Did you notice the plumes of Borkum Riff sweetening the air this weekend, the thousands of hoary, serious figures, shod in Rockports, garbed in a uniform of tweed, tattersall and flannel, walking the streets discussing, say, the "pre-Oedipal determinants of an infantile gender disorder"?
Fear not. You did not wander onto the set of "All About Ego" or "Id's a Wonderful Life." The two most prestigious psychoanalytic groups in the country gathered here to talk about the state of the science/art/therapy that Sigmund Freud invented in the first decades of this century. And while the members of the American Psychoanalytic Association and its smaller offshoot, the American Academy of Psychoanalysis, may have seemed the happy children of Herr Uber-Doktor, controversy -- economic, political and scientific -- dominated many of the conferences and informal discussions.
Analysis is often called the "talking cure," and in a traditional setting the patient does almost all the talking. This weekend was different. The doctors were downright forthcoming about their own problems. Psychoanalysis, what Freud himself called "the impossible profession," is, in some ways, getting even more impossible in the 1980s.
Leo Stone, a venerable figure in psychoanalysis and a key player in the hierarchy of the APA, said in a speech at the Capitol Hill Hyatt Regency that analysts may be "in danger of pricing themselves out of the market." He expressed concern that patients will be forced to turn to more "facile" forms of therapy as "a trickle-down treatment for those who are not rich enough."
A psychoanalytic patient usually sees his analyst four or five times a week for about six or seven years. In Washington, a session with an experienced analyst costs around $75; fees can run more than $100 for a 45- or 50-minute session in New York.
A recent study conducted by the APA showed that the country's approximately 3,000 analysts are doing less and less analysis. "In, say, 1955, an analyst here or in New York could reasonably expect to have a full load of patients in analysis," said one Washington analyst. "Nowadays, to have 50 percent of your practice taken up with analysis and the rest with teaching or psychotherapy is more the norm.
"There are any number of reasons. Obviously, analysis is expensive. Who has the money to spend $10,000, $12,000 a year on a rigorous, proper psychoanalysis? Even if you're making $60,000, that's a huge chunk of money to spend.
"Also, the insurance picture has changed radically. In the mid-'60s insurance companies would pay government workers $2,000 for psychoanalysis. In today's insurance plans for those people, it's still $2,000. Which buys a hell of a lot less analysis."
AAP President Paul Dince said, "We're trying to impress upon the public and Congress the idea that to cut back on outpatient insurance is a penny-wise and pound-foolish policy. The ultimate cost of people not getting treatment when they need it is too great."
Some analysts argue that to attract patients who would benefit from treatment, fees must be lowered.
The debate over fees is rife with political resentments. Many of the doctors who call for lower fees are academic analysts who are guaranteed a university salary of $50,000 to $75,000. Any patients they might see are part of their academic responsibilities, and so fees do not matter much.
Money, of course, is not the only issue. As Freud observed in 1909, "Anyone who wants to make a living from the treatment of nervous patients must clearly be able to do something to help them." Analysis, which offers no instant panaceas, finds itself competing for patients with a score of get-well-soon techniques ranging from est and Lifespring to total body massage.
There is a history of bitter debate within the American psychoanalytic community between traditionalists and a score of "liberals" -- followers of Carl Jung, Jacques Lacan, Otto Kernberg, Melanie Klein, Heinz Kohut, the English object-relation school, etc. -- who have either added to or debated certain tenets of orthodox Freudian analysis.
A half-century ago, rigidly conservative analysts -- many of whom were Central European Jews escaping the rise of Nazism -- were the unquestioned lords of the APA, especially in New York, still the epicenter of American analysis.
Debate became genuine strife in 1941 when the most powerful sector of the APA, the New York Psychoanalytic Institute, stripped Karen Horney of her teaching position because of her unorthodox departures from traditional Freudian doctrine. Horney, Sandor Rado, Clara Thompson and others believed that the human psyche was deeply influenced not only by the internal conflicts of the ego, superego and id but also by cultural forces.
Horney's departure from the APA orthodoxy spawned a number of new clinics and institutes that were more open to new developments in the field than the high-church APA. In 1956 the AAP was founded and became the umbrella organization for these newer groups.
For years the AAP and APA were like rival liberal and conservative parties, but they have drawn closer together in recent years as some of the APA's starchier figures have retired and younger, more flexible leaders have come to the forefront.
The New York Psychoanalytic Institute is still the scene of some bloody debates and power struggles. Powerful traditionalists such as Charles Brenner and Jacob Arlow remain influential, but as the APA's new president, Richard Simons, said, "There is a different atmosphere today. There are many diverse views being expressed in the APA without someone being asked to leave or disenfranchised."
The past few decades have seen a number of movements that have promised, presumptuously perhaps, to replace psychoanalysis, to make it a subject of merely academic or antiquarian interest. In the '60s Arthur Janov's "primal" or "scream" therapy was in vogue. In the '70s, Nathan Ackerman claimed that family therapy would be the principal treatment for a panoply of psychological disturbances.
For almost a decade now, discoveries in the neurosciences have captured the attention and the imagination of the psychoanalytic world. Biologists studying the tissues of the brain have discovered, for example, that some people are prone to depression for genetic reasons. Chemical analyses of schizophrenia have dominated the journals. Scientists have even claimed they have discovered the physiological evidence for Freud's great discovery -- subconscious thought.
In many ways the conferences of the APA and the AAP show psychoanalysis as a profession in perennial struggle: a struggle to attract patients who need treatment; a struggle to avoid being a therapy for the rich; a struggle to integrate the findings of the neurosciences with psychoanalytic investigations.
What's more, analysts continue to struggle against their rather imperious image. And to this, they object.
"Most of us are a lot like the Judd Hirsch character in 'Ordinary People,' " said AAP President Dince. "We care about our patients. We're not rigid, pompous oracles and we work very hard with people who are suffering mightily. We're in the trenches with people who have severe disturbances and wish to overcome them so they can live an ordinary life. We do what we can and I would insist that we can do a great deal."