The problem of lay analysis has not gone away in the interval since the offering and rejection of what was known as the “Chicago Proposal”. Faced at that time by a plan for the training of non-medical practitioners, with no greater prerequisite education than that leading to the master's degree, and for the conferring on graduates of this program a degree of “Doctor of Psychoanalysis”, the Board on Professional Standards concluded its debate with a vote of disapproval, and the plan was dropped. It is not necessary to review this debate; both sides were eloquently defended, and the majority was a clear one. The situation at the conclusion remained substantially what it had been before. It continued to be policy of this Association to permit individual institutes to admit non-psychiatric applicants to theoretical courses
only. Admission to clinical training, which means primarily to the undertaking of supervised psychoanalyses, still requires the prior granting of a “waiver” by this Board at the recommendation of its Research Committee. Such waivers are granted only to candidates who give positive evidence of a commitment to their field of research. They are not exepcted to become clinical psychoanalysts except in the pursuit of their researches, and it is assumed that they will be attached to universities or institutions devoted to investigation, scientific or humanistic.
The only liberalization in the application of this requirement in in recent years has been that applicants for the “waiver” are not required to be already advanced in their academic careers. The reasoning behind this lessened stringency seems to have been the fact that already recognized specialists in research are not as likely to seek out psychoanalytic training, with all its demands and hardships, as younger but promising investigators. A very small number of otherwise qualified clinical psychologists, psychiatric social workers, and others have been exceptionally granted waivers because of their already demonstrated administrative capacities. Others wanting primarily to be clinicians, if they are to have training in psychoanalysis, must go elsewhere than to our institutes; I do not think it is unfair to assert that other training facilities are in general inferior to ours.
Note that we are free to offer supervision of the analyses of assigned patients to “research” candidates approved by the Board on Professional Standards, historians, philosophers, literary critics, lawyers, who have never before been in the position of treating patients but are now presented to patients as their analysts. We may be hard put in our efforts to find some kind of preliminary clinical experience for them. Since we welcome such candidates and find them valuable participants in our seminars, and many of them have become capable analysts, we are glad to work out plans of study and clinical experience for them. But no matter how much we have to offer, it falls far short of the kind of experience which a well-trained psychiatric social worker, for example, would already have had before coming to an institute, but psychiatric social workers, or clinical psychologists, unlike psychiatrists, are required to present themselves—convincingly—as investigators, and not as clinicians.
The issue involved is an old one, at least as old as Freud's study of lay analysis: Is the practice of psychoanalysis to be limited to psychiatrists (even non-psychiatric physicians have to prove their research interest to be admitted)? More correctly, it should be asked whether superior training in clinical psychoanalysis is to be limited to psychiatrists, since there is nothing to prevent others from seeking training outside our institutes. Is that what we shall continue to recommend to them?
Although Freud's discussion of the matter took place under circumstances far removed from those which obtain today in America, and his conclusions with respect to the merits of medical as opposed to lay education clearly favor the medical, he also made it plain that in his opinion psychoanalysis is a discipline separate from medicine and psychiatry, and one that ought to be open to qualified persons of many backgrounds. Is the present situation so different that we now know that the medical-psychiatric experience is not only the best form of preparation but is, as far as the practice of psychoanalysis goes, the only one?
Objections to the training of lay practitioners are well-known, and some of them are intellectually and scientifically respectable. It is an advantage to have studied the physiological and pathological states of the human body, since we always analyse patients in their psychosomatic unity. In fact, it is questionable whether anyone should be allowed to analyze patients without some opportunity to become familiar with medical principles. It is however unfortunately true that most of us who have been analysts for many years have good reason to mistrust the fragmentary knowledge of medicine that is all that remains of four years of medical school education and a few years of residency and practice afterwards. We are as a rule quick to turn our patients over to other physicians when apparently physical symptoms arise. Our non-medical candidates—including those we already have—must with our assistance acquire the skill and judgment to make those referrals themselves, as other lay psychotherapists already have to do.
Other advantages of the medical education are too evident to require more than passing notice, especially those accruing to close and prolonged responsibility for patients beginning early in training. In principle at least, no other training offers this, and it is not likely that any other training balances this deficiency in this respect through other advantages. But lay analysts cannot be shown to have hitherto been notably lacking in the desired consequence of such experience: concern for patients.
The other objections are economic and political, but psychoanalysis is practiced in an economic and political reality, and such considerations deserve serious attention. If there is indeed a permanently limited market for psychoanalysis as a treatment, then it would make no more sense to expand the source of psychoanalysts than it would to provide midwives for a retirement community. The market for our services, however, seems to depend to a much greater extent on the availability of analysts and the means of payment for analysis. In other words, it is not the competition of our colleagues, but the ready availability of other forms of treatment, usually much less costly, that is restrictive. The increasing recourse to health insurance, private or national, at once promises a larger supply of patients and threatens an external limitation, if the trend is to limit third-party payments to medically trained practitioners. Notwithstanding, we ought to reflect well on what it means for us to allow insurance companies or government agencies to dictate to us the educational prerequisites of our students.
We are further reminded of our relations with our fellow psychiatrists and with other physicians. It has been pointed out that psychiatrists in institutional positions have moved away from psychotherapy, especially psychoanalytic psychotherapy, delegating that work to non-medical people. Now there may be a move back to the positions which our fellow-psychiatrists had earlier abandoned. Training lay analysts might in effect provide new nonmedical competition at a time when it is psychiatrists who need our encouragement and support. We are asked to wait for a more propitious time to train lay analysts, but on the other hand we are warned that doing so at any time would discourage future analysts from going to medical school. I think that it is not disrespectful of the cogency of these arguments to reply that a primary commitment to psychoanalysis gives us the responsibility of providing training for the best students we can find. The quality of their earlier education is one of the criteria of selection, but need we, indeed can we, identify that criterion with psychiatric training alone? Many gifted young men and women who aspire to become psychoanalysts are not at all convinced that medical training is for them. They are eager to have professional training in clinical work and to have their credentials evaluated as rigorously as any
psychiatrist's would be. Why can we not train the best of them we can find?
I do not claim to have exhausted the debatable issues with the foregoing comments, which have been put forth with due regard for the issues at stake. It will be up to the Board on Professional Standards to decide, and the decision will no doubt be difficult, as it has been in the past, over other matters which have come to progessive resolution. The formulation of criteria of training for non-medical candidates ought, however, to follow, not precede, the statement of principle. Bearing in mind that even medical and psychiatric training have their own limitations, we should be able to define what kinds of general and clinical education we expect of all candidates. To do so, I propose the establishment of a Committee on Clinical Training, parallel to, but independent of, the Committee on Research, to recommend to the Board the admission to full psychoanalytic training by our constituent institutes of non-psychiatric, non-medical applicants on their individual merits.
—Stanley A. Leavy