(1979). Int. Rev. Psycho-Anal.

, (6):15-21

A Possible Endangerment of Psychoanalysis in the United

States

K. Eissler 

The miraculous rise of science and technology in the second half of the
nineteenth century caused the illusion that a new era that would necessarily
lead to mankind's unending bliss had begun. Indeed, upon putting oneself in
the place of those who witnessed that historical process, one understands all
too well their conviction that harrowing problems that mankind had vainly tried
to solve from earliest times were on the verge of finding a happy solution. At
present, we witness, however, an antithetical process in the response to
science. The voices that warn against science, that recognize in it an
endangerment of human happiness, and even see in it the beginning of
mankind's final downfall, are on the increase.

The rise of science was not limited to physics, chemistry and biology: it
extended to psychology, whose history records great advance by various
schools during that period. Although initially negative reactions to
psychoanalysis were stronger than those to other schools of psychology,
psychoanalysis celebrated a veritable triumph after World War II, particularly in
the United States. I have only to remind the reader of Ives Hendrick's
Presidential Address of 1955 to the American Psychoanalytic Association, which
sounded like the report of a president or chairman of the board at the annual
stockholder's meeting of one of those modern multinational corporations. Its
tenor was that the membership of the American Psychoanalytic Association is
ever increasing, that our authority is acknowledged all over the United States,
and that the future of psychoanalysis is safeguarded as well as most promising.
No clouds on the far-off horizon seemed to give occasion for taking the
President's prediction with a grain of salt.

Even though many analysts claim that psychoanalysis is closer to the arts than
to science, psychoanalysis has evidently not been spared from the upsurge of
the antithetical movement in the two decades since Hendrick's Presidential
Address. This may give occasion briefly to point out a prominent difference
among the many between the arts and psychoanalysis. As time goes on,

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Mozart's and Verdi's operas are greeted with ever increasing enthusiasm, and
the ceiling of the Sistine Chapel makes more and more people spend their
money on a trip to Rome in order to crane their necks for the pleasure of
getting a glimpse of Michelangelo's far-off masterpiece.

Yet the number of applicants to psychoanalytic institutes is on the decrease in

the United States; the number of psychoanalysts who can fill their day with
patients ready to submit to a full psychoanalysis is small. Almost all analysts are
forced to make compromises and take patients into psychotherapy. Even such
compromises do not always fill an analyst's schedule optimally. One should
consider the possible reduction in professional activity not only from the
economic point of view, but also from the standpoint of the psychological stress
produced, which may be worse than the former. It is, indeed, a depressing
situation when a professional person's schedule is riddled with fallow hours.1

Copyright © K. R. Eissler

1I know this from my own experience, for I was twice exposed to such a situation,

fortunately only temporarily. These situations were so ennervating that they

readied me for taking patients into psychoanalysis without consideration of
remuneration, in order to escape that odious feeling of being superfluous if not
utterly dispensable to the community.
15

I do not want to blow the Marxian horn, as is fashionable in some quarters of

the international psychoanalytic scene, but it is clear that the extent to which
psychoanalysis is utilized as a therapeutic technique depends at least in part on
economic conditions. It has been obvious that this is true of political conditions.
Psychoanalysis cannot survive for long in countries whose political systems are
authoritarian. A minimum of democracy in the community is an indispensable
requirement for carrying out a psychoanalytic treatment. Medical practice
seems to be more immune to political conditions but also is dependent on the
state of the economy. But it is obvious that the psychoanalyst is at a greater
disadvantage than, say, the internist in an economic crisis. The psychoanalyst
cannot take more than 10 patients into treatment if he wants to fulfil the
minimum requirements of his profession, whereas practitioners of all other
medical specialities can increase their efforts to compensate for loss of income.

The limitation of the number of patients an analyst can take into treatment
makes him exquisitely vulnerable to the ups and downs of economic
fluctuations. Nevertheless, it seems to me that this drawback is not the

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essential factor that may eventually break the back of psychoanalysis in the
United States.

In Germany, the treatment of the majority of patients who are in regular

psychoanalysis is financed by insurance companies. The number of treatment
hours, large as it may be, is limited and is increased only under exceptional
conditions. The interference with the transference situation, the question of
whether under such circumstances the conditions of bona fide analysis can be
fulfilled at all is debated. Yet this problem can probably be solved, although I do
not underestimate the dangers to psychoanalysis that are involved.

