Transcending Otherness

Psychotherapy Action Network is far from the first organization that’s raised the alarm about what’s happened to the place of psychoanalytic therapies—and others of depth, insight and relationship—in the contemporary era.

We may be the first to gain traction, however. At this writing, we are just shy of 1300 individual members and can count 51 strategic partners, organizations with memberships totalling many thousands more. What follows was presented at the American Psychological Association in August 2019 as part of a discussion of the factors operating to place and hold psychoanalysis in the position of a devalued outsider. We have a history to transcend, and in that history, along with PsiAN’s experiences to date, are some clues to how that might be accomplished.

Our Mission

PsiAN is a global community of mental health professionals and stakeholders dedicated to promoting psychotherapies of depth, insight and relationship. We aim to restore these therapies to their fundamental place in the mental health landscape through education and advocacy regarding their personal, economic, and sociocultural effectiveness in alleviating suffering and transforming lives.

We believe that psychoanalytic practitioners need to join with other clinicians who value treatments of depth, insight and relationship to form a confident community that is outward-facing in order to accomplish our mission. We assert that this can be done through an awareness of our history and its effect on our culture; a fuller awareness of our evidence base; engagement in the contemporary mental health context; and by modelling inclusiveness in which we stop marginalizing each other and seek to engage other points of view without increasing polarization. This last is a tall order, very much a work in progress, and I invite you to be thinking about this as I talk about how we decided on this approach and what our efforts have been so far.

In reading about othering for this paper, I found myself very drawn to something Frank Summers wrote about treating a person with an othered self-organization:

So, the clinical proposal here is that the analytic process may be divided into two distinct, but interdependent, parts. In the interpretive phase, the aim is to understand how the patient came to be as she is. If this process is successful, the analytic space is opened so that a second phase may take place. In this second phase, the analytic strategy is to sustain the openness of the space and detect transcendental possibilities so that the patient can experiment with different ways of being to replace the historical patterns. The way this is done is unique to each clinical moment, but the same overarching strategy is applicable to any clinical problem…. In every case, the potential of occluded psychic capabilities can be called upon to initiate the creation of new ways of being. ¹

I could spend my time today making the parallels between the process he’s describing and the one necessary for psychoanalysis to emerge from an othered position, but I think it’s my job here to speak less to analysis and more to action, so I will just offer you the idea for its framing and evocative value. PsiAN aspires to hold open the analytic space while experimenting with replacing historical patterns and to bring this same style of relating to our audiences—the public, policymakers, and our larger profession.

The history we need to understand

PsiAN began two and a half years ago with the energy generated by a conference held in Chicago. It brought together clinicians, academics, policymakers, people with lived experience, lobbyists, perspectives from insurance and the law, and seasoned activists--and it was galvanizing. As of August 2019, our membership has grown to over 1200 individuals and 47 strategic partners representing multiple disciplines, practice areas, orientations, and missions. We’ve done this simply through writing to each other and talking to each other. We charge no dues. We connect around our passion for the importance of our work.

We were, and are, concerned about a rather long list of things:

• The erosion of respect for and training in psychodynamic treatment.
• The erosion of the influence of psychoanalytic understandings.
• The marginalization of our research.
• Our visibility to the public as a viable option for treatment.
• Our accessibility to those who need us the most.

These concerns mount as we witness increased social concern about mental health problems, mounting levels of need, and too poor outcomes in many parts of the mental health system. Our expertise working with individuals and the potential we have for bringing transformative ideas to the system as a whole are needed.

But we’re not welcome. APA and the field of mental health at large has us near extinction, dinosaurs burdened with unnecessary and expensive methods. In fact, we’re a vital, busy, and large collection of practitioners whose avenues for participating as full colleagues in research, training, and treatment are being shut down with explanations sometimes as harshly attacking as those of Watson and others 100 years ago. ²

How did it get this bad?

