Freud’s talking cure has become shorthand for costly self-indulgence with no obvious benefit. And many psychiatrists barely hide their disdain for what they regard as an outmoded approach to treating mental disorders. 

Yet thousands of Americans – it is not known exactly how many – continue to seek out psychoanalysis. Like Ms. H., they believe that the arduous, uncertain and often emotionally painful dissection of mental life such treatment entails offers something they can find nowhere else. 

”Obviously I think it’s an incredibly valuable thing that I’m doing. Otherwise, why would I do it?” said Ms. H., who spoke on the condition that her last name not be used out of concerns for her privacy. 

”You have to see things for what they are, and I think that’s essentially all that it’s about,” she said. ”It’s about lifting the veil, seeing relationships and seeing yourself, so that you can begin to make choices that will not lock you into an unhappy future and an unhappy life.” 

In its heyday in the 1950’s and 1960’s, psychoanalysis attracted a wide swath of the intellectual elite, along with many middle class patients who, backed by generous health insurance plans, were referred to psychoanalytic treatment as the best psychiatry had to offer. 

Experiences on the couch, good or bad, provided routine fodder for dinner parties. And the language of classical psychoanalytic theory – the unconscious, the Oedipus complex, the superego and the id – became firmly embedded in the culture. 

Yet most psychoanalysts now acknowledge that analysis was practiced far too broadly and that its effectiveness, particularly as a treatment for severe mental illnesses like schizophrenia and manic depression, was greatly oversold. 

”Many analysts thought that psychoanalysis was the treatment of choice for virtually every mental disorder,” said Dr. Kerry J. Sulkowicz, the chairman of the public information committee for the American Psychoanalytic Association, which held its winter meeting in New York last week. ”We’ve learned that that’s not the case.” 

Today, pharmacology and focused, short-term psychotherapies predominate in the treatment of mental illness. Psychoanalysts are more cautious about whom they will treat on the couch. And those who seek their help represent a far smaller and more select group. 

According to a survey conducted in 2001 by the psychoanalytic association, analytic patients in the United States are typically well educated, well-off financially, white and 30 to 50 years old. Some are mental health professionals, trying to understand themselves better in order to better help their patients. But business people, artists, writers, academics and others also find their way into analysis. 

Many have tried other forms of talk therapy and have been dissatisfied with the results. Some have taken, or continue to take, antidepressants or other psychiatric drugs and have found that while helpful, the medications have not solved their problems in forming intimate relationships or in avoiding destructive behavior patterns. Still others remain stubbornly committed to the notion that their emotional difficulties are rooted in the unconscious rather than in the ebb and flow of brain chemicals. 

”I had this really strong conviction that my problems were psychological, and I wanted to deal with them psychologically,” said Patrick Cody, 40, a communications consultant in Washington who spent 10 years in analysis, which he sought out after experiencing depression and severe panic attacks. 

In an era of managed care, most patients pay out of their own pockets for their treatment, which typically involves three to five sessions a week, at fees varying from $10 a session at a psychoanalytic training clinic to more than $200 a session at a Park Avenue practice. 

But time is often a bigger issue than money. 

”I don’t have a problem with patients’ affording fees,” said Dr. Henry Bachrach, a researcher and analyst at the New York Psychoanalytic Institute. ”But I can’t get to see them four times a week, because I can’t ask them to give up their livelihood.” 

Hollywood portrayals to the contrary, studies suggest that few people enter analysis for casual reasons. 

In a 2002 survey of 342 American analysts conducted by Dr. Norman Doidge, an assistant professor of psychiatry at the University of Toronto, most said that many of their patients in analysis suffered from multiple longstanding psychiatric disorders like anxiety, depression, sexual dysfunction and pervasive personality problems. 

About 80 percent of the 940 patients reported on in the survey had received other treatment before analysis. Eighteen percent were taking psychiatric medication. 

At the same time, three-quarters of the analysts’ patients were steadily employed at the start of analysis, Dr. Doidge found. And they were mentally tough enough to survive the rigors of treatment on the couch – an experience that bears some similarity to immersion in a sensory deprivation tank and that Dr. Bachrach described as ”putting you on the stove and turning up the heat.” 

Psychoanalysis itself has undergone profound changes in the last decades. 

In Argentina, France, Germany, Finland, Canada, especially in Quebec, and other countries, Freud’s legacy continues to thrive. Psychoanalysts are held in esteem and patients are plentiful. In some cases, the cost of psychoanalytic treatment is underwritten by national insurance. 

But in the United States, the scientific and economic events that have transformed psychiatry have squeezed psychoanalysts to the margins. Most analysts’ caseloads include only a few full-fledged psychoanalytic patients, the rest arriving once or twice a week for less intensive psychotherapy. The American association, the largest of the psychoanalytic organizations, counts roughly 3,500 members, 700 of them in New York. The average age of the association’s membership is 62. 

