Reader Response: David Lotto

David Lotto on Sebastian Thrul’s

Psychoanalysis at the End of the End of History

(ROOM 10.22)

A few responses to Sebastian Thrul’s excellent wide-ranging article on the current state of psychoanalysis. First, a comment on the rise of the relational turn. Relational psychoanalysis certainly incorporates postmodern sensibilities into its perspective on both psychoanalytic theory and practice. A good example is Irwin Hoffman’s 2009 paper “Double-thinking Our Way to ‘Scientific’ Legitimacy: The Desiccation of Human Experience,” which was given as the plenary address at the 2007 American Psychoanalytic Association’s winter meeting. In this paper, Hoffman presented his version of relational psychoanalytic theory, he calls the hermeneutic/constructivist position, which is solidly embedded in the postmodern view of the world, favoring narrative truth over historical truth, to use Donald Spence’s terms. For Hoffman and like-minded relational theorists,reality is co-created by analyst and patient. A problem with the hermeneutic/constructivist account is that if there are no truths out there that are not dependent on a particular context and there are no objective criteria that can be used to evaluate theoretical or clinical assertions, how would we determine if these assertions have a stronger or weaker connection to reality?

As Thrul suggests, the end of history thesis fits well with the rise of the biological deterministic model for understanding mental distress. The widespread adoption of this paradigm in the psychiatric and psychotherapeutic communities has much to do with the current devalued status of psychoanalytic psychotherapy. In addition, one of the effects of the end of history triumph of neoliberalism on psychoanalysis is that it becomes commodified, a service provided to consumers that is in economic competition with other forms of treatment of troubled people. Its value is determined by a cost-benefit analysis. Short-term, often manualized and most often under the CBT theoreticalumbrella, or psychopharmacological treatments, have a competitive advantage in the marketplace because of theirlower cost as compared to psychoanalysis.

In this country, for most people except for the minority who can afford to pay out of pocket, psychotherapy is paid for by health insurance companies. The health insurance companies get the money to pay for psychotherapy frompremiums paid by employers, with employees usually paying a small portion. These premiums are quite high, as they cover all medical care. The full cost of health care for an average family of four is just over $30,000 a year. Government partially subsidizes the cost for some low-income people.

Insurance companies desire to pay for as little as possible. There is an unholy alliance between the health insurance industry and the mostly university-based psychotherapy research projects, which generated research studies supporting the effectiveness of brief, most often manualized psychotherapy treatment. This becomes the evidence for “evidence-based treatment.” Manualized treatments make those conducting psychotherapy outcome studies happy since it solves the reliability problem—how to assure that all the experimental condition subjects in the study are receiving the same treatment. Insurance companies often use this research as a justification for refusing to pay for long-term treatment, arguing that there is “no evidence” that long-term treatment is more effective than short-term.

With regard to psychoanalysts’ retreat from the public sphere, there have always been psychoanalysts, starting with Freud, who were active although usually in a fairly restrained way, in public affairs. This tradition continued through the generations of psychoanalysts, Wilhelm Reich, the Berlin free clinic, Winnicott, the Mitscherlichs, Fromm, Erickson, Lacan, and Lifton, to name several. Unfortunately, in the more orthodox analytic circles, entering the public sphere was considered to be a contaminant that would interfere with the purity of the unfolding of the transference and was therefore frowned upon.

Concerning the issue of which patients psychoanalysts actually work with in this country among psychoanalytically oriented clinicians, there is a two-tier system. Within the private-practice community there is a split between those who accept insurance and those who don’t. The fees paid by the insurance companies are significantly lower than those that a well-established practitioner can command in the marketplace. The net result of this is that the top-tier clinicians see a small minority of fairly well-off individuals who can afford their fees, leaving the majority of people to seek psychotherapy elsewhere.

And last, my response to the defeat of the left-wing populist movement represented by Bernie Sanders and Jeremy Corbyn, mentioned by Thrul. For me, it was a severe disappointment, a not unfamiliar feeling from times gone by, as the last time I remember feeling this way was in 1972, following the landslide defeat of George McGovern. Once again the hope of progressive change has been stymied by the forces of fear-inspired right-wing politics.