In the United States, according to some experts, the coming of national health
insurance is certain. It is not probable, however, that the legislation will make
possible publicly funded treatments of the length that is inescapable in
psychoanalysis. Most patients will have to make personal contributions in order
to obtain psychoanalytic treatments of optimal duration and thereby of optimal
benefit. To make such personal contributions may become quite difficult if, as
now seems to be planned, the beneficiaries of national health insurance will not
be permitted the privilege of medical deductions on their income tax returns. In
a country in which deduction of medical expenses is traditional, national health
insurance may leave deeper wounds on psychoanalytic practice than in others,
like England, where the public had never been trained to expect tax relief for
medical expenses. Thus it is to be expected that in the United States moderately
well-to-do patients will hesitate to spend money on psychoanalytic treatment.

Be that as it may, I see a still graver danger to psychoanalysis in another field of

public life. As is well known, the present excessive costs of malpractice
insurance in the United States are an economic threat to many physicians. In
some medical specialities it has taken on such proportions that some
physicians have had to give up private practice. It is true that steps are being
taken to stop the further deterioration of insurance protection. Further, it is
possible that certain types of excesses will no longer come to pass.2 And yet the
inclination of juries to side with the plaintiff who allegedly has been harmed by
a physician's negligence is still present, and one need not go too far afield in
order to understand this preference.

Up to now, so far as I know, malpractice claims have not played a significant

role in psychoanalytic practice in the United States, and insurance rates in this
country are therefore relatively low for physicians limiting their practice to
psychoanalysis. However, in the following I present a hypothetical construction
of an event which I anticipate could possibly be realized in the current situation

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of medical practice and be followed by devastating effects on the practice of
psychoanalysis.

A 30-year-old man, let us assume, is referred to a member of the American

Psychoanalytic Association because of a variety of psychosomatic symptoms
and sporadic depressions. The

2Thus it happened that a jury was ready to decide a malpractice claim favourably

even though the alleged neglect, that of not using a certain treatment, could not
have been malpractice since this treatment was unknown at the time the patient
was treated.
16

initial interview reveals a latent paranoid character structure. Since the patient's
symptoms fall into the category of disorders suitable for analytic treatment, the
consultant recommends a full psychoanalysis. The procedure, and the length of
treatment to be anticipated, are explained to the patient, who accepts the
advice. Let it further be assumed that the fee which is agreed upon does not
cause the patient hardship. Let us further suppose that the patient is treated in
accordance with the technique that is accepted by most analysts as correct.

The treatment makes slow progress. The patient feels better; he is co-operative
and hopeful that the analyst's skills will free him of the pain his neurosis has
subjected him to. After 4 or 5 years, however, the transference takes an
increasingly paranoid turn. Finally the patient decides to discontinue his
analysis, even though—let us assume—the analyst's technique in dealing with
the paranoid transference reactions has lived up to present standards. A few
months later, however, the analyst is sued for malpractice. The patient requests
the return of fees paid to the analyst during the course of treatment and a
considerable sum of money as compensation for suffering. He specifies a score
of reasons as justification for his suit: the analyst did not tell him that there are
other techniques that lead more quickly to a cure or at least to symptomatic
relief; psychoanalysis is an outmoded method of treatment; the analyst delayed
his recovery, consequently retarding his professional advancement; the
analyst's interpretations caused him anguish as well as harm, since they only
confused him and generated serious feelings of guilt.

In court, the analyst may take the position that even with the patient's
permission he will not reveal anything about him, and that therefore, in
accordance with psychoanalytic professional ethics as he and many of his
colleagues understand them, he will not submit to cross-examination. I

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presume that this would unavoidably be followed by the plaintiff's winning his
suit and gaining his desired pecuniary solace.

Alternatively, the analyst might co-operate with the insurance company's

attorney and explain to judge and jury why he took the patient into
psychoanalysis and what happened in its course. But even if the analyst is
highly successful in evading the traps of a cross-examination by an attorney
who is uninterested in ascertaining the truth and excessively eager to win his
suit, will the analyst's explanations be accepted by the jury? The plaintiff's
attorney will bring in any number of expert witnesses who will confirm that
psychoanalysis is outmoded, that it has been superseded by group therapy, a
variety of behaviour therapy modalities, transcendental meditation and their
like.

