Betty Draper lies on a couch in a dimly lit room, wringing her hands. A middle-aged man sits in a leather chair behind her head, silently holding a pencil and notebook. “I don’t know why I’m here,” Betty tells the psychiatrist. But she returns, and eventually she realizes that despite living what seems like a fairy-tale life, she’s deeply unhappy–not least because her sexy ad-executive husband, Don, is cheating on her.

Betty and Don Draper live inside the television world of Mad Men. The show is set in the early 1960s, when the standard treatment for mental illness was the “talking cure” promoted by Sigmund Freud at the start of the twentieth century. For many patients, that meant psychoanalysis–daily sessions on the couch that might stretch on for years.

Since then, anti-depressants and other drugs have revolutionized psychiatry. “If you looked at the major departments of psychiatry in the 1960s, in the major medical schools, all of the chairs were psychoanalysts,” says U-M psychiatry professor Ken Silk. Yet by the mid-1980s, “there were very, very few psychoanalysts that were department chairs.” Silk says he can think of only a couple who survived “the shift that occurred in academic medicine, away from psychoanalysis, toward psychobiology.”

Today, Betty Draper’s doctor would be far more likely to prescribe medication or, at most, short-term psychotherapy. Compared to psychoanalysis, psychotherapy “has more modest aims and goals,” explains Ron Benson, senior training analyst with the Michigan Psychoanalytic Institute (MPI). Whereas psychotherapy is often used to help people cope with their current problems, Benson says “psychoanalysis’s goal is restructuring the patient’s mental functioning”–a process that can take 1,000 or more sessions on the couch.

The change was driven in part by managed care–insurers are no longer willing to pay for years of talk therapy. Yet Ann Arbor still has dozens of working psychoanalysts, with dozens more in training. Some, like Betty Draper’s, are classic Freudians, dark-suited and silent. Others dress more casually and speak more freely. More now are women, and many now come to therapy with a PhD in clinical psychology or a master’s in social work instead of an MD.

Analyst Marvin Margolis, a past president of both the MPI and its parent organization, the American Psychoanalytic Association, says that the pendulum swung away from men and medicine in the latter part of the last century. Margolis, who has both a MD and a PhD, says the organizations are hoping to continue the trend away from the stereotypical “white Jewish male from New York,” while attracting more candidates with backgrounds in psychiatry and neurology.

Dwarakanath “Dwarky” Rao embodies the change. “I did my psychiatry training in India,” says Rao, who succeeded Bronx-born Harvey Falit as president of MPI last year. But like his predecessors, Rao, who practices in Ann Arbor, remains a Freudian at heart.

The pioneering therapist “was wrong about so many things,” Ann Arbor’s Jim Hansell, a training analyst with MPI, told Newsweek in 2006. “But he was wrong in such interesting ways.” Few now believe, for example, that the Viennese physician’s patients were quickly “cured” once he uncovered their repressed childhood traumas. But psychoanalysts continue to work from Freud’s premise that revisiting their patients’ pasts is the road to a happier, more productive future. Says Hansell, “Every form of [talk] therapy out there today rests on the foundations that he laid.”

“I trained with neurosurgeons, neurobiologists, [and] psychiatrists,” says Rao. “I have nothing but awe and respect for what they can teach us. I have no doubt the translations [between medical and talk therapies] will get easier, and we will speak the same language, and maybe we will then have the same disciplines. But that is some way off.”

Despite today’s more diverse credentials and backgrounds, Betty Draper would instantly recognize a contemporary psychoanalyst’s office–the analyst in the chair, the patient on the couch, the box of tissues close at hand. I ask Rao if his twenty-fourth-floor session room in Tower Plaza is any different from one in the 1960s. “The lights are no longer dim,” he smiles. “See how bright it is in here?”

The tools of psychoanalysis, Rao says, are “confidentiality, privacy, [and] frequent meetings.” The key to success, most practitioners say, is the intensity and intimacy of the relationship that develops between therapist and patient. And forming that relationship remains a slow process based, in Rao’s words, on “free association to guide and help us understand what is going on in the mind.” And so, as many as five times a week, hundreds of Ann Arborites travel to session rooms in Tower Plaza or Maynard House or along Washington Street, where they pay anywhere from $50 to $200 to lie on a couch for forty-five minutes and say whatever comes to mind.

