Psychoanalysts undergo one of the most lengthy, rigorous training periods of any profession. To be accredited to practice by a psychoanalytic institute, a candidate must typically have completed medical school, a medical internship and a psychiatric residency. In increasing numbers, PhD psychologists and social workers are being accepted for training as "lay," or "non-medical," analysts.
Each candidate must undergo psychoanalysis, which usually requires four to five hours a week for five to 10 years.
"That's lost income, plus you're paying for it," notes psychoanalyst Dr. Stefan Pasternack. "Then you must start classes at a psychoanalytic institute, plus five to 10 hours of reading a week.
"In addition to that, now you start to treat patients, and now, in order to learn, you have supervision, so you have to schedule supervisory hours. At one point in your training you can have four to five hours a week for your personal analysis; four to five hours in supervision of cases you are currently treating until you've met your required number, plus the reading hours and the five hours of classes -- that's almost a 40-hour week, and on top of that you have to earn a living."
Most serious mental illnesses have been eliminated from the list of those ills responsive to full-scale psychoanalysis, yet there are more patients in therapy than ever before. Patients must be chosen with skill and care, however, because not every person seeking therapy will be a good candidate for psychoanalysis.
To be a candidate for analysis, a patient must have a combination of a character or personality attributes that prevent an individual from attaining life's goals -- in career development or human relationships. For the analysis to succeed, the patient must also have a strength that will enable him or her to face the stripping away of the defenses the mind has put up against the memory of early trauma or psychic injuries and hurts or the infantile misconception of early childhood incidents.
"Let us say," proposes Pasternack, "that a 30-year-old lawyer comes in because he is unhappy and depressed. You evaluate the case and it turns out he's just lost his first case. After a few sessions -- three to five hours -- he feels better and he's on his way. End of story.
"On the other hand, let's say this person has been losing things that he should have won all his life. No matter how hard he tried, every time he builds himself up to a success, he does something at the last moment to throw it away. He'll forget to file papers on time, or will lose control of himself. Then you see this long-lasting, self-defeating pattern that is not likely to be changed by a less intense form of therapy."
"Proper diagnosis is of crucial importance," says Dr. Gertrude Ticho. "As long as there was only one kind of treatment, diagnosis was an intellectual exercise, important academically, but making little difference to the patients. Now we have different approaches and different modalities, but for the right patients there is still a lot of advantage in psychoanalysis . . . To quote a famous saying of Freud, we do what we can to 'change neurotic misery to ordinary suffering.' "
Dr. Frederick Goodwin, scientific director of the National Institute of Mental Health, is a kind of bridge between the sometimes seemingly armed camps of the so-called biological psychiatrists and the so-called talk therapies, especially the lengthy therapy of psychoanalysis.
"Psychoanalysis is an extremely important training tool for psychotherapists," says Goodwin, a biological psychiatrist who is trained in psychoanalysis. "I do think a psychotherapist who has been analyzed is likely to be a better psychotherapist than one who is not."
On the other hand, he believes that the analysts and the analytically trained psychiatrists err when they think of "person first and then illness. You have to know and respect mental illness to get the frame of reference."
Similarly, he says, he has "arguments with my biological colleagues who are reductionistic," and emphasizes that "even in such an irrefutably biological illness as manic depression, where everyone will agree psychotherapy alone will have no impact on it, nevertheless, the efficacy of a very potent drug -- lithium -- will be substantially enhanced when people are involved with psychotherapy simultaneously."
To psychoanalyst Dr. Cecile Bassen, "doing analysis is more like doing or studying molecular biology, because you are looking at things on the most detailed level -- an intracellular level rather than gross anatomy . . .
"As I treated more people, I became a lot less naive about how difficult it is for people to change in significant and lasting ways. And once I began to appreciate that, the length of treatment and the intensity of analysis no longer seemed excessive. In fact, it began to seem appropriate."