Psychoanalysis continues to have relevance for American psychiatry, as shown by its inclusion as a discrete segment of the American Journal of Psychiatry book review section. What is the contemporary truth claim for the therapy and theory that psychoanalysis offers the psychiatrist? For Douglas Kirsner, central to the answer is the way in which knowledge has been transferred from teachers to students by American medical psychoanalytic institutes during the six decades since the death of Sigmund Freud. Kirsner, an articulate scholarly writer, interviewed more than 100 influential analysts and reconstructed a detailed organizational-educational history of four important U.S. institutes. From this large oral history database he extracted generalizations indicating serious didactic deficiencies in the profession, and he now offers his remedies.

The book features comprehensive histories of the New York, Boston, Los Angeles, and Chicago Institutes and follows them from their founding to the mid-1990s. It documents massive failures to teach consistent theories and to develop scientifically proven treatments. Analytic education at all four locations failed to achieve the minimum quantitative standards of a scientific discipline or even to acquire consistent criteria for the identification of student performance typical of a fine art academy or social science university department. What went wrong? Answer: "A basically humanistic discipline has conceived and touted itself as a positivistic science while organizing itself institutionally as a religion" (p. 233).

For decades, the New York Institute worshipped its immigrant European analysts as direct descendants of Freud. In the educational air there was a "language of magic, of religious experience, of a cult, complete with ecstatic insiders and outsiders envious of Freud’s genius" (p. 135). The training analysis of student candidates resembled a "master-apprentice" model of teaching, and the revered senior analyst acquired an autocratic, almost aristocratic aura. The latter’s theories and clinical style signified absolute truth. Such a model stifled innovation, skepticism, and objective self-scrutiny. Protesters and dissidents emerged who founded the Columbia Psychoanalytic Institute.

In 1974, an internal conflict at the Boston Institute and its associated Psychoanalytic Society led to a dispute between Freudian orthodoxy emphasizing pure scholarship and a group desiring a university identity. This dispute produced major leadership splits and led to secession by a dissident group that founded the Psychoanalytic Institute of New England. In Los Angeles "there was a fratricidal battle between the scholarly Rangell (who in 1946 described the state of Los Angeles psychoanalysis as "golden as the southern California sun") and the charismatic, glittering Greenson, Marilyn Monroe’s therapist. The battle’s characteristics resembled aspects of the city of Los Angeles itself, which Kirsner says is "ill-defined in appearance, has a number of ecologies, no easily recognized center, and appears to lack the comfortable unity of a normal city" (p. 231). During the 1990s, internal dissension resulted in the painful birth of a second major institute.

The characteristics of the Chicago Institute are also compared to Chicago, a "city on the make," and the "city of broad shoulders." The Chicago Institute sanctioned the establishment of an authoritarian leadership directed by an "oligarchy of director and institute staff" (p. 113). During the 1990s, a powerful director (who was also a former president of APA) exploited a patient financially, and the consequent legal charges precipitated a governance crisis. National economic problems for psychoanalysis, however, including a legal challenge by American Psychological Association analysts, forced the new institute leaders to cling together. Even a conflict between traditional Freudians and a strong new group of analysts dominated by the thinking of Heinz Kohut did not result in splintering of the institute but led instead to its current successful democratic administration, which prizes diversity.

Can psychoanalysis in the 21st century lay claim to the legitimacy and efficacy that medicine attained during the 20th century by incorporating basic sciences like chemistry and by doing controlled variable outcome studies? Recently, Bucci (1), in search of a "psycho-dynamic science," requested empirical research capable of mobilizing normative data that can be compared with the material of valid taped case histories. Such a grand proposal has little chance of success because statistical studies of psychoanalysis so far have yielded trivial results, and funding for even pilot research into treatment outcome is feeble.

Kirsner wisely avoids any such utopian solutions to the educational problems of psychoanalysis while proposing specific remedies: 1) end the requirement for "training analysis" or completely separate an educational analysis from a treatment analysis, suggested earlier by Thoma (2). 2) Establish public procedures for selection of institute leaders through democratic voting. 3) Evaluate students by using elected, not appointed, analyst judges and include a referee not connected with the analytic institution. 4) Establish a student performance assessment system like that of a fine art school or college department of history. 5) Promote a university-like atmosphere of critical inquiry and skepticism.

This completely persuasive book shows such objectivity and scholarly intensity that its clear assessment of the status of psychoanalytic education at the end of the 20th century must be valid. Leaders of American psychoanalytic institutes, take heed!