“It’s almost a faith,” says Jeff Mason, an associate dean in the U-M school of information. “Not so much as faith in God…But there’s not a lot of scientific evidence that if you stick with this for ten years you will reach your goals…. A favorite phrase of my analyst was, ‘psychoanalysis is a science in a profound state of immaturity.'” Mason laughs. “It is a serious resort–you don’t want to do it lightly.”

Mason was born and raised in New York, the son–shades of Mad Men–of an advertising executive. It was a home “with not a lot of warmth or closeness.” He describes his father as “very troubled…unofficially mentally ill.” Mason, his mother, and two siblings all eventually went into therapy, but never his father–“Nothing was wrong with him!” Instead, “everyone around him suffered.

“From a very early age, I always wanted for close relationships,” Mason recalls. He started dating at a young age, and married “quite young. I had not realized that I could not cope on my own.”

He first saw a therapist in 1984, when he was twenty-five years old. For the next nine years he saw “maybe three different therapists for relatively short periods of time….we dealt with things on a functional level, more behavioral therapy, to improve the ways I interrelated with other people.”

But he found he was getting unhappier and felt he was growing distant from people, more isolated–in psychoanalytic terms, he was “heavily defensive.” He had lost touch with childhood friends. “I focused too much on achieving external success and quality–tenure, salary, all of that,” he says. “I tried to please.”

In 1994, on sabbatical at Berkeley, he plunged into a depression and into more serious therapy. A friend recommended a therapist there, and he began going twice a week. “I started to feel like it was reaching a crisis,” he recalls. “My marital problems became more evident…my low self-esteem…it was all plummeting.”

Returning to Ann Arbor, he again turned to friends for advice and was referred to two therapists–one a PhD psychologist, the other an MD training in psychoanalysis at MPI. After trying both out for a month, “I picked the analyst,” he says.

By then, he had tried cognitive-behavioral therapy, once- and twice-weekly psychotherapy, even going on sabbatical–and nothing had worked. Despite his outward success, he says, “things were going badly in my life.” So when his therapist suggested switching from psychotherapy to more intensive psychoanalysis, he took the leap.

In his own work, he collected data, so the long-term process made some sense to him. And “I liked the idea that someone would be listening to me every day.” But “it was odd” making the transition–from two times a week to five, from sitting in a chair to lying on the couch. No longer able to see his therapist’s face, “I was on my own more–I was forced to realize the difference between what was in my head and the other person’s. I could be quiet at times, let my mind wander, free-associate more.”

When he started in the mid-1990s, he paid $90 for a forty-five minute session; that increased to $130 by the time he finished ten years later. Insurance initially covered some of the therapy. But after that, he says, “it was entirely out of pocket.”

During that time, his life went through major changes–he divorced and has since remarried. But the analysis itself was an incremental process. “There have been three ‘aha moments’ over the ten years,” Mason says–times “when I saw in a different way my neurotic behavior. It was stuff we’d talked about for months or a year.”

One breakthrough concerned his relationship with music. “I was a moderately serious piano student as a child,” Mason explains. His teacher thought he should pursue it, but he suffered from such severe performance anxiety that he stopped actively working on music as a teenager. Later, in his twenties, he played for fun. During analysis, however, “I started thinking harder about what was important to me. I became more serious [about playing] than ever.”

Analysis also spurred him to reconnect with childhood friends. And it helped him understand “how complex my relationships are–with students, for example. Over time the relationships are not only teacher-student, but part parent-child, and there are more other types of feelings that come in. It [analysis] has helped me draw the boundaries.”

Freud believed that we all unconsciously replay important childhood relationships in our adult lives–a phenomenon he called “transference.” “In outer life we have skirmishes with transference,” says MPI’s Rao. “In analysis we make it a systematic exploration, with the hope that because [the childhood relationship] comes alive in the transference, we learn about the past that much more.”

Analysis seeks not just to understand childhood conflicts but to reshape them. MPI’s Jim Hansell calls it “the best method we have for learning how and why we unwittingly recreate in adulthood our own childhood hells, and for providing a second chance to grow up.”

“I spent a lot of time unconscious, not recognizing what the real problem was,” Mason says. “I got very good at avoiding pain and not dealing with difficult feelings.” Exploring emotions in analysis “is almost like learning a new language–you don’t know the grammar, context, structure.”

