The Anthropologist on the Couch

A review of Illusions of a Future: Psychoanalysis and the Biopolitics of Desire, Kate Schechter, Duke University Press, 2014.

Have you ever been tempted to eavesdrop on a psychoanalyst’s conversation? Not in a therapy session of course: these conversations are private, and they usually take the form of the patient talking and the analyst listening. But psychoanalysts also talk about their trade in professional associations, congress meetings, or interviews. This public discourse is what interests Kate Schechter in Illusions of a Future. As an anthropologist-in-training, she took as her dissertation topic the psychoanalytic community in Chicago, going through their local archives and interviewing key members. Combining ethnography, history, and theory, she went beyond participant observation and archival work: she herself underwent psychoanalytic training, and is presented on the book cover as being “in the private practice of psychoanalysis and psychotherapy in Chicago.” According to Dr. Schechter (and here the title “Dr.” refers to her PhD, not to her qualification as a medical doctor), there are three remarks that are often made by psychoanalysts when commenting on the activity of their peers. “Where does she get all her analytic patients?” “It’s not psychoanalysis.” “It’s all about the relationship.” Three mechanisms are at play in these remarks: envy, denial, fetishization. Let us consider each of them in turn.

Psychoanalysts suffer from a bad case of patient envy

Psychoanalysts nowadays suffer from a bad case of patient envy. The majority of psychoanalysts in the United States—and the Chicago practitioners are no exception—have only one or two patients in actual psychoanalysis. Some of them achieve to get a higher number of subjects in analysis—defined as a demanding regimen of intensive, four-times-a-week introspective sessions on the couch pursued over a period of several years. A lesser intensity and frequency means that a treatment is expressly not psychoanalysis but rather psychotherapy. Measured by that rigid standard, most psychoanalysts nowadays only have one or two analytic patients in tow, if any. The other patients who visit them are here for therapy or counseling. They don’t sit on the couch, they don’t consult three or four times a week, and the expect answers to their problems from their analyst, not just passive listening. But psychoanalysts don’t think of themselves as therapists or counselors. They are in the business of getting analytic patients—hence their envy for the analysts who ostensibly attract a higher number of analysands.

So most of what psychoanalysts do is “not psychoanalysis”. How today’s psychoanalysts manage to maintain their professional identity while they cannot practice what they preach is the topic of Kate Schechter’s ethnography. Finding, making, and keeping analytic patients when there are none has become an existential challenge for Chicago psychoanalysts. Some blame the patients themselves: “people simply don’t want to do the work anymore,” says one. “Psychoanalysis is too rigorous for people today; patients want a quick fix, they want symptom relief as opposed to enduring structural change,” says another. Others blame the system: in the era of psychopharmaceuticals, managed care, and cognitive-behavioral therapy, psychoanalysts have to demonstrate value as defined by neoliberal medicine. After World War II, generous medical insurance plans and government programs funded psychoanalysis because it was the only treatment for anxiety and depression that was available. By the 1980s however, with costs in medicine exploding and numerous new and cost-effective pharmacological treatments of anxiety and depression emerging, the psychoanalytic talking-cure has come under attack as ineffective, unaccountable, and wasteful.

Using numbers and coding patients

Psychoanalysts overall take issue with the epistemic universe of managed care and evidence-based medicine. Historically, many psychoanalysts have viewed quantitative and behavioral research with disdain. They strongly reject the categories of the DSM-V, which explicitly excludes psychiatric notions based on Freudian theory. Nonetheless, psychoanalysts have to find ways to negotiate with the insurance companies and managed care organizations that will allow them to preserve their practices and their sense of autonomy. They report their cases using DSM diagnoses and CPT codes to keep records and submit to out-of-network benefits. Some analysts insist among one another that they are doing psychoanalysis but nonetheless code for psychotherapy because most insurance plans will cover psychotherapy (90801) but not psychoanalysis (90845). They use numbers to quantify the frequency and duration of analysis, basically responding to corporatized health care on the enemy’s terms. Some even craft their defense using the audit practices and scientific methods of neoliberal medicine: “We need to start speaking the language of evidence-based psychology,” advocates one. Others remain strangely in between, tinkering with categories and practices, like this analyst who reports having “four and a half” patients under analysis.

Psychoanalysts also have to grapple with issues of deskilling, feminization, and the lower status of mental health professions. One interviewee bemoans this loss of status: “There’s been an enormous change in the whole character of the profession. People used to wear ties. I think someone who is a doctor, someone who’s seeing patients, should.” The fact is that being a medical doctor is no longer a prerequisite to become an analyst. From the late 1930s until a 1989 lawsuit, the psychoanalytic regulating body held firm to the view that psychoanalysis was a medical science and that only physicians should practice it. Now the profession is open to psychologists, social workers, group therapists, family councillors, and other kinds of care providers. The only requisite is that they follow a full analytic talking-cure provided by a training analyst—in fact, analysts-in-training may be the last patients willing to submit to the strict discipline of the traditional analytic cure. Once trained, these therapists offer various kinds of services, from child psychology to group therapy or marriage counseling. They develop these psychotherapeutic activities “in a psychoanalytic way”, based on their training and understanding of the discipline, but for the purists and guardians of the profession, “it’s not psychoanalysis”.

Envy, denial, and fetishism

So let’s sum up. A growing number of analytically-trained professionals compete for a dwindling number of patients ready to subscribe to the whole analytic course: four weekly sessions, the use of the couch, the interpretive resolution of a transference neurosis, a proper termination. Most psychoanalysts practice some kind of psychotherapy that is, by their own recognition, “not psychoanalysis”. They envy those who are able to secure proper patients, and deny that their profession as a whole might be to blame. Another mechanism is at play here: the logic of the fetish, the denial of a feared absence through a replacement with a substitute presence. Fetishization takes the form of the emphasis on the importance of the relationship between the analyst and her patient. This personal relationship was deemed nonessential by the founding fathers of psychoanalysis. What mattered was “transference”, that artificial illness whose resolution by interpretation led to psychoanalytic cure. The analyst’s ostensibly technical work was reading and interpreting the transference neurosis. In more recent years however, the relationship itself has come to be seen by many psychoanalysts as curative.

Kate Schechter shows that the opposition between these two logics—the orthodoxy of transference, and the heterodoxy of the relationship—goes back to the origins of the Chicago school of psychoanalysis. I will not try to summarize her history of the debates between the two ancestors, Lionel Blitzsten and Franz Alexander, as well as the constant infighting between their disciples and epigones. Based on archival work, her analysis straddles several disciplines: the sociology of the professions, the history of scientific knowledge, the anthropology of medical care, and psychoanalysis itself. This is not just local history: the Chicago school of psychoanalysis was the most important one west of New York City, and the quarrels between its founders echo wider debates in the discipline. But I found this historical part less interesting than the firsts chapters when the author eavesdrops on psychoanalysts bemoaning the lack of proper patients, the elusive nature of psychoanalysis, and the growing importance of the human relationship between analyst and patient.