Once rulers, analysts now more often find themselves supplicants, mounting public relations campaigns to improve their image and reaching out to attract more candidates for psychoanalytic training and to forge better relationships with other psychiatric disciplines. 

This is not always an easy battle, as was evident in the focus groups assembled as part of a ”strategic marketing initiative” undertaken by the association in 2000. Asked to describe their psychoanalyst colleagues, the mental health professionals who participated in the groups used adjectives like ”arrogant,” ”elitist,” ”uninvolved,” ”cultish” and ”insular.” 

The public was no more helpful. Freud’s name still rang a bell. But the marketing effort found that the only thing most Americans knew about psychoanalysis was that it took a long time and that it involved a couch. Asked what kind of mental health professional they might look to for treatment, no one mentioned an analyst. 

Still, much of the tarnish that clings to psychoanalysis derives from an earlier time, when rigid neo-Freudian orthodoxy was the rule. 

”I think there’s been a shift in the last 15 years,” said Dr. Robert Galatzer-Levy, an analyst in Chicago. ”There was a time that if people deviated from whatever was at that point standard, they risked being thrown out of the analytic community.” 

Now, Dr. Galatzer-Levy said, ”the ideas get heard, they get discussed, they get debated, they are often integrated with one another.” 

In fact, few analysts these days adhere to a strict Freudian model, though most subscribe to the basic tenets of psychoanalytic theory, including the importance of unconscious fantasies and conflicts, the influence of childhood experiences, the centrality of the relationship with the analyst as a replaying of other important relationships in the patient’s life. 

Most talk to their patients, rather than sitting silently. Many are willing to divulge information about their personal lives: whether they are married, for example. Many exercise eclecticism in treating patients, drawing upon different theoretical perspectives. And many endorse the use of medication, in some cases prescribing it themselves. 

At one time, analysts were required to have medical degrees. But social workers, psychologists, art therapists and other mental health professionals have now joined the ranks of those who pursue the four years of training or more that becoming a psychoanalyst requires. 

At its best, Dr. Galatzer-Levy said, what analysis has to offer is change that is far deeper than what may be achieved in the 6 to 20 sessions of therapy covered by most insurance plans, change affecting ”the way people think and feel about things, the way they act in the world.” 

Some of that change may take place after the last psychoanalytic session has ended. 

In one of the first tightly controlled studies of the effectiveness of psychoanalytic treatment, Dr. Peter Fonagy, a professor of psychoanalysis at University College London, found that adult patients with borderline personality disorder, given psychoanalytic treatment in a partial hospital setting, showed significantly more improvement than a control group that received no formal psychotherapy. 

But Dr. Fonagy also found that the patients receiving psychoanalysis continued to improve in the 18 months after the treatment, progress he believes occurs ”when you face new problems and you are then able to deal with them in a superior way.” 

Patients who have had good experiences in psychoanalysis also describe substantial personal growth.

For Mr. Cody of Washington, the fruit of his treatment has been emotional maturity, he said, a lessening of fear, a greater ability to control his emotions, an ability to laugh off criticism where he once would have rankled. 

In his analysis, Mr. Cody said, there were ”periods of great stagnation but also periods of great benefits.” 

”There would suddenly be one session where things popped open,” he said. ”Every time that happened, I’d say, ‘That’s worth $3,000.’ ” 

Ms. H. said that in the course of her sessions on the couch she had examined every aspect of her life, from her fears of abandonment to her perfectionism to her repetitive dreams of running through city streets to save her brother from an attack by urban guerrillas. 

She has learned, she said, that ”the truth is mutable, the story changes.” 

”You might hold your parents responsible for some of your unhappiness and then later on that becomes incredibly unimportant,” she said. 

Yet Mr. Cody and Ms. H., like many others in analysis, have moments of doubt and disillusionment, and lingering questions that may never be fully answered: How much growth would have taken place anyway, with time and life experience? How much of what has been accomplished in 10 years could have been accomplished in 4 or even 2? 

Dr. Doidge, in his survey, found that the average length of analysis was 5.7 years. 

In an address to the psychoanalytic association last week, Dr. Owen Renik, a training analyst at the San Francisco Psychoanalytic Institute and Society, said that keeping patients in analysis ”for years or even decades” when no improvement was taking place represented an egregious – and common – ethical violation by psychoanalysts. 

”Too many analysts keep too many patients too long in treatment in the absence of any evidence that it’s helping,” Dr. Renik said later in a telephone interview. 

Analysts, he added, often rationalize why they are keeping a patient in treatment, but actually may be delaying the end of the analysis out of a desire for financial gain, an unwillingness to admit defeat or other unconscious motives. 

