Strange Shadows (Shadow and Substance), 1950, a painting by Gertrude Abercrombie, from the book Gertrude Abercrombie: The Whole World Is a Mystery, which was published by DelMonico Books. Courtesy D.A.P.; Private Collection, Illinois

On the morning of February 2, 2023, I exited the subway at 57th Street to find the air growing colder. It had been a warm winter. But the first proper cold front was moving in, and I already felt underdressed. I propelled myself toward the warmth of the Midtown Hilton, where the American Psychoanalytic Association (APsA, as it’s styled) was gathering for its winter meeting.

APsA has long been the institutional center of psychoanalysis in the United States. Founded in Baltimore in 1911 by, among others, Ernest Jones, Freud’s first biographer, its goals were to consolidate the profession and to standardize both training and treatment. Since then, the organization has overseen virtually every aspect of mainstream psychoanalysis in this country—research, education, and practice—and has resisted changes to many of its standards, casting a suspicious eye on analysts who proposed new ideas. In Psychoanalysis: The Impossible Profession, Janet Malcolm described APsA as having an “iron hold” over psychoanalysis in the United States.

The annual in-person meeting, which is traditionally held in New York, is an opportunity for far-flung colleagues, used to working in solitude, to interact. It’s also an opportunity to discuss, face-to-face, whether and how their profession might change to meet the historical moment. A second annual meeting, held online in June, would continue discussions started in New York. Many attendees were clinicians, professionals who had completed many years of psychoanalytic training. I was there as a journalist, an interloper, but I was not unfamiliar with psychoanalysis. For six years, I had seen an analyst; I lay on a couch for fifty minutes, four days a week, and I spoke about whatever came to mind: an essay I was writing, a dream I’d had, an irksome meeting with a student, a memory from childhood. In time, and in ways entirely mysterious to me, I became a less reactive, more stable person, someone capable of loving, working, and playing. My treatment had made me curious about psychoanalysis as a profession.

But I was in New York mainly to investigate rumors I’d heard about major changes afoot in the American psychoanalytic community. Psychoanalysis, I’d heard, was modernizing. APsA was opening up to the broader world. There was a push to bring in new members, as well as a rising tide of psychoanalytic work that sought to make analysis more accessible to and effective for people of different stripes. I wanted to understand what these changes meant for clinicians and patients and whether they were being resisted. What would it take for psychoanalysis to change?

APsA may have an iron hold on the profession, but it has a small fist, I thought, as I counted the people milling about on the hotel’s second floor. It was Thursday, the convention’s third day but only the first with a full slate of panels and discussions, and there were perhaps fifty people present before the afternoon sessions. The crowd seemed old, strikingly so; I saw a lot of gray hair and sensible shoes and the kind of funky jewelry worn by women of a certain age. According to their name tags, many attendees hailed from a few coastal cities: Boston, San Francisco, New York. Almost every person I saw was white. There was a small book exhibit next to a poster display that reminded me of a high school science fair. Representatives from the mental-health treatment center Austen Riggs, advertising in-patient treatment in the Berkshires (more than $70,000 for six weeks), had set up shop just a few steps away.

The sleepy atmosphere, the sparse crowd: it was hard to believe that psychoanalysis had once been central to American culture. From the aftermath of World War II through the mid-Sixties, analysis was seen as a reliable treatment for mental illness. Psychoanalysts sat on the boards of medical schools and chaired departments of psychiatry. Psychoanalytic researchers received government funding. A rosy portrait of the psychoanalyst appeared in the press; journalists themselves entered treatment. The historian Nathan G. Hale Jr. calls this time the golden age of psychoanalysis.

