The American Psychoanalytic Association is considering a proposal for a new pathway to psychoanalytic training. It would require a prior doctorate in clinical psychology or a related field and would lead to a career as a clinician-psychoanalyst. Various arguments have been advanced for and against the proposal: community need, equity, relations with other professions, and fiscal impact, to name only a few. I would like to speculate about the possible consequences of the approval of this program, its effect on the American, on individual institutes and societies, and on the profession itself.
The most profound effect of the proposal would be to shift the functional definition of the profession of psychoanalysis from a subspecialty of psychiatry to a specialization of several different mental health professions. Psychoanalysis was born from clinical medicine (not from psychology or even psychiatry), and many believe that essential attributes of the analyst-analysand relationship are derived from the doctor-patient relationship. The American has long recognized that the role of this medical model in psychoanalysis does not preclude the training of nonmedical analysts, and it has admitted selected nonphysicians to full training and embraced them as colleagues. Nevertheless, were a major segment of the profession to enter through nonmedical routes, a demedicalization of psychoanalysis might follow—“patients” might become “clients”, and the Freudian tradition might be disembedded from the Hippocratic one. A more positive effect of this shift follows from a problem that psychoanalysis has shared with the rest of medicine, that of not having a true research tradition. However, unlike most other medical specialties, psychoanalysis has had difficulty forming liaisons with scientific disciplines that could contribute to the expansion of its knowledge base. In contrast, psychology does have such a tradition, and the “psychologizing” of psychoanalysis might enrich its research, scientific, and scholarly characteristics. Indeed, this was one of the important motives that led the American to its initial approval of nonmedical pathways to psychoanalytic training in the form of the Committee on Research and Special Training (CORST).
The boundaries between psychoanalysis and other professions would be altered by such a proposal. Biological psychiatry might move closer to other medical disciplines, while the gap between it and psychoanalysis would grow larger. Some believe that this has already happened and that the proposal recognizes a fait accompli, allowing us to adapt to it rather than leading to its occurrence. This shift of boundaries would make it easier for third party payers or other policy makers to separate reimbursement for biological treatments from reimbursement for psychoanalysis; it would thus make the economics of psychoanalysis even less like the economics of other medical practice than it currently is. This would probably tend to reduce the fees and incomes of psychoanalysts and make the profession of psychoanalysis economically less attractive to future physician psychiatrists. They would view psychoanalytic training as a route to a lower status, lower paying profession. The appropriate trade union concern about this issue is a major source of the negative response to the proposal from some members of the American.
The proposal would probably improve relationships between psychoanalysis and clinical psychology, as psychologists would no longer feel discriminated against by what they perceive as irrational barriers to their acceptance. (Psychologists who were previously trained in programs not approved by the American might be bitter because the change came too late to help them, but they would probably be a minority.) In addition, the large group of scholars in the humanities and the social sciences who are interested in psychoanalysis would probably be more comfortable if the discipline developed a broader academic base and included representatives of university faculties of arts and sciences, as well as medicine. The greatest difficulty would probably appear in the relationship between psychoanalysis and psychiatric social work. The proposal does not in fact weaken a barrier; it shifts it so that it will no longer be between psychiatry and psychology but rather between psychiatry and psychology on the one hand and the other mental health professions on the other. Social workers would believe themselves to be “next in line” and would work hard to follow this proposal with a later one that would embrace them as well.
What would be the impact of the proposal on the local institutes? First, it would be highly varied. The proposal is permissive, not obligatory, and some institutes would no doubt choose to ignore it. Others would expand, formalize, and regularize programs that they have developed through secondary routes. For many institutes it would mean access to a much larger group of potential candidates—indeed this was a major stimulus for the development of the program. There are now approximately equal numbers of psychiatrists and clinical psychologists practicing in the United States, and clinical psychology is growing more rapidly and has fewer barriers to continued expansion. Indeed, many feel that this proposal itself would encourage the further expansion of clinical psychology, with the secondary effects of increasing the number of therapists in the community, the potential number of applicants for psychoanalytic training, and the number of competitors for patients and fees. Institutes that are geographically tied to a single or small number of psychiatric programs would be less dependent on the leadership or the flavor of those programs, and institutes that have few applicants would be able to enlarge or increase the frequency of their classes. Some hope that the special gifts that are so often found in research candidates would be better represented, but I suspect that one unfortunate corollary of “regularizing” a nonmedical clinical track would be “regularizing” the applicants who sought training through it.
A less desirable effect would be the diminished interest of psychiatrists in psychoanalytic training. If an institute's classes had more than a certain fraction of nonphysicians (I would guess at one-fourth to one-third), physicians might come to see its training as a step away from medicine rather than a track within it; this, together with the economic factors mentioned above, might add to a psychiatrist's preference for subspecialties other than psychoanalysis.
The proposal would have little impact on the American Psychoanalytic Association itself for many years. Admitting a relatively small number of candidates in a new category would mean that five or six years from now there would be consideration of
how they might be included in the membership of the American. Assuming that they were accorded full membership status, it would still be several decades before they constituted more than a small fraction of the total membership. Probably the most immediate impact of the proposal on the American would be a clarification of the role of CORST. There has been some concern that it has drifted into sanctioning an alternate pathway for clinical training for a small group of well-connected and well-qualified nonphysicians. The recognition of an approved alternate pathway would allow CORST to function without question of its fidelity to its charge.
In summary, the proposal suggests a broadening of the psychoanalytic profession beyond the boundaries of medicine and psychiatry. This might dilute some of the core clinical values of psychoanalysis, although recognition of the issue might be sufficient to prevent the problem. It also might enhance the research and academic themes in psychoanalytic life. Opening the institutes to clinical psychologists would increase the pool of potential candidates, enhance the status of clinical psychology, and probably diminish the status of psychoanalysis within psychiatry. Economically, it would become easier for insurers to differentiate between psychoanalyis and other psychiatric treatment, and fees and incomes of psychoanalysts will diminish. Finally, I would add that many of these trends will occur anyway, although the proposal might facilitate them, and that the failure to approve the proposal will lead to the charge that the American is placing the trade union interests of its members above its concerns with professional values or public need.
Robert Michels, M.D.
New York