A HUMBLER PSYCHOANALYSIS

NEW YORK---Psychoanalysts, it would seem, have reason to be gloomy:
These are difficult times for the couch.

Once the undisputed rulers of American psychiatry, analysts now stand
at the margins of a field where drug treatments and short-term talking
therapies predominate. Analytic patients are in short supply: Without
insurance reimbursement, even those who still desire the four or five
sessions a week typical of fullfledged psychoanalysis can rarely
afford to pay for them.

In managed-care circles, analysis has become a synonym for treatment
that costs too much and achieves too little. And the profession fares
little better in the public forum, where Freud-bashing enjoys
unflaggingly popularity as an intellectual sport. Yet in the
psychoanalytic community these days, there is little hand-wringing and
only an occasional foray into nostalgia. In a field notorious for its
insularity and resistance to outside critique, the threat of
extinction has inspired a frenzy of self-examination and the urge to
connect with the world at large.

The result is a retrofitted psychoanalysis that is humbler, more
communicative, and considerably more tolerant than it has been since
Freud first floated his revolutionary notions in Vienna. The rigid
neo-Freudian orthodoxy that long held a lock on American
psychoanalysis has gradually given way to a gentler theoretical
pluralism, and, in a major sea change, analysts are no longer required
to have medical degrees.

In an echo of the early days of the profession, women are once again
a strong presence, offering a feminist perspective on traditionally
male-oriented theory. And the old figure of the silent, austere,
authoritarian psychoanalyst is slowly being replaced with a new model
who is just another human being and not averse to uttering a word or
two.

Whether such shifts will succeed in rekindling interest and
replenishing the dwindling supply of patients is anyone's guess. But
they represent a new determination to sdck around for the fight.

This is a field that in its most vital aspects is changing, wants to
change, and is trying to think about what it is and what it wants to
be," said Kimberlyn Leary, associate director of the University of
Michigan's Psychological Clinic and a trainee at the Michigan
Psychoanalytic Institute. The presence of Ms. Leary---as a woman, a
black and a psychologist rather than a medical doctor---at the annual
meetings of the American Psychoanalytic Association in New York
recently, in itself was proof that much has changed.

Even a decade ago, the yearly gatherings of the association, which
was foundedin 1911 by American followers of Freud and remains the
dominant psychoanalytic organization in the United States, were
populated by gray-haired men in dark suits, the atmosphere one of
sober formality. Discussions focused narrowly on technique and
practice, with little acknowledgment of events in the outside world.

In contrast, the attendance roster at the recent meetings included
many younger analysts, a large group of women and at least a few
minorities. Panels addressed issues like race, adoption, homophobia
and sexual abuse. Analysts spoke of their work in atypical settings:
with baseball teams, in nursery schools, with police departments
trying to combat community violence. And different theoretical
perspectives---including the British school of object relations, Heinz
Kohut's self-psychology and Lacanian analysis---were listed in the
program. Yet perhaps the most striking difference was in how the
analysts at the meetings talked about their interactions with patients.

"The degree of certainty in the way we talk has changed, " said
Marvin Margolis, a former president of the association. "We're a
little more modest, more hypothetical about our interventions and how
we frame them."

Where once the analyst was seen as an authority who took charge of
treating the patient's pathology, most analysts now describe the
analyst-patient relationship as a collaborative endeavor, the patient
a full partner. Many practitioners have abandoned the notion that the
analyst should be an entirely blank screen, revealing no emotions or
personal details.

And while most analysts embrace the fundamentals of Freud's "talking
cure" ---the power of unconscious images and fantasies to influence
behavior, the importance of chilhood experiences in shaping
development and the central role of transference, or the replaying of
early patterns of relating to others within the analytic
treatment---few adhere inflexibly to a unified theory. Instead, they
practice a kind of utilitarian eclecticism, drawing upon different
psychoanalytic schools as needed in the treatment of individual patients.

In any field, a transformation of this magnitude does not take place
overnight, and the changes in Freud's "impossible profession" began
long before the managed care revolution. In the 1960s, psychoanalysis,
ascendant in psychiatry departments across the country, was hugely
successful --- and enormously over confident. "We had a monopoly,"
said Arnold Richards, a New York analyst who is editor of the Journal
of the American Psychoanalytic Association.

But bythe 1980s therewere increasing signs of malaise. In academic
departments, psychoanalysts were rapidly losing ground to
psychiatrists with a more biological approach to mental illness. In
the public arena, interest in Freud's legacy was declining. Growth of
the psychoanalytic association, which now has 3,200 members about a
third of the psychoanalysts in the United States, came to a
standstill, while the average age of members rose.

One antidote to these complaints, many believed, would be an
injection of new blood, and it came in 1988, when in response to a
restraint of trade suit by psychologists, a settlement overturned the
psychoanalytic association's longstanding policy of restricting
analytic training to candidates with medical degrees, opening the
field to lay analysts.

Yet perhaps the biggest transformation in the way psychoanalysis
views itself and its place in the world came with the arrival of new
leaders, armed with a sense of urgency about the plight of
psychoanalysis and a determination to do something about it.

ROBERT PYLES, president of the psychoanalytic association, is one
example. Unlike his predecessors of a few decades ago, who prided
themselves on a scholarly detachment and made no attempt to promote
their profession's image, Mr. Pyles is a political activist.

He has broken down traditional barriers, reaching out to other mental
health organizations like the American Psychiatric Association, and
calling for "a new vision of ourselves as psychoanalysts of the 21st
century." And with other leading psychoanalysts he is shepherding a
variety of projects designed to increase public knowledge and broaden
the field's influence.

"Ever since I was in training, this attitude of psychoanalysis having
to exist in some isolated hothouse has driven me nuts," Mr. Pyles said
recently. "I think it damn near killed us."