Science Desk: Even in the Age of Prozac, Some Still Prefer the Couch

Cites consultant Kerry J. Sulkowicz
Featured on New York Times

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