Furthermore, he would most probably adduce evidence of the therapeutic

effect of the modern chemotherapy of mental and emotional disorders and in
order to gain the jury's full sympathy he may quote from the last work of the
founder of psychoanalysis: 'The future may teach us to exercise a direct
[therapeutic] influence, by means of particular chemical substances, on the
amounts of energy and their distribution in the mental apparatus' (Freud, 1940,
p. 182). The time has arrived, so the hypothetical attorney might argue, when
Freud's prediction has become reality; the 'particular chemical substances' have
been discovered and the analyst, by not giving them a chance of curing the
patient prior to instituting a therapy that is expensive and time-consuming and
whose curative effect is questionable to say the least, made himself negligent
even in terms of Freud's clinical views.

Furthermore, when the patient is examined, he will report that after he had
interrupted the analytic treatment and had experienced a few sessions of
transcendental meditation, all his symptoms vanished and that he now feels as
though born again. The patient's wife may confirm the favourable change in
her husband since he stopped his analysis. His treatment, she will state, had
made her husband irritable and self-centred and in any case she had never
wanted him to be in analysis because of the large number of treatment failures
among her friends and acquaintances, some of whom had gone through
tribulations like her husband's.

Possibly a skilled attorney for the defence could succeed in unmasking these
charges partly as exaggerations and distortions and partly as the result of
psychological mechanisms of defence. The jury might respond favourably

17

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to the testimony of expert witnesses who confirmed the skills and professional
integrity of the therapist and the adequacy and correctness of the technique
employed. They might even convince the jury that the success of the
subsequent non-analytic therapy praised by the patient and his wife had been
made possible by the preceding psychoanalytic treatment.

Yet two strategic moves of the petitioner's attorney, I suspect, would gain the
jury's favour irretrievably and produce a deep distrust of the defendant as well
as a barrier that not even a highly skilled attorney might be able to overturn.
During his client's examination, counsel would let him repeat some of the
analyst's interpretations. The patient would report that he had been told
repeatedly of his hostile impulses against his father, of his envy of his father's
large penis, and perhaps even of his desire to castrate him; of his voluptuous
wishes for his mother's body when he was a child and possibly of his occasional
death wishes against members of his family; of the conflicts that had been
aroused by these unconscious wishes; and some of the other standard
interpretations that are given so often in psychoanalysis and for which the
analyst allegedly was unable to adduce any convincing evidence. It is to be
expected that the jury would feel repulsed by the interpretations reported by
the patient. Further, it would probably not be sophisticated enough to
appreciate the defendant's attorney's quotation from Plato that in sleep 'the
wild beast within us … starts up' and that then we dream of 'incest or any other
unnatural emotion, or parricide, or the eating of forbidden food' (Republic). The
jury's feelings would be all the stronger in view of the petitioner's report that
the interpretations had caused nightmares and states of agitation and
emotional upset during the daytime, leading finally to a state of chronic
despondency.

But I anticipate a result that is even more dangerous (if that is possible) for the
defendant, when the petitioner's attorney searches among the members of the
American Psychoanalytic Association for an expert witness whose testimony
may be helpful to his client's cause. The American Psychoanalytic Association is
no longer a community whose members strive toward goals that could be
called at least equivalent. Of course, even at the time when Hendrick was
President there were disagreements among members about many chapters of
psychoanalysis, but by and large it was the custom of members who could no
longer identify with basic principles to resign their membership and join other
societies. But at present it can be safely said that the beliefs, convictions,
principles, and professional aims of members can no longer be brought to a
common denominator.

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Thus the attorney for the suing party would be able to bring into the courtroom
an expert witness who is a member of the American Psychoanalytic Association
of long standing, who after training as a psychoanalyst in one of the best
psychoanalytic institutes practiced psychoanalysis for several years and has a
high position in the academic hierarchy. Would he refuse to act as an expert
witness and repeat what not so long ago he has put into print (Szasz, 1976) i.e.:

that psychoanalysis

is a threat to human dignity (p. xiii);

is a cryptoreligious movement (p. 10);

is a 'collectivistic-coercive practice of

social control' (p. 78);

suffers from 'fundamental moral, political

and linguistic defects' (p. 25);

'is the name of a militant sect, not of a

medical science, of a cult, not a cure …'

(p. 72);

is 'base rhetoric' (p. 25);

influences people in the direction of evil

(p. 53);

'endeavors to overcome' truth (p. 53);

that it is 'irrefutable' to bracket psycho-

analysis with Marxism, Communism, and

even National Socialism (p. 72);

that Freud's basic aims were to annex

morals to medicine, to create a crypto-

religious ideology (p. 52);

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 that 'Freud was a collectivist and totali-

tarian' (p. 39) and was 'the most explicit

and courageous demoralizer' (p. 63);

that the language of psychoanalysis is 'not

only sterile but also destructive and

dehumanizing' (p. 38);

that 'evil potentialities [are] inherent in

psychoanalysis' (p. 90);

18

that 'the doctrines of psychoanalysis …

are nothing but "metaphorical conquests"

over earlier doctrines concerning human

nature and social control, mainly of

Judaism and Christianity' (p. 47).