But the golden age didn’t last. In the Sixties, psychoanalysis came under attack from feminists, as well as from advocates of community mental-health services who derided the practice as a luxury for the well-off. Meanwhile, a new generation of physicians and psychiatrists were turning away from psychoanalysis—particularly with the development of what would later be called cognitive behavioral therapy (CBT), which was evidence-based and promised concrete results within a set time frame. By the late Seventies and early Eighties, insurance companies largely excluded psychoanalytic treatment on the grounds that it wasn’t evidence-based, and the majority of analysands had to pay out-of-pocket. In 1980, the third edition of the Diagnostic and Statistical Manual of Mental Disorders purged its pages of psychoanalytic theory, explicitly bringing American psychiatry into a post-psychoanalytic era that was more focused on “biological” explanations and cures, like drugs. Soon pharmaceutical companies began promising patients that their depression or anxiety could be treated with selective serotonin reuptake inhibitors, and by the end of the century, mainstream American psychoanalysis could be said to be on the decline—and in crisis.

A quarter century later, little has changed. Despite its recent trendiness—articles about Freud and his followers appear in the popular press with surprising frequency—the practice of psychoanalysis is fairly niche: APsA has around 3,500 members, and there are about 10,000 patients currently in analysis in the United States. (As of 2018, nearly 40 million Americans were prescribed at least one antidepressant.) CBT continues to be regarded as the gold standard, and many insurance plans still refuse to cover psychoanalytic treatment. Few people have the time and money to come in for treatment three or more times a week, and most clinicians spend a good deal of their time doing something other than psychoanalysis: they see patients for psychotherapy, or they teach, or they do consulting work in the public or private sectors. In 2023, 56 percent of psychoanalysts in APsA were seventy years old or older. It’s no stretch, then, to say that psychoanalysis is dying out. What would it take for the profession to survive? This was one of the implicit questions at the New York meeting, at which institutional changes were to be proposed and new approaches demonstrated.

That same afternoon, I found Donald Moss—the longtime chair of APsA’s program committee—at a discussion group considering how psychoanalysts might account for social and historical factors while treating patients. An analyst in his late seventies with a rosy complexion and a low, comforting voice, Moss had led this discussion group for many years. His fellow organizers were two practicing clinical psychologists and psychoanalysts: Dorothy Holmes, a professor emerita at George Washington University, who is widely recognized for her pioneering work on race and gender, and Stephen Seligman, on the faculties of the University of California, San Francisco, and New York University. They had invited Usha Tummala-Narra, a professor of counseling, developmental, and educational psychology, to present a case study drawn from her private practice that raised questions about how cultural factors—particularly those related to race and ethnicity—might influence clinical work.

Roughly seventy audience members, most of whom were themselves therapists, listened to Tummala-Narra, an elegant woman wearing an emerald dress, describe several sessions with her patient, whom she had “de-identified”—that is, rendered unrecognizable by omitting personal details. Everyone present had agreed to keep confidential the details of the case. During intermittent pauses in the presentation, participants asked questions. How might the concept of intergenerational trauma apply to the case? How had racism operated on the patient’s desires? But some participants, especially older ones, resisted this approach. A white man who looked to be at least sixty insisted that the patient’s psychic problems had nothing to do with ethnicity; they instead stemmed from the universal need to be loved. Love, he said, “transcends culture.” Another participant reflected on a patient’s “need to be understood as singular”—wasn’t there something damaging about viewing a patient as just one among many people who shared an ethnicity, rather than as a unique individual? A third pushed back against the very premise of the discussion group, asking, How much is too much to think about culture? A younger participant responded, saying that he didn’t think it was possible to draw a line.

This debate resembled similar ones taking place in other spaces, from academia to medicine to journalism. It often splits along generational lines. On one side are the defenders of the old ways of doing things, of objectivity, rigor, and the universal human subject. On the other side are those who understand norms as culturally constructed. They often argue that the universal subject is always racially coded and that lived experience produces (or limits) certain forms of knowledge. This second camp usually suggests that the profession needs to find new and more equitable ways to do its work.

The conversation during the discussion group remained decorous, but it was clear there was a lot at stake. Near the end of the session, Holmes acknowledged that the group was violating analytic tradition by attending so closely to the social and the cultural—categories that had historically been seen as beyond the purview of psychoanalysis. For some analysts, violating tradition can be a declaration of war. “Each side really feels that unless their side wins the day,” Moss told me later, “there’s going to be enormous damage.”