External forces

Oksana has pointed out that American behavioural scientists and psychoanalysis were polarized from the beginning, fundamentally disagreeing about how human suffering should be understood. ³ Not much has changed in that perception in more than 100 years, even though the social forces operating to sustain it may be quite different.

Our marginalization, as you have heard today, is blatant in the limited extent to which treatment outcome research supporting our work is recognized, while flawed conclusions from the study of short-term, manualized treatment outcome hold sway. ⁴

We’ve receded from public visibility while both pharmaceutical companies and advocates of CBT have poured money and effort for many years into shaping the public perception of “what works.” Insurance companies have been trying for a generation or more to find ways to limit how long people can be in treatment, and psychotherapy as a treatment modality often is not even mentioned in models of intervention on a programmatic level, except sometimes as synonymous with CBT.

We unquestionably live in a world in which there is a synergistic pull towards short-term solutions. Success for people operating in this world depends upon seeing cost-effectiveness as accomplished by short-term treatment. In fact, treatments of depth, insight and relationship pay off in long-term cost-effectiveness for individuals, employers, and society as a whole. ⁵ That fact, if acknowledged, is a threat to current alliances and to today’s mental health treatment paradigm.

Psychoanalysis has never had a robust presence in academia, but the number of clinical programs that teach psychoanalytic theory and research is dwindling rapidly. Programs are adopting standards requiring that what’s taught needs to have been published in the last five or ten years. We’ve heard from South Africa and Australia that the same standard is being implemented. ⁶ Training programs with a psychoanalytic focus are also disappearing as their accreditation depends increasingly upon training in a monoculture of CBT. ^{7 8} The case being made against psychoanalysis based on its poor research base is the accepted narrative.

Where might the tide favour our efforts?

There’s an upsurge in attention to mental health problems—war trauma, childhood trauma, gun violence, the opioid crisis. Preventive care is part of many narratives. Perhaps at least as important, a growing number of public figures have spoken up about their personal experience in psychotherapy, and they tend to speak about relationally based treatments of insight, depth, and relationship. It may be that there is a significant difference between how our larger profession sees what helps and how people who are suffering do.

Internal forces

Psychoanalytic practitioners have been under attack and marginalized for a long time, and for a long time, as a community at least, we’ve been behaving as if it isn’t true. ⁹ As a community, we’ve accepted the role of the other.

How? We tend to be folks who prefer to sit in our offices and work in deep and intimate relationships to help people, mostly one by one—how could we not be self-selected for those traits and do our work? When we’re outward facing we tend to engage social justice issues that resonate with our need to address problems which lead to human suffering. We protect our work by avoiding contemporary obstacles, we manage insurance pressures by carefully selecting networks (how many Medicare providers do I know who consider their enrollment a mitzvah and limit it to ten cases in order to avoid triggering an audit?), we leave networks altogether and invent our own sliding scales so we can extend what we have to offer to people without adequate coverage. We have had, at least historically, a mild to severe allergy to anything resembling advertising. Some of us might even think better of ourselves for it. When we gather, we’ve historically debated our theoretical differences, and that has led to a proliferation of different theoretical vantage points and much internal conflict.

This is our otherness. It’s arguably an outgrowth of being othered but it has also been a fertile field for othering. These characteristics of us as a group keep us at the margin of mental health practice, and that makes us easier to marginalize.

Ten years ago, Paul Stepansky, in his book, Psychoanalysis at the Margins, said

The profession to which American psychoanalysts belong—the profession that nurtured and trained them and bestowed on them special therapeutic identities—has long fractured into various subcommunities of analysts…whose proponents see the world in different and often incommensurable ways. The fractionation of the past four decades has occurred in tandem with the dramatic contraction of the field in the wake of the biological turn of American psychiatry, managed care, the cost-effectiveness of nonanalytic therapies, the maturing of psychopharmacology, and the failure of psychoanalysis to provide compelling evidence of its efficacy in relation to other interventional modalities. ¹⁰

He goes on to point out that this fractionation has left us without a clear paradigm out of which to operate in the world as a group. A clarion call a decade ago—and actually, only one of several--but the troops didn’t rally.

