Conclusion
Until the late 1980s, becoming a psychoanalyst in the United States meant doing postdoctoral work, primarily post-MD, in an approved institute of the American Psychoanalytic Association. Of the 3000 or so certified analysts, the majority were psychiatrists or other physicians who had completed 4–5 years of additional course work, undertaken a personal analysis, and passed written and oral assessments of their capacities as clinicians and therapists. In addition to the 29 institutes of the American Psychoanalytic Association, nonmedical institutes exist, some of them run by psychologists and other non-psychiatrists. With the death of Freud and the passing of the generation of psychiatrist-psychoanalysts who knew him personally, and with the rise of biological and laboratory methods in psychiatric research, American psychoanalysis confronts new demands.
The relevance of a patient’s internal world (defined as “unconscious ideas,” personal schemata, self-representations, ego states, core conflicts, and so on) to the patient’s overt behavior, including psychopathology, is indisputable. How best to conceive of that world, how to modify it toward health, and how to assess the various and competing theories that make up contemporary psychoanalysis and its points of view is an exciting and major research task for the future. One task will be comparative psychoanalysis. Also, thanks to new research instruments generated primarily by psychologists investigating psychotherapy effectiveness, we can look forward to sophisticated studies that can distinguish the most effective treatments for given diagnostic categories and for use with particular types of patient-therapist interactions.
In the political battles of the 1950s and 1960s, between strict behaviorists who denied the relevance or even existence of an inner world and Freudians who championed such a belief, little exchange took place. Both sides tended to caricaturize the other and rained polemics down upon the other camp. The simultaneous rise of cognitive-behavioral-developmental research efforts and a focus on cognitive aspects of the inner world in contemporary psychoanalysis suggests a confluence of two heretofore independent research traditions.
Researchers long ago answered the extreme skepticism of the placebo argument: We can show systematically that treatment enhances patients’ positive outcomes along most lines of interest. Indeed, some forms of intensive psychotherapy, such as cognitive-behavioral therapy, are more effective than antidepressant medication alone for treating some forms of depression. In its best moments, psychoanalysis has added immeasurably to our grasp of human self-understanding. That it was oversold and idealized for many years should not require now the reverse error of denigration and abandonment.
We know that some people are expert and highly effective clinicians whose talents and efforts cannot be duplicated with medication alone. We know that some patients, recalcitrant to all other forms of treatment, blossom with some therapists, overcoming lifelong disability and impairment. The question remaining before us is how, precisely, all these wonderful things occur.
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