Moss and Holmes were at the vanguard of a burgeoning movement: what some called the profession’s “social turn.” Depending on whom you talked to, the social turn was an old tradition rightfully resurgent, a minor tendency now becoming major, a change necessary to the survival of the profession—or the death knell for psychoanalysis as we know it.

Though many proponents of the social turn are experienced analysts—both Holmes and Moss were in their seventies—the approach is particularly attractive to younger clinicians as well as to current analysts in training, who tend to be in their thirties or forties. Many of these clinicians and candidates began psychoanalytic training in part because they wanted to fight for social justice; some had become attuned to inequities while training in social work, while others were drawn to psychoanalysis through exposure to the tradition’s radicals, such as Frantz Fanon.

To understand the social turn, Moss told me during a phone call after the meeting, you must do what an analyst does in the consulting room: go back to the very beginning. “When Freud established psychoanalysis, he made a very sharp division between what he called psychic reality and material reality,” he explained. Freud thought that a patient’s hysteria, say, wasn’t primarily caused by the present conditions of that patient’s life but rather by experiences and fantasies in very early childhood, especially those that took place within the nuclear family. These now resided in the patient’s unconscious and contributed to their psychic reality. He was more concerned with the patient’s feelings and fantasies about their experiences than with the experiences themselves. Many other factors shaping the patient’s life—social and historical forces, verifiable facts and experiences, matters of money and race—were left outside the consulting room door.

In some ways, the method Freud developed was a helpful one: it allowed him to bracket questions of “what really happened” to his patients during their childhoods for the sake of doing psychoanalytic work of rigor and depth. Many analysts after Freud erected a similar wall, and the consulting room became a kind of sanctuary, for the clinician as well as for the patient. Whatever was going on “out there”—liberation movements, economic depressions, wars—was secondary to what was going on “in here.” At their most extreme, American psychoanalysts were reluctant to discuss external realities; if anything, they encouraged their patients to adjust to them.

Moss wanted to increase what he called the “porosity” between psychoanalysis and the social. He had, by his own account, used his position as chair of the program committee to do just that. “We’ve become responsive to a decades-long critique that we’ve ignored the social and the historical to no one’s benefit,” he told me.

Moss had his allies. One of them was Francisco González, an analyst based in the Bay Area. When we spoke by phone following the meeting, González emphasized the importance of collectives to psychoanalysis throughout its history, from Freud’s work in Civilization and Its Discontents to the community program that González himself helped co-found at the Psychoanalytic Institute of Northern California. For González, the turn to the social was really a return—to a politicized version of psychoanalysis that was present, and even quite prominent, at an earlier moment in the profession’s history.

Others saw the social turn as something new—and dangerous. Some members of APsA feared that psychoanalysts were taking on problems that existing disciplines such as sociology or political theory were better equipped to analyze. Others worried that the social turn would cause analysts to abandon clinical neutrality—the poker-faced suspension of judgment that therapists cultivate—and turn them into “avatars of anti-racism and social justice with each and every patient,” as one Massachusetts-based psychoanalyst put it in a message to APsA’s email list, a forum where analysts debate issues affecting the profession. Still others questioned whether this perspective best served patients, who may be primed to see themselves as victims and their problems as the product of external forces. The analyst’s job, according to some, is to push patients past superficial accounts of their suffering and, ultimately, to empower them to make different choices. This was how analysts could best effect change: not by addressing social problems but by helping one individual at a time.

But some advocates of the social turn insist instead that analysts, as individuals, and psychoanalysis, as an intellectual discipline, can effect social change. Beverly Stoute, a psychiatrist and analyst in Atlanta who at the time of the meeting sat on APsA’s executive committee, believes that racial and ethnic violence is “the modern question,” and that, with new social and historical approaches, psychoanalysts are becoming better equipped to answer it. She told me that if psychoanalysts can find ways to address this question, they “could really change the world.”