Historically and currently, there have been admirable efforts to bring psychoanalytic understandings and treatments out of the echo chamber of its internal battles into involvement with community mental health, with psychosomatic medicine, with social justice efforts. There are many psychodynamically informed community mental health efforts alive today—Harlem Family Institute, The Kedzie Center in Chicago, Reflective Spaces Material Spaces in San Francisco, among others. And while several strong efforts to push back against managed care restrictions, and APA’s participation, like that of the National Coalition of Mental Health Professionals and Consumers, ¹¹ energized some for a while, those who made the effort largely didn’t feel they had their community behind them, and the efforts withered. We don’t have, nor have we ever had, a communal voice facing the public, policymakers, and our profession.

To challenge the othering of psychoanalytic treatments requires transcending our otherness so that we act as a community committed to healing. What does that look like? Actively bringing usable and resonant understandings to those who can benefit from it; creating collaborations among ourselves, with policymakers and the public that embody our usefulness; challenge the most egregious examples of exclusion from our professional disciplines.

The early evolution of PsiAN

PsiAN is evolving and I couldn’t have articulated what I’ve just said two and a half years ago. We started simply as a listserv, sharing information and initiatives with people as they seemed important to us, hopping on suggestions made by members, making initiatives of the concerns our members expressed, trying out our voice. We were reactive, focused on the raw act of speaking up.

In the soup pot of the listserv, members voice their concerns about public narratives that exclude our perspective and share their public responses to media contents, spurring others to do the same. A clearer and clearer narrative about outcome research is emerging, comfortable in many more mouths than when we started –and may I thank Jonathan Shedler for his leadership here.

Importantly, a parallel conversation about how we conduct these conversations, about inclusiveness, has developed—for instance, not everyone thinks what APA does is the thing we should care about, nor shares political views that many find it easy to slide into, thinking they’re in their silo. It’s helped us as a group to develop an informal ethic guiding discussion, which is respectful, inclusive, often imaginative, and often richly thoughtful. Our leadership looks for ways to turn these comments or discussions into effective dialogue if we’re not sure they’re headed that way, as well as into effective action. This is what I think of as the function of holding the analytic space, a role that can move from person to person, from leadership to membership, depending on the situation.

Our earliest mission statement talked about protecting psychoanalytic therapies, but we rather quickly found that we had significant membership among humanistic psychologists and others who share our values whether they practice as we do or not. We decided that we would prefer the language of therapies characterized by depth, insight and relationship to psychoanalytic, thus speaking to what we have in common rather than in language that emphasized difference. This shift was also motivated by involvement with the diverse array of people who make mental health policy and run large programs, who turn off when they hear the word “psychoanalytic.”

Restricted training in and practice of our therapies affects not just psychologists but psychiatrists, social workers, marriage and family therapists—anyone practising in a way that considers these variables to be central to healing. As people have joined us from around the world and talk about their professional worlds, it’s become completely clear that worldwide and in all disciplines, mental health training and systems have marginalized our work, and we need to be working together to change this. While our initial membership was naturally heavily weighted towards psychologists given that all three co-chairs share that discipline, over time it has enlarged to include many others.

Thus, PsiAN is deliberately interdisciplinary, international, and ecumenical. We want to be a big tent representing many who are not psychoanalytic practitioners along with those who are. We see this as an antidote not only to siloed aspects of our field but to our own stark history of isolationism. It’s ok to stay in your clinical silo, but please move it under our tent! We ask only that members ascribe to our mission.

Actions

We have three audiences:

• The public
• Policymakers
• Our professional institutions.

