A 1980 CAPE survey report (CAPE Journal, Fall, 1982) reported, “The general impression among candidates is that graduation cannot be achieved because of the scarcity of suitable analytic cases available for training.” The Survey of Psychoanalytic Practice in 1976 revealed that rarely did a candidate have more than three patients in analysis; many had only one. It appears that a number of candidates were trying to learn analysis when major energies were focussed elsewhere.
In the 1980 CAPE Survey, of the 368 candidates responding, the average patient load among those who had analytic cases was 2.7, with 15 percent reporting five or more cases. Of the 1066 cases treated by the respondents, 75 percent were neurotic, 16.4 percent narcissistic disorders, 8.8 percent borderline, and 0.6 percent psychotic. Almost 30 percent of the borderlines were assigned as first cases.
To track further the nature and extent of the problems and explore solutions, a less systematic investigation was undertaken, interviewing leaders of committees in the American that were especially interested in the issue, various clinic heads and other representatives from 14 institutes, and leaders of the national candidate group. Institutes were sampled from the largest cities, from medium sized cities, and from smaller, more academic centers. This range involved newer institutes as well as the oldest ones, with the attendant great variations in past and present relationships between institute and community.
The Chicago Institute, for example, has, since its beginnings, actively engaged the community. Generous donations have funded a paid Director, who can devote intense efforts to community relationships. It has generated many educational programs for lay public and non-psychoanalyst mental health professionals. Both directly and indirectly, these have contributed to a demand for psychoanalysis, proper. An intensive training program in child psychoanalytic psychotherapy requires trainees to have personal analysis. The Clinic, with a paid staff, including three social workers who help screen out and then place in treatment those not accepted for clinic analysis, has been a longstanding provider for those seeking analysis, including many whose awareness was activated by the Institute educational program.
Candidates in Chicago must take two Clinic cases; the Clinic Committee also passes on the suitability of other supervised cases. Given this system, despite complaints from graduates about lessening demand for analysis, the Clinic has continued to supply sufficient supervised cases. The general decrease in demand for analysis may be causing more candidates to come to the Clinic for third or fourth cases. However, the Clinic currently seems able to meet that need, as well, so that candidates need not have their progress delayed for lack of cases.
St. Louis, with a similar institute structure but in a smaller city and with many fewer candidates, likewise has a Clinic with a long history of serving the community as a diagnostic and treatment center even before trainees were present. When the demand for analysis seemed to fall off, the Clinic was activated more intensively, calling on its longstanding relationships, and now meets the need for supervised cases.
A common feature of Chicago and St. Louis has been the function of the clinic as a resource for patients, even when supervised analysis is not offered. Such activity is more feasible with a paid clinical staff than with volunteer analysts.
The New York Psychoanalytic Institute, perhaps not only because of its philosophy but also its history and location, has in contrast done little outreach; but, by virtue of its existence and reputation in a highly sophisticated community, it has received enough calls to meet the needs of their candidates, though lately only marginally. They rely mainly on Society members for referrals, whereas Chicago, in contrast, has many self-referrals from other professionals in the community.
The Boston Psychoanalytic Institute, like New York, does not rely on a paid clinic staff. However, their kind of community, with many university students and faculty (including many who have been analyzed), as well as the extensive involvement of many members in teaching and agency activities, probably accounts for their relative ease in meeting demands for supervised cases. After a recent decline, a communication to members quickly produced the needed rise in applications for analysis.
Clinics, in addition to providing a more central source of cases, are also a natural focus for outreach activities into the community. However, not all institutes have clinics. In fact, two newer institutes, including one in a relatively small, old, and poor city, have focussed primarily on consulting with candidates on how to develop suitable cases from their own practices. Not only have they currently been able to help candidates find enough suitable cases, but the method has highlighted, and thereby facilitated work on, candidates' internal resistances.