During the summer of 2020, as the Black Lives Matter movement was flourishing, APsA’s executive committee approached the nonprofit Black Psychoanalysts Speak. Together, the organizations appointed Dorothy Holmes to build and chair an independent group to address race and racism within American psychoanalysis, with funding and administrative support provided by the association. She selected three co-chairs, all eminent clinicians of color: Stoute; Dionne Powell, an analyst at Columbia University and the Psychoanalytic Association of New York; and Anton Hart, an analyst on the faculty at the William Alanson White Institute. Together, they created a commission of twenty-three members and began conducting a systematic study of how issues of race are broached, or not, in psychoanalytic institutions across the country.

On the fourth night of the meeting I attended, more than five hundred people gathered in the hotel’s largest conference room to hear a preview of the results. The crowd seemed noticeably more diverse than at other events. (Later, Stoute said to me, “So you were in that room. You now know most of the black psychoanalysts in the country.” She estimated that about 0.2 percent of analysts in the United States are black.) Holmes, after whom the commission was named, took the podium first. Dressed in a neat red skirt suit, she spoke matter-of-factly about the barriers she had faced as a black woman making her way through graduate and postgraduate study. She was followed by Hart and Powell, who described the commission’s process, then González and Stoute, who shared some of the results of the surveys they had conducted with candidates at training institutes. They told the audience that, according to the data, racism “has been killing our institutes.” Facing microaggressions and misunderstandings, candidates of color were dropping out or not even enrolling in the first place. The institutes didn’t know how to deal with racial trauma, to the dissatisfaction of candidates and patients alike. Sweeping changes were needed, even if, Stoute suggested, those who ran the institutes were largely resistant to change and those who wanted to change didn’t know how.

During the question-and-answer period, one white audience member after another spoke. They applauded the commission, though a few alluded to APsA members who might disapprove of the changes that the Holmes Commission’s report, set to be released four and a half months later, would propose. Near the end of the session, a woman who looked to be younger than the average attendee stepped up to the mic. A woman of color, she explained that she had recently dropped out of psychoanalytic training owing to the racism she experienced at the institute where she had been a candidate. When she received the Holmes Commission’s survey, the first thing she felt was rage. “You just want to take from me,” she said she remembered thinking. “You just want to pick my brain to help you grow.” But now that she understood the purpose of the survey, she was grateful. As she thanked the panelists for their efforts, her voice broke.

It appeared to be a moment of catharsis, for both the former candidate and for the group. Bad feelings had been aired; mutual understanding seemed to have been reached. Later, González told me that APsA was changing, at long last, and “there’s this kind of vibrancy through that change.”

The tensions on display at APsA—between flexibility and rigidity, between freedom and repression—date to the dawn of psychoanalysis and were present, too, in its founder. If Freud defined psychoanalysis with a clear set of rules and criticized the “wild” version practiced by doctors untrained in his method, he also sometimes encouraged experimentation. In 1918, he imagined that a democratizing turn in the world would loosen the strictures he’d placed on psychoanalysis. In this “fantastic” future, outpatient mental-health clinics, staffed by those with analytic training, would provide treatment to the poor and the working class for free. When this happened, clinicians would have to “alloy the pure gold of analysis freely with the copper of direct suggestion.” (During the interwar period, free clinics sprang up in ten cities, including London, Vienna, and Berlin. According to the scholar Elizabeth Danto, the first and second generation of psychoanalysts devoted at least one fifth of their clinical work to the urban poor.)

Still, many resisted change. Over time, as psychoanalysis became established, different tendencies hardened into factions—particularly in the United States, where, according to Hale, the most conservative analysts became “more Freudian than Freud.” When these analysts were in power, as they were for much of the twentieth century, heterodox analysts—including Karen Horney, who challenged Freud’s views on gender and founded what became known as “feminine psychology”—were frequently marginalized.

In the end, history took a cruel turn. The Nazi Party came to power in the Thirties, threatening psychoanalysts—many of them Jews, Communists, or both—with annihilation. Freud died on September 23, 1939, twenty-two days after World War II began, and didn’t live to see the war’s devastating effect on the psychoanalytic community. Many European analysts were imprisoned and killed. Others fled to the United States; the influx of émigré analysts was one among several reasons that psychoanalysis took off in America after 1945. But anticommunist sentiment had forced some analysts to suppress their leftist politics. González described this moment of collective repression to me as one of several traumatic moments in the history of the discipline that must be worked through. “What’s needed now is the psychoanalysis of psychoanalysis.”

