The tripartite structure of psychoanalytic training—personal analysis, seminars, and supervision—is well known to all of us. I would like to address another aspect of psychoanalytic training that is not usually covered within that structure, which, for lack of a better term, I will call the practical issues. For instance, if candidates are having difficulty finding suitable control cases, their progression will be delayed, since they won't have the requisite number of supervised cases to graduate. And, according to the recent Survey of Psychoanalytic Practice, graduate analysts are also treating fewer cases in psychoanalysis than in the past.
The personal experience of the candidate, as well as that of his older colleagues, often leads him to ask a frightening question: “How viable is psychoanalysis as a career choice?” Since assuming the presidency of CAPE (Council for the Advancement of Psychoanalytic Education) this year, I have heard this concern echoed across the country. The difficulty in finding control cases seems to be a reflection of the problem graduate analysts are also having in doing as much analysis as they wish. If one is having problems finding low fee cases, then there may be no reason to expect referrals at standard fees. In fact, one might pose the thesis that getting control cases, usually at reduced fees, should be easier than finding full-fee cases. In any case, if there are not enough patients for candidates and graduates, then that is an issue for all of us—candidate, graduate, and even training analyst.
The reasons for this decrease in the psychoanalytic caseload are increased competition from other forms of treatment (however inappropriate) such as pharmacotherapy, brief psychotherapy, marital and family therapy and group therapy; inflation and the general economy; and the concomitant problem of poor coverage for psychoanalysis under most health insurance plans.
The question really is: What can we do to address these problems? Perhaps some of the character traits which lead us to choose psychoanalysis as a career make it difficult for us to respond to this challenge. We tend to be thoughtful, introspective, thorough (if not obsessive), and somewhat passive. Living in the realm of the unconscious also might make it difficult to address these all too reality-based issues.
But back to what can be done. Now that we have defined the problem, I think we have to look at our relations to various components of the community at large. For example, psychiatry, and more specifically psychoanalysis, has tended to split itself off from both academic and clinical medicine. I think our relationship to medicine can be examined on a workshop level to see how we might improve communications and work with our medical colleagues, lending our analytic insight to their medical problems. In addition to teaching medical students and becoming active in our psychiatric societies, we can do more consultation psychiatry, join medical societies, and become active on general medical hospital staffs.
Other activities which have proven beneficial at some institutes are well-developed extension divisions that both mental health professionals and members of the local community attend. A few psychoanalytic and psychiatric societies (specifically in Virginia and Ohio) have found it helpful to hire public relations firms to speak with large corporations and show them the value for their employees of insurance coverage that includes psychoanalysis.
Virginia has been particularly successful in this area.
I am sure that, when local candidates and graduate analysts sit down and define the problem of finding both control and regular analytic cases, they will come up with solutions. After all, we are a talented, intelligent, and dedicated group of individuals. Perhaps once we acknowledge and address these reality issues, we will put our collective secondary processes to productive use for our profession, future generations of analysts, and our patients.
Joel E. Rosen, M.D.
President, CAPE
La Jolla