Finally, might this expert witness also declare under oath that Karl Kraus, the
Viennese author, critic and poet, was right when he put into words what
perhaps will remain the most vulgar notion of psychoanalysis—the
transformation of mankind into swine (Verschweinung) through psychoanalysis
(p. 30)?

This testimony would be the final blow to the defence. A jury friendly towards
the plaintiff cannot be expected to resist the deposition of an expert witness
who testified that he once believed in the beneficial effect of psychoanalysis
and its raison d'être, but since then found out that it would have been better for
the world if Freud's work had never been written or psychoanalysis had
disappeared forever from the planet.3

Exempla trahunt. No one would know how many patients who had never
thought of proceeding in such a way might be unable to resist the temptation
and sue for reimbursement of their considerable expenditures for past or on-
going treatments.

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The immediate effect of a court decision, as presented above, would be a
skyrocketing of malpractice insurance rates, which, as I mentioned, up to now
have been moderate for psychoanalysts. Since the claims in question would be
for substantial amounts, and the frequency of such suits would be expected to
be rather high, the insurance premium might become so high as to make
private psychoanalytic practice impossible.

Because the consequences I have outlined are so dire, even though

hypothetical, the obvious idea comes to mind that the best measure against
such eventualities would be to adhere to the most stringent selection of
patients for psychoanalysis. I purposely postulated a paranoid character
structure in the hypothetical case in order to lend it greater verisimilitude. But
in truth, it is hardly possible to be certain as to the kind of acting out that may
be precipitated in the patient once deeper layers of the personality are reached
by the psychoanalytic process. To be sure, the preliminary interviews will
suggest grades of probability but will only in exceptional instances permit
certainty one way or the other.

I know of one instance in Freud's practice which can be used as illustration. The
patient, who acquired biographical importance in Freud's life because her
intervention made it possible for him to receive the title of professor which
otherwise would not have been his at all or would have been awarded much
later, left Freud's treatment, as I was told, in great anger and spread rumours
most detrimental to his reputation. This must have been a shock to Freud, for
he had written in a letter to Fliess of 11 March 1902 that the patient had been
promised by a governmental official 'that he would give a professorship to the
doctor who had cured her' (Freud, 1950, p. 343) (italics added). Evidently, at that
time Freud thought his treatment had led to a full success. The patient's
subsequent acting out in this instance may be explained by a confusion of ego
boundaries. Possibly the patient was no longer certain whether she or the
Emperor had conferred the title on Freud and perhaps even whether Freud or
she had advanced in the academic hierarchy. Since then, as a result of Freud's
teaching, one has learned to handle transference cautiously, and the analyst is
warned against accepting any favours from his patients. But even with a correct
handling of transference, one does not have full control over the degree of
possible acting out. In the vast majority of clinical treatments, no such
posttreatment acting out occurs, but if my hypothetical incident should come to
pass the probability of this type of acting out may increase. After all, not only
the type of neurosis, but also the kind of acting out are partly correlated with
environmental factors.

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3
Conceivably, of course, the credibility of this witness' testimony in the hypothetical
suit may be discredited in the eyes of the jurors should the defendant's attorney
cite from the witness's recent publication (Szasz, 1978), in which he calls the
modern chemotherapy of mental and emotional disorders 'fakery' (p. 92). Such a
blatant falsification of facts may arouse the suspicion of a jury even though it is
most favourably disposed toward the plaintiff.
19

In anticipation of this kind of acting out, it might be further proposed that

analysts could protect themselves in the United States by advising patients,
prior to taking them into treatment, to try first some of the psychotherapies
which are now in vogue. I think that Freud's proud assertion (1933, p. 157) that
as a method of treatment psychoanalysis is 'primus inter pares' is no longer valid
in the public eye, if it ever was. Most neurotic patients do not ask for more than
temporary alleviation of mental pain and therefore are satisfied with many of
the non-analytic psychotherapies that are offered to the public. Most of the
psychotherapies grant patients extensive wish fulfillments, whereas
psychoanalysis has preserved its traditional principle of conducting the
treatment under conditions of minimal wish fulfillments.