“Psychoanalysis can go burn!” said Sameer Khan. “We’re here to serve patients.” The future of the profession writ large was not Khan’s concern.

Khan, a psychiatrist in New York, is a friendly man in his forties with long, dark hair and an easy smile. We met in between sessions on the penultimate day of the conference. By that point, change was in the air. In panels and plenary addresses, speakers encouraged the audience to try out new clinical approaches, and to resist change at their own risk. During one event, Kerry Sulkowicz, APsA’s president, a slick figure who works in leadership and organizational consulting, took the stage to announce that a ballot measure loosening APsA’s membership requirements had passed with 81 percent of the vote. Before, it had been the case that only M.D.s, Ph.D.s, and social workers who had completed psychoanalytic training at an APsA institute could become full members of the association—but now others (therapists, academics, and researchers) who were trained in psychotherapy at APsA or equivalent institutes could join the association with full membership. The change “helps ensure our future,” he said, to raucous applause.

Khan was skeptical of all this celebration. “Is change nice?” he asked, rhetorically. Psychoanalysts, he told me, tend to romanticize change, fear, and uncertainty, as if they were always productive. He seemed to doubt the social turn—not because he objected to training more analysts of color, or to adjusting treatment plans to better reflect the patient population, but because he didn’t think it would change the profession very much. (Another skeptic declined to speak with me on the record, fearing being branded as conservative or racist. Some others I contacted refused to speak altogether.) For all this talk of the social, there wasn’t as much talk about how to make psychoanalysis more affordable to patients. APsA represented people who often earned six figures a year. “It’s like, yes, we want to do good, but also, how much do these pants cost?” he asked, gesturing to the pair he was wearing. (They cost three hundred dollars.)

“You’re supposed to get people to talk about things so that everything can be metabolized,” Khan said. But during many discussions, analysts of color were careful and controlled, as they had been in the discussion group on social and historical factors. They were inhibited. Such self-censorship was pragmatic: those in power would resist change if they felt themselves threatened. What we had witnessed at the meeting might be reform rather than revolution—or, worse, simply a self-congratulatory discussion of things that might never come to pass.

Not long after the New York meeting, the American psychoanalytic community erupted.

During planning for the June meeting, several committee members proposed inviting Lara Sheehi—an assistant professor of clinical psychology at George Washington University known for her work on Palestine—to participate in a panel. Sheehi was being investigated by her own university (and would later be investigated by the U.S. Department of Education) after StandWithUs, a pro-Israel advocacy group, filed a complaint with the department’s Office for Civil Rights alleging that there had been anti-Semitic discrimination in her classroom. APsA’s executive committee, headed by Sulkowicz and president-elect Dan Prezant, forbade extending the invitation, claiming that organizers wouldn’t be able to “contain” reactions to an event with Sheehi. In response, the program committee ultimately refused to plan a June program entirely. The executive committee then disbanded the program committee. APsA’s email list promptly went nuts.

Discussion on the email list was vicious, with some posters supporting the executive committee’s decision and others supporting the program committee. People leveled accusations of racism, misogyny, and anti-Semitism at one another. APsA members on both sides claimed to feel “unsafe.” One member characterized those angry at the executive committee as “birds of prey” who were “willing to rip [APsA] apart.” Another member told me that it felt like everyone had to pick a side.