Mason says, for instance, that he has a strong tendency “to feel responsible for the other person’s happiness–I worried I was wasting [my analyst’s] time–I would look out for him.

“That is how I felt for my father–it was my fault my dad didn’t have a happy life….It sounds so simple now, that I had things in reverse–I was the kid, it wasn’t my job to keep my father happy. And it’s not my fault if someone else is unhappy.

“I still fall into that trap, but analysis has made me more aware–I take more notice of it.”

That issue arose again when Mason decided he was ready to terminate his analysis. “My analyst didn’t think that I was ready, and I gave it time–part of my neurotic structure is that I like to please people.” And he could see his analyst’s point.

“I didn’t feel I was done. In certain ways, I did relive struggles and pains of childhood, but I didn’t completely let go. I didn’t complete the transference. I was still avoiding pain. I probably didn’t confront certain things–but I feel OK about that.”

Finally, after a year of discussion, “I convinced myself that it [termination] was the right thing to do. If I wasn’t ready to make that decision, then maybe I wasn’t ready to stop the treatment.”

One reason the process takes so long, Mason says, is that “you are learning to be your own analyst–that’s the goal….In sound-bite summary, intentionally superficial, you want to know what and why you’re feeling, when you’re feeling it. And if you can reach that stage, you’ll be able to manage your life relationships.”

Looking back at his own analysis, Mason says, “I felt it was a big success. I feel much better. I don’t loathe myself. I feel comfortable with my decisions and [was] able to help my kids through the hard time of the divorce.” (One son is now a junior at the U-M, the other a high school senior.)

And he has the pleasure of his music. “I practice now about two hours a day,” Mason says. “I go to a piano institute each year for ten days. I still have terrible performance anxiety, but I don’t think of it as pleasing people anymore, but of pleasing myself.”

The time he spends at the annual camp “puts a burden on my wife,” he admits. “But my family is very supportive. I no longer feel guilty–it’s a positive thing. It makes me a better person.”

Asked if his family benefits from that improvement, though, he’s careful not to take responsibility for their happiness. “You’d have to ask them!” he laughs.

An “Old Trauma”

Etta Saxe earned her PhD in psychology at the U-M in 1965 and went on to study psychoanalysis with disciples of Sigmund Freud. She was a therapist at the Detroit Psychiatric Institute and was the first female president of the Michigan Society for Psychoanalytic Psychology (MSPP). Yet she could never legally call herself a psychoanalyst–because she wasn’t a medical doctor.

For most of the twentieth century, physicians controlled psychoanalysis in America. Because she lacked an MD, Saxe’s training was dismissed as “bootlegged.” Her mentors, Richard and Editha Sterba, both trained at the Vienna Psychoanalytic Institute–but only Richard, who was also a physician, could legally call himself a psychoanalyst after they fled to the U.S. in 1938.

In the Viennese tradition, Richard Sterba continued to train non-physicians to do analysis. In 1953, the American Psychoanalytic Association (APsaA) retaliated by stripping him of his teaching credentials and disaccrediting the institute he headed.

“It’s an old trauma that’s never been healed,” says Jim Hansell. The conflict over who can learn psychoanalysis–and who can teach it–explains why two separate groups offer analytic training locally: the Michigan Psychoanalytic Institute (MPI), where Hansell is a training analyst, and the Michigan Psychoanalytic Council (MPC). Local analyst Murray Meisels, a founding member of MPC, calls the groups’ relationship “separate but hostile.”

In the 1980s, four PhD psychologists sued the APsaA, contending that the group’s exclusion of non-physicians violated antitrust laws. In an out-of-court settlement, APsaA agreed to open analytic training to “psychologists and other qualified non-medical clinicians.” But many therapists in Saxe’s group, the MSPP, didn’t wait for their old rivals’ blessing. Instead, they created MPC and began offering their own training in psychoanalysis.

Ironically, the settlement turned out to be a lifesaver for MPI as well. By then, many fewer psychiatrists were seeking training, as physicians shifted their orientation from analysis toward medication. “Indeed if we had won the lawsuit to restrict entry of non-MDs into our organization in 1988, we would have been impoverished and…far more vulnerable,” writes former APsaA president Newell Fischer. Today, only one-third of MPI’s analysts in training are physicians, and three-quarters are women.