Can Freud Get His Job Back?

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How can psychoanalysis compete with that? Freud's methods may be intellectually exciting, but they're slow and largely unproven. A course of cognitive therapy can take as little as six to eight sessions to finish; a course of analysis often takes five to 10 years. Even its supporters admit there are few clinical studies to show that psychoanalysis actually works. After all, they argue, the ultimate goal of psychoanalysis is deeper self-understanding, and how can you demonstrate that with a study?

But try telling that to an insurance company. Another reason cognitive therapy has been so successful Judith Beck estimates that there are 5,000 cognitive therapists nationwide is that it's the perfect therapy for the age of managed care: quick, cheap and backed by statistics. Classical Freudian psychoanalysis demands four or five sessions a week, and a session with a qualified psychoanalyst can easily run you $125, if not twice that amount. Few insurance companies will pay for a treatment that costs $30,000 a year and has hardly any clinical outcome studies to back it up. Insurers would rather pay for a cognitive therapist or for that matter, a psychopharmacologist, especially since the introduction of Prozac in 1987. Prozac and the other selective serotonin reuptake inhibitors are widely used to treat disorders like depression and anxiety, which were once the bread and butter of psychoanalysis. Of the 14 million patients treated for depression in the U.S. every year, around 80% take some form of antidepressant medication.

That's how Freud has gone from being the founding father of psychotherapy to a poor, eccentric cousin on the fringes of psychotherapeutic practice. "Classical analysis is a very, very small percentage of what is practiced in this country," says Dr. T. Byram Karasu, editor in chief of the American Journal of Psychotherapy. "It's almost a negligible fraction." Judith Beck believes psychoanalysis will die out in our lifetime. "Managed-care companies and insurance companies," she says, "are finally waking up and looking at research, and finding that it's not effective." Practically the only place patients actually lie down on couches anymore is in Woody Allen movies and New Yorker cartoons.

In the hope of finding a place in modern mental-health care, however, its practitioners are trying to change with the times. One way they're doing that is by dropping the austere, formal pose of the classic Freudian analyst. "The image of Sigmund Freud sitting there smoking on his pipe is nothing like the modern 21st century analyst," says Kerry Sulkowicz, chairman of the committee on public information at the American Psychoanalytic Association. In modern psychoanalysis, that formal reserve is disappearing, and the analyst's personality comes much more into play in treatment. "The process is far more transparent today," says Sulkowicz. "An analyst may say, 'I'm choosing to remain silent to allow your thoughts to bubble up.' Analysts are much more up front. That never would have happened in Freud's day." Many analysts have even given up the beloved couch in favor of face-to-face conversation. "I don't know if that's gotten out to the general public," says Dr. Elio Frattaroli, a psychoanalyst who practices in Pennsylvania. "We made a lot of mistakes by being too much in our heads."

Psychoanalysts are also learning to borrow from other disciplines. According to a survey conducted by the Journal of the American Psychoanalytic Association, more than 18% of patients undergoing psychoanalysis in America also take some form of psychoactive medication. Some psychoanalysts even borrow techniques from cognitive therapy. "The analysts have moved more in the direction of understanding cognitive distortions," says Dr. Glen Gabbard, a psychoanalyst and professor of psychiatry at Baylor University. "If you look at good therapists on videotape, you'll find that the cognitive therapists and the analysts do many things in common." Many psychoanalysts also offer patients a treatment known as psychodynamic therapy, which requires less of a time commitment. It's like psychoanalysis lite: the same techniques are used, but the patient comes for only one or two sessions a week. "The current state of psychoanalysis is such that Freud would probably not recognize it," says Gabbard.

But old-school Freudian psychoanalysis has its true believers, and not all of them are doctors. Some are patients. "It's allowed me to figure out some pretty basic things about myself and why certain situations keep coming up," says a graduate student in her 30s in Brooklyn, N.Y., who went into analysis after a difficult breakup. "A lot of the jokes about analysis talk about blaming your parents, but being in analysis is more about learning to take responsibility for yourself and to take care of the people around you. That kind of control only comes from understanding your past." After four years of analysis, she is more productive, less moody, less angry and less depressed. "It was one of the best decisions I ever made."