The weeks that followed were chaotic: it seemed the June meeting wouldn’t happen, then it was back on. (It did, in the end, take place as planned.) The program committee was gone for good—then, suddenly, reinstated. In a stunning reversal, the executive committee offered an apology to Sheehi, who had recently been cleared of wrongdoing by George Washington University, and, in late March, invited her to present at the June meeting after all. (She declined, and has since been cleared by the Department of Education’s investigation.) Less than two weeks after that, Sulkowicz, although a self-described proponent of the social turn, sent a letter to membership resigning from his position as president of APsA and pointing fingers at an “illiberal, extreme left” that had “asserted its exclusive occupancy of the moral high ground” and that aimed “to transform APsA from a professional organization into a primarily political activist organization.” He worried for the future of psychoanalysis: “Our tendency to turn against ourselves represents a social defense against psychoanalytic progress vis a vis the outside world, and may be our greatest risk.”

On Juneteenth 2023, just days after the contested June meeting took place, the Holmes Commission released its report. Across 421 pages, the report offered a comprehensive account of the commission’s qualitative research methods—which involved surveying institute faculty, staff, administrators, and candidates, and following up a sample of these surveys with in-depth interviews—as well as its findings. The commission found that many participants felt unequipped to address racism, that word-of-mouth recruitment methods led to majority-white training institutes, and that “racial enactments”—the manifestation of racist attitudes and behaviors—were common. The report recommended that training institutes focus on the recruitment and retention of candidates of color; that the curriculum at psychoanalytic training institutes be diversified; and that there be a “top-down prioritization of issues of race and racism within psychoanalytic settings.” Many of the training institutes affiliated with APsA, including those in Boston and Minneapolis, committed to organizing group readings of the report. It was understood that, as in analysis itself, meaningful change would take many years.

Meanwhile, people were leaving. Some APsA members, including members of color and Sheehi herself, resigned from the organization, citing controversy around the program committee and Sheehi’s invitation as the reason. Others who had planned to join—like Khan—decided not to. Mitchell Wilson, an analyst in California and the former editor in chief of APsA’s publication, the Journal of the American Psychoanalytic Association, lamented the development. “Having a younger set of folks who are theoretically sophisticated, politically active, and committed is incredibly important. And those people overall have left,” he told me. “That’s a huge loss for some of us. I think, for others, it’s a relief.”

As 2024 began, analysts gathered once again in New York. With some of the more progressive members of APsA absent, the gathering felt more relaxed, though also less energetic. Some months after the meeting, Moss was replaced as leader of the program committee, and the committee was reduced in size.

“Very deflating for many of us,” Moss wrote to me in an email.

The Holmes Commission concluded its formal work in February 2024. At that year’s New York meeting, the commission held a panel for what it called “collective processing” of the report. In an email, González—who, like several people I spoke to, did not attend the 2024 meeting—said a number of commission members were then working to establish the Consultation Liaison Network, which he described as a “network of individuals working psychoanalytically with a shared interest in race work, diversity, and, generally, a more inclusive and progressive psychoanalysis” that could coordinate with training institutes on issues of race and that would be entirely independent of APsA.

“I think there’s going to be a lot of splintering,” said Khan, when we reconnected in the spring of 2024. Cheerful and loquacious during our previous encounter, he now seemed more despondent, muted. The past year had been “sucky”: he’d fallen out with his own analyst over the war in Gaza, stopped treatment, distanced himself from APsA, and like other clinicians of color, felt “a general jadedness” about institutional psychoanalysis. He’d attended only one event at the 2024 New York meeting, the Holmes Commission’s panel. “You make your environment inhospitable, and then minorities leave,” he explained. “APsA was like a beacon. You could go there, you could hear people, and you could get inspired. You could be like, Oh, maybe I want to be an analyst.” Now younger and more progressive analysts would have to seek out the splinter groups, which are smaller and less well known. He wasn’t sure they would find them.

Like many institutions in the early 2020s, APsA felt compelled to change: to diversify its membership, to address racism, to speak to the political moment. But it seemed to Khan that the moment for change had passed. The social turn had its problems—and many, if not all, of its critics raised their questions in good faith—but it had drawn an influx of clinicians and researchers to a profession in desperate need of new blood. Without them, the American psychoanalytic community might well remain a homogeneous group of aging professionals talking among themselves. “I think it’s going to be more of the same, but in a more aggressive way,” Khan told me. “Because you have to do a lot more aggressive things to stay the same.”