I recall a consultation with a female patient who had a long-drawn-out course

of treatment with a psychotherapist who favoured the technique in which
patients screamed unrestrainedly. The patient felt better under such treatment
but was dissatisfied because she did not achieve the proper kind of relation to
men which would lead to marriage. After consulting me, she decided to
continue the screaming therapy. Such a decision is understandable when a
patient does not expect more from therapy than release—temporary as it may
be—of unbearable or at least troublesome tension. One can also observe that
modern drug therapy brings relief for symptoms whose cure requires
psychoanalysis. There is an undetermined number of patients suffering from
anxiety, even from phobias, who manage well with the conviction that the
bottle of Valium in their pocket can bring immediate relief should anxiety raise
its ugly head.

Vanggaard's (Vanggaard, 1965) ; (Brandrup & Vanggaard, 1977) papers on the

cure of an extremely severe compulsive neurosis with the injection of small
quantities of LSD at properly spaced intervals opens the possibility that even
such severe and stubborn neuroses might be cured, at least symptomatically,
by drug treatment.

It is clear that the suggestion that patients prior to starting psychoanalytic

treatment should first try out behaviour therapy or transcendental meditation

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is not feasible. It would be unfair to patients who seriously seek therapy to
expose them to treatments which from the psychoanalytic point of view are
somewhat bogus.

But there are other ways in which psychoanalysts in the United States could
protect themselves against the eventuality I have outlined. Counsel-at-law
could devise a form in which it is clearly stated that the patient has been
informed of the existence of short-cut therapies that are at present in vogue,
that psychoanalysis is considered by many leading psychiatrists and
psychologists as outmoded, and that psychoanalysis is a long-lasting treatment
whose success cannot be promised. There are, I am sure, other conditions that
might be included. The signing of such a form may avert court proceedings of
the kind envisaged above that would have a catastrophic effect on the future
practice of psychoanalysis.

The question, of course, is whether the signing of such a form is compatible

with basic principles of psychoanalysis and whether or not it might have a
lasting effect on the transference. Such a form may be understood by the
patient as a sign of distrust in his reliability of character or honesty.

I have reported in a previous paper the instance of an analyst who required a

patient to have the father, who paid the fee, sign a paper in which he accepted
the financial obligation. I thought that such a procedure is not compatible with
the psychoanalytic technique.

However, the form to be signed that I have in mind would not be primarily the
expression of the analyst's selfishness or monetary interest. It would be a
measure necessary primarily for the protection of the entire profession. One
might argue, indeed, that in view of present conditions, insurance companies
should require that such forms be signed by patients prior to inception of
treatment.

I anticipate that only few analysts will agree with me that the danger I have
outlined exists at all, and that still fewer will agree with my idea of how the
analyst should avert it. In that case, I should ask that my paper may be
favourably received by the reader, at least as a study of some aspects of the
possible influence of economic conditions on psychoanalytic practice.

20

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SUMMARY

The psychoanalyst is very vulnerable to the ups and downs of economic

fluctuations, since he can have only ten patients in treatment. Another threat is
that malpractice claims, which so bedevil medical practice in the U.S.A., could
easily be extended to psychoanalytic practice. Court cases would be even more
likely to be won by plaintiffs because the analyst's professional ethics would
prevent him from revealing anything about the patient. Some of the ways in
which suits against analysts might go are suggested, and possible methods of
protection are discussed.

REFERENCES

BRANDRUP, E. VANGGAARD, TH. 1977 LSD treatment in a severe case of

compulsive neurosis Acta psychiat. Scand55127-141

FREUD, S. 1933 New introductory lectures on psychoanalysis S.E. 22 

FREUD, S. 1940 An outline of psycho-analysis S.E. 23 

FREUD, S. 1950 The Origins of Psycho-Analysis.Letters to Wilhelm Fliess Drafts

and Notes: 1887-1902. New York: Basic Books, 1954

HENFRICK, I. 1955 Presidential address: professional standards of the American

Psychoanalytic Association J. Am. Psychoanal. Assoc. 3:561-599 

SZASZ, T. 1976Karl Kraus and the Soul-Doctors Baton Rouge: Louisiana State
Univ. Press.

SZASZ, T. 1978 The Myth of Psychotherapy.Mental Healing as Religion. Rhetoric

and Repression Garden City, N.Y.: Anchor Press/Doubleday.

VANGGAARD, TH. 1965 Indications and counter-indications for the LSD

treatment Acta psychiat. Scand40427-437

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