The public

Early on we knew we’d need a narrative that reached the public about what our approach to therapy had to offer. As we’ve gained experience, we feel even more strongly that the direct conversation with the public is crucial, even to being heard within our guild organizations. Luckily, within our membership, we had career-changers, former marketing executives who had become psychotherapists—and luckily, one of those was my co-chair, Linda Michaels, whose brainchild it was to design a rebranding project for talk therapy. She had spent fifteen years running branding projects for businesses who were trying to figure out how to make a product appeal to consumers, and she suggested that instead of going to the public and telling them what we think they need to hear about psychoanalytic therapies, that we should start with finding out what they already know, and think, about therapy, and how they react to a non-jargony description of what psychoanalytic psychotherapy is and what it aims to accomplish. We’re in the middle of that project now, having collected pilot data from in-depth interviews and nearing a larger quantitative study. We have the help of a group of Northwestern marketing grad students this summer, who are bringing new insights to our efforts as they put in the hours needed to collect and analyze this data. Once the data is in, we’ll design a public-facing campaign that speaks about psychotherapies of depth, relationship, and insight, in language that resonates to the participants in the study, and this way of talking about our work will become a basis for our communications with the public.

In other public-facing efforts, we’ve tried to understand how to make inroads into the almost exclusive equivalence between CBT and psychotherapy, and CBT and EBT, that dominates media coverage. This, together with spreading a simple, persistent narrative about what we have to offer, are actions we expect to develop and continue going forward.]

Policymakers

In facing policymakers and legislators, we’ve joined organizations that bring together policymakers in the mental health field, seeking to understand what their concerns are and how they view what we have to offer. As a member of the Mental Health Liaison Group, a national organization of mental health stakeholders who track federal legislation, we follow what’s happening on that level and weigh in both to support potential friends and to bring our concerns to a larger audience. Recently, for instance, a call went out for recommendations for early intervention programs that could be based in Head Start. We were able to pass on information about half a dozen excellent psychoanalytically informed programs already functioning around the country.

I and others have sat for two years in monthly meetings of Illinois’ Mental Health Summit, a similar organization on the state level. It’s been a fascinating education in how nobody in the larger system pays much attention to what happens once someone actually gets to treatment because of the often-horrific things that stand in the way of getting treatment at all. Good, dedicated people try to heal these wounds and are themselves traumatized by them. They think on a programmatic level and understandably see success when there’s a connection between someone and a provider. As providers of a particular kind of psychotherapy, I feel like we’re merely details—any rescue vessel will do when you’re caught in a flood, and the one that claims the most efficiency for the most people is at the top of the list. We must find ways to engage these problems more knowledgeably, and with viable strategies, if we want to be treated as serious players in the system. PsiAN advocates with its members and member groups to pick up these activities, share their efforts and results, providing an awareness of action and efficacy for our larger community to identify with.

Our professions

Facing our guild organizations, like APA, where the othering of psychoanalysis has been rooted and expressed in its hegemony over education, training, and accreditation—that’s challenging and painful. [Linda] has provided a strong research case for APA to rethink its model of evidence-based treatment, and along with it, the evidence. It’s crucial that member clinicians are comfortably familiar with this evidence so that they can move out of a defensive posture about their work. Psychology as a whole needs us to do this, because a system that promotes as evidence-based treatments that are unsuccessful undermines everyone’s professional credibility.

Our call to APA is to rebuild the three-legged stool, taking on the challenge of integrating the outcome research presented today and arguing to insurers and policymakers for the cost-effectiveness of treatments that show robust long-term effects. We need an independent professional organization that can speak up for the complexity of the problems we are tasked with addressing, without preferencing the social conditions and financial interests that push it towards premature solutions based in flawed research. We need a profession that tries to solve the economic problems of service provision without abandoning an honest, complex appraisal of what works to relieve human suffering.

APA’s promotion of education and training almost exclusively in CBT techniques institutionalizes the consequences of misapplied data. We want to engage in fruitful dialogue to discuss what a true well-rounded educational program might look like, one in which the Boulder Model doesn't roll over and flatten the practice needed in making clinical interventions that take time to cultivate.

