After more than a century mining the unconscious, psychoanalysis is really showing its age.
Only 15 percent of members in the American Psychoanalytic Association are under 50. And traditional Freudian analysis — lying on a couch, talking about your childhood, day after day for years — is widely seen as a musty relic, far too expensive and intensive to fit into modern life.
But analysts aren't ready to give up on Sigmund yet.
Determined to reinvigorate their profession, they're seeking to train a new and more diverse generation of therapists. They're introducing the concepts underlying analysis to schoolkids. They're holding public talks, including recent ones taking an analytical view of President Trump. They're opening their field to more rigorous research, sometimes in collaboration with neuroscientists.
And they're working to persuade a skeptical public that psychoanalysis is relevant. Yes, busts of Sigmund Freud stare down anyone who enters the New York Psychoanalytic Society & Institute, the oldest training center in the United States. But analysts say they're not unduly fixated on his stages of psychosexual development or his ideas on the id, ego, and superego.
"People say, 'Oh, does that mean you're Freudian?'" said Adele Tutter, a psychoanalyst in Manhattan. "That's kind of like asking a modern-day nuclear physicist whether he's Copernican. Much of what Copernicus said was not true, but it helped. It was the foundation."
The foundation for psychoanalysis starts with the unconscious. Freud theorized that humans act in order to satisfy needs they don't know exist. If patients in therapy could speak whatever came to mind — a concept known as "free association" — he thought they'd eventually push to the surface subconscious feelings that can lead to self-destructive behavior.
Now, practitioners are trying to make the case that such ideas have power beyond the analyst's couch.
"We've started applying psychoanalytic ideas outside of our offices — in schools, in agencies, in business," said Mark Smaller, the immediate past president of the American Psychoanalytic Association. "We've made social issues much more on the minds of our membership."
Smaller, for instance, has been bringing psychoanalysis to at-risk teenagers at Morton Alternative School in Cicero, Illinois. Now in its 12th year, Project Realize has treated more than 400 students who were expelled from regular high school for aggressive and dysfunctional behavior. Smaller said the program has helped lower violence and improve graduation rates.
Another form of public engagement comes from an experimental psychoanalytic group called Das Unbehagen. It holds public readings and performances — often on edgy topics — in hopes of drawing an audience that may be receptive to Freudian ideas.
"Talking about the arts or the occult is helpful," said Vanessa Sinclair, a clinical psychologist and psychoanalyst in New York and a co-founder of the group. "I get younger people who are interested, and then I can throw psychoanalysis at them. It makes sense intuitively to a lot of people."
The struggle to get more patients on the couch
Is the outreach working?
Perhaps, if the goal is public awareness. In January, the Library of Congress unveiled a digitized archive of Freud's psychoanalytic and personal papers. Two new books on Freud — one a study, the other a biography — have been published within the past six months. Essays claiming to "psychoanalyze" figures like Kanye West and Donald Trump are routinely shared across social media.
But analysts acknowledge it will be an uphill battle to get more patients on their couches. Approximately 1 in 5 adults in the U.S. will experience mental health issues, yet psychoanalysis is rarely covered by insurance — or considered a viable treatment option.
"There's much more emphasis on medication," said Lisa Deutscher, vice president of the 106-year-old New York Psychoanalytic Society & Institute. "Even in a rather privileged stratum of society, there are shifts away from the idea that it would be useful to spend your time doing therapy. There are greater pressures, like the fact people are on call for their jobs 24/7. It makes other commitments in life that much harder."
It can even be hard for would-be analysts to find the time to train. They can't start until they've earned an MD, a PhD, or a license to practice clinical social work. After that, they must complete four years of coursework in psychoanalysis and 200 hours of clinical training.
On top of all that, they have to undergo analysis for at least two years — for at least four sessions per week.
"They're requirements that fit the 1950s, when every psychologist wanted to be an analyst," said Jamieson Webster, a psychoanalyst with a private practice in downtown Manhattan. "If you're doing a MD or a PhD or an LCSW, the conditions of starting a private practice and having a job don’t fit with analytic training anymore. Candidates find their analytic voice at 50. That's nuts."
It may also help explain why 52 percent of members in the American Psychoanalytic Association are between 60 and 80 years old.
"We are an aging organization," said Smaller, who runs the school program in Illinois. "When I became president-elect at age 62, it was scary that I might have been considered a Young Turk."
To bring in a new generation of analysts, training centers have embraced a mode of treatment called "psychoanalytic psychotherapy." It incorporates Freudian ideas about motivation and the unconscious, yet requires only two years to learn, making it an easier and cheaper route for new candidates to join the profession.
And last year for the first time, the American Psychoanalytic Association offered two "diversity grants" to help training institutes develop programs to encourage diversity among their students. (The grants, however, were tiny: Just $2,500 each to the St. Louis Psychoanalytic Institute and the Psychoanalysis Institute at Emory University.)
A tentative embrace of neuroscience
Perhaps the most radical move for psychoanalysis is to actively embrace scientific research in a quest to see how applying Freud's theory of the mind affects the physical brain.
Analysis "needs to open these concepts up to new evidence, to new terminologies, to new methods," said Mark Solms, chair of neuropsychology at the University of Cape Town and research chair of the International Psychoanalytical Association. Blending analysis with neuroscience, he said, "is the way forward."
The concept sparked considerable resistance when Solms first proposed it in the mid-'80s. Now, though, it's gaining acceptance.
"Psychoanalysis, as I see it over the last few years, is right back at the table of science," said Smaller.
A 2010 meta-analysis assessing the recent body of research found that psychoanalysis is more powerful for some patients than medication and about as effective as cognitive behavior therapy, a short-term course of therapy that seeks to give patients practical tools to control conditions such as anxiety. But analysts say more rigorous research is needed.
"We have to be open to the fact that undoubtedly some of things we think work don't work," Deutscher said. "We have to know that if we're testing our ideas, some will be proven and some will be disproven."
One key side effect of research: banishing a reputation that analysts are arrogant and aloof — and not willing to partner with other health-care professionals.
"It's only in recent years that psychoanalysts started being willing to do randomized control trials and actually measure the outcomes of their treatments," Solms said. "As that information is accumulating, it's up to us to advertise. You must remember what we're up against. The pharmaceutical industry is enormous and has enormous resources. It's going to be an uphill battle, but the evidence speaks for itself."
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