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Forty years after Freud's death, the effectiveness of his therapy is still being debated, even among psychiatrists and psychologists who generally accept his theories and discoveries. (A sample panel discussion, scheduled for next month in New York City: "The Outcome of Psychotherapy: Benefit, Harm or No Change?") Psychoanalysts usually cite the "one-third" rule of thumb: of all patients, one-third are eventually "cured," one-third are helped somewhat, and one-third are not helped at all. The trouble is that most therapies, including some outlandish ones, also claim some improvement for two-thirds of their patients. Critics argue that many patients go into analysis after a traumatic experience, such as divorce or a loved one's death, and are bound to do better anyway when the shock wears off. One study shows improvement for people merely on a waiting list for psychoanalytic treatment; presumably the simple decision to seek treatment is helpful.
From its inception, psychoanalysis has been plagued by an elitist image. Most patients are middle and upper class, and even today only 2% are nonwhite. Analysts say that the treatment works best for the YAVIS (Young, Adaptable, Verbal, Intelligent and Successful). It also helps to be W (Wealthy). A psychoanalytic hour (actually it is now usually 45 to 50 minutes) costs from $20 to $100, with the average at $50, or $12,000 a year for the five-times-a-week treatment recommended by Freud. As a concession to economic reality, most American psychoanalysts see patients only once or twice a week, and some have begun to stress even more limited short-term therapy to cut expenses further. One sign of the times: Freudian Judd Marmor, a former president of the American Psychiatric Association, now recommends treatment limited to 20 or 30 sessions, with analysts abandoning their passive role to confront patients more and speed recovery. Marmor points out that even Freud complained that some psychoanalyses seemed interminable and made the patient emotionally dependent on the analyst. "A Cadillac may be a very fine car to drive," he says, "but it would be uneconomical to say we're dedicated to buying Cadillacs for every person in our society."
Shervert Frazier, a Harvard Medical School professor and psychiatrist in chief at McLean Hospital in Belmont, Mass., reports that no patients are psychoanalyzed at his hospital. Frazier, himself "a card-carrying psychoanalyst," sees his own patients for only as long or short a time as he deems necessary, some for as little as 15 minutes, others for 2½ hours. Months may go by between visits, he says, but "when we see each other, these people really go to work."