Modelling open-mindedness

I return to the problem of othering and how the othered group gains serious consideration without contributing to the dynamic of polarization. I’m proposing, as a jumping-off point for discussion, some principles for doing this that follow from seeing transcending otherness as the path to challenging othering. The purpose of coming out of our offices and meeting the world in a more direct way isn’t self-advertisement but shedding what’s become an accommodation to an othered position. It’s crucial to becoming a community with a common goal and a common narrative which explicitly seeks and contributes to the social benefit of all. We need to model respectful dialogue and honest discussion of the very complex and difficult problems we face, not just those experienced by our patients but those within our professional and social worlds as well. We can do this with the confidence in our work that we know it deserves, facing our various audiences with positive contributions to the greater good as we stand firmly against the misapprehensions of how we work and the misuse of data that characterizes how we’re othered.

It means making more ventures into community-based efforts and interdisciplinary collaboration with a clear branding of our particular contribution. In our history are old paths, once a part of the psychoanalytic endeavour, that can be expanded, like community mental health, or re-opened, like psychosomatic medicine. There are other newer paths as well. The work of Mark Solms ¹² and others in the new field of psychoanalytic neuroscience brings fresh opportunities to build bridges of understanding around the structure and function of unconscious processes. As training in clinical relationship skills and understanding shrinks, there may be room for us to breathe new life into that enterprise, especially given the misgivings expressed by many more recent graduates that they haven’t learned enough about being in the room with a patient. And establishing a standard of inclusiveness and collaboration, we hope, can have a transformative effect on our field, pushing all of us to consider and learn from other clinical approaches.

In PsiAN’s two-and-a-half-year existence, we’ve heard many people say we’ve touched a nerve, that we have a resonant message, that they’re grateful that we’re speaking to them and for them about protecting the treatments that we know can transform lives. We think we’ve been successful so far exactly because people are ready to think differently about our place in the field, recognizing that for us and for everybody else, we need a seat at the table.

We’re shooting for the moon here, hoping to model an attitude towards mental health and its treatment that holds complexity and ambiguity and creates safe space for exploring and addressing deep needs for healing. Wherever this takes us, the energy, depth of knowledge, and sense of community of our membership reminds me, on a daily basis, that we have the potential to be a force to be reckoned with.

Janice Muhr, PhD.

Presented at APA, August 8, 2019, as part of the symposium

The Othering of Psychoanalysis

End Notes

¹ Summers, Frank, The Transcendent Experience of the Other: Futurity in Empathy. Journal of Theoretical and Philosophical Psychology, Nov 2012, p. 241.

² Yakushko, O. “Freud Bashing” in Psychology: A History. Presented at the 2019 American Psychological Association Annual Meeting, August 2019.

³ Yakushko, O. “Freud Bashing” in Psychology: A History. Presented at the 2019 American Psychological Association Annual Meeting, August 2019.

⁴ Shedler, J. Where is the evidence for “evidence-based” therapy?. Journal of Psychological Therapies in Primary Care. 2015; 4:47-59.

⁵ Lazar, S.G., ed. Psychotherapy is Worth It: A Comprehensive Review of its Cost-Effectiveness. Arlington, VA: American Psychiatric Publishing, Inc. 2010

⁶ Psychotherapy Action Network listserv communications, 2019

⁷ Levy, K.N., and Anderson, T. Is Clinical Psychology Training Becoming Less Intellectually Diverse? And If So, What Can Be Done? Clinical Psychology: Science and Practice. Volume 20 Issue 2, June 2013, pp. 211-220.

⁸ Norcross, J.C., Sayette, M.A., Pomerantz, A.M., Doctoral training in clinical psychology across 23 years: Continuity and change. J.Clin.Psychol. 2017:1-13.

⁹ Stepansky, P.E. The Marginalization of Psychoanalysis. Other Press, 2009.

¹⁰ Stepansky, p.xi.

¹¹ Scholom, A., Managed care’s assault on our hearts and minds. Psychologist-Psychoanalyst, 1998,18:2, pp. 6-10.

¹² Solms, M., The conscious id, Neuropsychoanalysis, 2013, 15(1), 5-19.