Other institutes have not paid such explicit attention to case finding and development of candidates' practices; one respondent felt it would be too intrusive. CAPE, however, has since 1980 held workshops designed to help candidates develop their analytic practices.
The survey found no instance where candidates were finding many full-fee cases. This was, perhaps, possible in Washington, D.C. until 1982, since a large number of people
had health insurance that would cover 70 to 80 percent of the fee. However, even low fee cases are now difficult to find in some places. This is especially true in some small cities with a relatively high ratio of analysts to population.
What is most encouraging are reports from such disparate locations as Detroit, Baltimore, and Los Angeles that revitalization of clinic efforts have produced increased numbers of cases. Clearly, the same program in one community will not necessarily be effective in another. For example, the Extension Division in Chicago seems to have been a mainstay in developing local interest in analysis; but reports from another city, where the Extension Division is one of the oldest in the country, indicate that it seems often used as a substitute for full training for competing and otherwise untrained mental health practitioners.
Three major factors appear to influence availability of cases: (1) problems within the candidates (2) institute organization and philosophy, and (3) external factors. Resistances within the candidate will be diminished by a successful personal analysis. One candidate leader suggests that a resulting tolerance of one's own success may be an important facilitator. The CAPE workshop on case finding encourages more interaction with the community by individual candidates to build referral sources.
Within the institute, there is some variation in the number of cases required. Many that require only three cases suggest a fourth. Some require only one low-fee or clinic case, but many require two. However, in all the institutes surveyed, it was clear many candidates were taking third and fourth cases at low fees. This is not surprising, since many graduate analysts, especially non-training analysts, regularly accept reduced fees for analysis.
The role of the clinic committee in screening and approving cases varies, often being less dominant for third and fourth cases. Some institutes have found that decreasing the formality and number of screeners has helped to increase the number of suitable cases for analysis. The percentage of clinic applicants actually beginning analysis is small, ranging from three to twenty percent in the survey. Clinics vary in their service to the patients who are not accepted for analysis; though all take some responsibility for referral, some provide some low-fee psychotherapy within the clinic.
A few institutes require supervised cases to be seen five times weekly, but four times is the more usual standard. At least one institute now sets time limits by which candidates must have a certain number of cases and has found this to be an effective spur. Though one surveyed institute worries about contamination from any prior psychotherapy and is certainly against “conversion” of the candidate's own psychotherapy patient, most of the surveyed institutes do not reject patients who have been in previous psychotherapy with a candidate, provided it is not too extended and an analytic stance has been maintained. Many, however, caution against such conversion in first or second cases.
The Survey on Practice indicates that about 30 percent of patients now receiving long-term intensive psychotherapy do not receive the analysis that is considered the treatment of choice for them solely because of economic considerations. The reasons may in fact be more complex, but this group might still provide additional cases for candidates willing and able to treat a patient at a low fee.
The main environmental factor emphasized by respondents was the availability of less taxing treatments which exploit the fertile ground of any prospective analysand's resistance. In one city, these alternatives are reported to have virtually eliminated analyzable child cases; and most analysts there, except training analysts, often accept very low fees to do analysis. In cities with large numbers of federal employees, the cutback in insurance benefits for them has drastically altered practices, so that many graduates are accepting reduced fees. However, more active mobilization of the institutes in the direction of community treatment service may provide enough cases for candidates, though generally at reduced fees.
Insurance coverage, where it is present, does seem an important factor in enabling many people to afford full fees. The economic recession was cited as important in reducing demand for analysis in several industrial centers, but was less emphasized as a factor in cases for candidates.
All the surveyed institutes indicated some decrease in availability of suitable cases for candidates. Those institutes with long established ties and traditions of service to the community, however, seemed well able to handle the pinch. Others are developing more outreach and community service capacity to attempt to find more suitable cases. Both a workshop sponsored by the Committee on Associate and Affiliate Membership and the Workshop on Clinics are now planning to focus efforts at the December 1983 meeting on investigating this very problem.
L. David Levi, M.D.
Milwaukee