Those whose time on the couch has been less than positive could add other breaches to the list: Analysts so psychologically damaged themselves that they make their patients worse, not better. Analysts who allow the transference to become a pseudo love affair that replaces relationships in the real world. Analysts who are unable to admit their mistakes. 

Dr. Bachrach of the New York institute said it was no surprise that analysis could cause damage. 

”If it can do a lot of good, it can also do a lot of harm,” he said. 

Yet in a world of quick fixes and glib explanations for human behavior, analysis still symbolizes a commitment to complexity and deeper understanding. 

”It is a question of values,” Dr. Bachrach said, ”of what you want and what you expect out of life.”

Written by Erica Goode

Not to dredge up old news, but you may recall that several weeks ago America’s most lethal psychiatric patient, Tony Soprano, walked out on his shrink, Dr. Jennifer Melfi.

Yes, yes, we realize this was a television show. But we’re not the only ones with trouble at times separating reality from illusion. Even the American Psychoanalytic Association can fuzz the line between the two. So smitten is it with Dr. Melfi that barely a year ago it gave a special award to the actress who plays her, Lorraine Bracco.

What, then, does it think about an honored colleague being treated so cavalierly by this lug?

It seems fair to ask, given that hundreds and hundreds of association members are in New York for the first time since that award. They are here for their winter gathering at the Waldorf-Astoria, a five-day affair that will stretch through the weekend.

(Note that of the association’s roughly 3,500 members, 700 live in and around the city. Metro New York’s share of the United States population is about 7.5 percent. Yet we have 20 percent of the shrinks. You be the judge of what this says about the state of our mental health.)

Back to Tony Soprano. Let’s put the question to the shrinks in terms that everyone can understand: how does what he did to his therapist make them feel?

Not bad at all, they say. Who knows? He may yet come back.

More important, ”it’s real life — patients leave us all the time,” said Dr. Leon Hoffman, a former chairman of the association’s committee on public information. His successor in that position, Dr. Kerry J. Sulkowicz, added, ”Patients don’t stay in treatment forever.”

These guys must have missed a lot of Woody Allen movies if they believe that.

In fairness, they have bigger concerns than Dr. Melfi’s patient load. One is their own public image. It isn’t good, they say, and in part they have themselves to blame.

”We’ve probably isolated ourselves too much from the rest of the mental-health community,” Dr. Sulkowicz said. With the general public, he said, not enough has been done to ”articulate some of our ideas in plain language and to be useful to the world outside the consulting room.”

Dr. Newell Fischer, the association’s president, is even more blunt about the problem. The image of psychoanalysts is ”dismal,” he wrote in the organization’s newsletter. They are viewed as ”aloof, uncaring, too intellectual and arrogant.”

Thank goodness, he threw in ”too intellectual” with the other adjectives. Otherwise, we might have thought he was talking about journalists.

OF course, defining positive and negative when it comes to image is a tricky business.

The Melfi character was praised by Dr. Hoffman for having established ”professional boundaries” with Tony. She doesn’t hop into the sack with him, as the Barbra Streisand shrink does with Nick Nolte in the film ”The Prince of Tides.”

But they can be full of surprises, these psychoanalysts.

You would think they’d like warm and cuddly film shrinks like Judd Hirsch in ”Ordinary People” or Robin Williams in ”Good Will Hunting.” No way, Dr. Sulkowicz said. ”The characters create totally unreasonable expectations of what an analyst can do,” he said. They give you the idea that ”once you get connected up with a long-forgotten memory, you’re fixed.”

”While on the surface it sounds great,” he said, ”this ultimately does a disservice.”

Want to hear Dr. Sulkowicz’s idea of good shrink characters?

Hold onto your couches. He likes the chomping Hannibal Lecter in ”The Silence of the Lambs” and the bumbling Billy Crystal in ”Analyze This.” They may be outlandish, he said, but they ”touch on some fairly ubiquitous fears that patients have about being in therapy.” One fear for patients is that they may be sharing their innermost thoughts with someone who is in as bad shape as they are.

It’s almost enough to make you reach for a drink.

Some psychoanalysts at the Waldorf did just that yesterday, while listening to Toby Williams, a singer with a group called Cocktail Angst. She sang numbers with titles like ”Shrinker Man” and ”I Can’t Get Adjusted to the You Who Got Adjusted to Me.” There was also a Rodgers and Hart song called ”To Keep My Love Alive.” Sounds sweet, no? It’s about a woman who marries one man after another, killing each before the romance can wear off.

With so many Freudians on hand, Ms. Williams steered clear of that Sinatra standard, ”You Make Me Feel So Jung.”

Written by Clyde Haberman