To the Editors:
The contrast between Dr. Stanley Leavy's carefully reasoned discussion of the question of waivers for lay analysis and Dr. Gregory Rochlin's unsubstantiated indignation that the value of a medical education for psychoanalytic practice should even be questioned, speaks for itself. Dr. Leavy said that he did not claim “to have exhausted the debatable issues with the foregoing comments” and I would simply like to elaborate on a few of the points in his rather comprehensive discussion.
There can be no doubt that there is positive value for the practice of psychoanalysis in a medical background supplemented by a psychiatric residency. Learning to take responsibility for the life and the death of a human being is undeniably useful. It should be pointed out however, that the attitudes which are engendered in the developing physician also have some disadvantage in psychoanalysis. Confidence in caring for and prescribing for a patient all too frequently may become associated with authoritarianism and pomposity, and in any case may have to be unlearned to some extent in the process of becoming an analyst.
An essential in psychoanalytic technique, or more precisely in the character and attitude of the analyst, is respect for the patient's autonomy. Anyone who has supervised analytic candidates can testify to the difficulty a supervisor experiences in trying to help students unlearn years of medical training in prescribing for and taking charge of the patient's life.
Medical training does indeed involve dealing with matters of life and death, and one consequence is that medical students and physicians develop defenses against the poignant human tragedies with which they are constantly confronted. These defenses; denial, intellectualization, and other kinds of distancing obstruct, rather than facilitate, the physician's ability to deal with the emotional conflicts of his patients, and also have to be undone to some extent in the process of analytic training.
Another facet of medical training which has to be modified in becoming an analyst is the concept of “disease”. The medical diagnostician is taught to search for The Illness, the single pathological entity which is causing all the symptoms. The analytic concept of over-determination of symptoms, of a multiplicity of genetic elements, is the antithesis of conventional medical thinking. A corollary conceptual difficulty is the analytic idea of symptom as compromise formation, the result of dynamic conflict between elements of the personality which are neither simply “sick” nor simply “healthy”. The one-disease concept of medicine has the unfortunate consequence of orienting the physician to search for overly simple solutions to overly simple problems, identified by overly simple labels. It also encourages him to isolate the patient from his illness, and to treat cases instead of people.
Furthermore, psychoanalysis requires a special and peculiar talent which is not widely distributed in the population, and without which no amount of training or experience will produce an effective psychoanalyst. Nothing in my experience would lead me to believe that this special talent is conspicuously prevalent among physicians, and there is certainly nothing in my experience of deans of admission at medical schools which would suggest that they place any great value on potential analytic talent, or that they have any special capacity to perceive it when it is present. Nor, in my opinion, is it proper to fault them in this decade for not doing so. Medical education and medical practice has changed drastically in the last 30 years, and the stereotypical model that many of us have in our minds is very far removed from today's facts. Medical science is a very much more scientific science than it was, and despite nostalgic wishes to the contrary, the old family practitioner is likely to disappear because technology is forcing medical practice into patterns of group work in which several highly specialized technicians are involved in the care of any particular patient. The intense competition to get into medical school today is essentially a competition in scientific proficiency and academic achievement, in which personality, character, judgment, and compassionate empathy seem to be quite secondary considerations. Indeed, one could argue that some elements in these two sets of qualities may be antithetical. Since 1938 we have permitted the deans of admissions of medical school to preselect our psychoanalytic students, and this has got to be wrong. It is even wronger now than it was 40 years ago.
Another point to consider in relation to medical education is its relative value to a psychoanalyst. Even if one concedes, as Dr. Leavy and I do, that there are certain aspects of medical training which are advantageous and even essential for analytic practice; how much? And how shall we compare the relative value of a medical education and experience to other useful preparations? Are pathology and bacteriology more useful than neurology or neurophysiology? Should analysts know more about cultural anthropology, statistics, literature, art, philology? Could hours be spent on radiology and public health be more usefully spent on experimental psychology and psychological testing? Would working in a nursery school for six months be more useful for an analyst than working on the locked ward of a state hospital? All of these disciplines have their utility and since analysis embraces the entire gamut of human experience, one could easily argue that any one of them should be given a larger share of the analytic curriculum. No one ought to say that a medical background is useless or a waste of time, but at the same time no one ought to say that the 11 or 12 years that a psychiatrist has spent in college and medical school and residency are the best possible uses of that education and training time, and certainly no one ought to say that it is an absolutely necessary prerequisite to being an effective psychoanalyst.
I would like to close by reiterating Dr. Leavy's statement that “A primary commitment to psychoanalysis gives us the responsibility of providing training for the best students we can find.” This is not only a moral duty we have to our patients, but analysis cannot survive if it is practiced by mediocrities. If we omit to train gifted and talented individuals because we have set up criteria for selection of students which are irrelevant to our main objective, we shall do analysis a profound disservice. Nobody is suggesting, as Dr. Rochlin implies, that psychologists or social workers or writers are more talented in analytic ways of thinking than physicians. They may be more or less talented on the average than a group of physicians; but that is not the issue. If among them there are some very gifted and capable people, instead of excluding them we should be out beating the bushes to find and recruit them.
Gene Gordon