Yesterday, Today, and Tomorrow: Some Reflections on the Position of Psychoanalysis in American Mental Health Care

Abstract

In September of 2008, the United States Congress approved legislation intended to help revitalize the state of mental health care in the United States, requiring private insurers to provide the same level of benefits for mental illness as for physical disorders. Despite this, the vast majority of insurance companies fail to provide for more than at most a few weeks of benefits for psychotherapy, relying mostly on short-term hospitalizations and frequent, constant medication to treat patients. Psychotherapy of whatever orientation has almost entirely disappeared from our nation’s psychiatric training programs, as cultural historian Paul Stepansky acknowledges out in his book Psychoanalysis at the Margins, pointing to “a ‘muting’ of psychotherapy under the impact of managed care,” that has been to date chalked up largely to “the financial constraints of managed care,” a system which forced practitioners to move from individual to group therapy (Stepansky 294). Where psychotherapy exists, it is largely oriented around short-term cognitive behavioral therapy (CBT) interventions combined with medication. Despite the widespread nature of this practice, however, Dr. Arnold Goldberg of Rush Medical College and the Chicago Institute for Psychoanalysis points out that much of the new psychiatric research attests to the fact that “CBT efficacy does not last,” and that in studies that compare the effectiveness of psychodynamic psychotherapy, CBT, and psychotropic medication, “psychodynamic psychotherapy is longer lasting [in its effects] than the others” (Goldberg, personal interview). Why, then, has psychoanalysis (and its less ambitious branch, psychodynamic psychotherapy) been subject, as Stepansky phrases it, to such an explicit “marginalization”? (Stepansky 13). I spent this week interviewing two prominent mental health care professionals, Dr. Goldberg and Dr. Richard Zinbarg, Director of Clinical Psychology at Northwestern University, and reading widely on this question, and here will attempt to present my findings.