The debate which has been forthcoming for so many years has now arrived. Last December, Morton Reiser, president of the Association, and Homer Curtis, chairman of the Board on Professional Standards, appointed a joint committee of Board and Council (the Joint Ad Hoc Committee on Training for Nonmedical Candidates) chaired by Vann Spruiell. The charge to this committee was to develop a proposal or proposals detailing explicit procedures and bylaws changes whereby qualified nonmedical candidates could obtain full clinical training in those member institutes that wished to provide such training. These proposals could then be discussed by the Board, the Council, and the general membership—at the national meetings, and locally within member institutes and societies. Using the feedback from these discussions, the Spruiell committee would then draft a single proposal detailing the necessary bylaws changes upon which the entire membership could vote.
Dr. Reiser, in a President's Report in the Newsletter last April hoped that “the experience of confronting a concrete proposed mechanism [would] precipitate, enable, and facilitate full debate about the entire range of issues.” He alluded in the same report to the need for us to deal with fundamental issues related to psychoanalysis as a science, a discipline, and a profession, as well as important factors bearing on the American Psychoanalytic Association as a professional organization. If the April meetings in Philadelphia were any indication, this hope may be realized. The discussion in Council was limited by time constraints, but the two-hour discussion at the Board was intense and articulate. Provocative and potentially divisive issues were raised by advocates of varying points of view, as well as by many participants who were involved and concerned, but not yet persuaded as to the proper final course. The discussions were on a high level—passionate, but without rancor. The various models proposed by the Spruiell committee did seem to provide the necessary springboard to allow what were to be the most central issues to emerge.
Freud wrote The Question of Lay Analysis in 1926. He argued that psychoanalytic treatment was unlike traditional medical treatments in that medical training was not a prerequisite for analytic training nor competent psychoanalytic practice. He was defending Theodore Reich, a lay analyst accused of quackery for practicing psychoanalysis in Vienna. Despite his major argument, Freud is actually widely quoted by both sides in this controversy about lay analysis. On the one hand he did argue that a true psychoanalytic scholar must have knowledge of such things as myth, culture, literature, history, religion, social science, and all of psychology, not merely biology, neurology, and medical
science, and that the average medical education was deficient here and in other ways. He also believed that if psychoanalysis were to live or die according to its status as a medical treatment, it could too easily be lost. On the other hand, he had widely quoted reservations and qualifications. Though a competent psychoanalyst could be a physician or not, only a medical analyst could do a differential diagnosis or prescribe psychoanalysis. And, while not finding any existing preliminary education ideal preparation for psychoanalytic training, he had to agree that it was among “people who have had a preliminary education in medicine” where the best current preparation was likely to be found. He also noted the special predisposition of American psychoanalysis to define itself as a medical discipline, noting the unique need that apparently existed in this country to establish standards that would disallow the easy claim by self-proclaimed but less well-trained “experts” to claim status as accredited practitioners in the field and do harm to patients and the reputation of psychoanalysis. He felt these concerns with professional standards to be “practical” ones, however, and less relevant than larger issues related to the interests of psychoanalysis as a science. To this day, unlike in other parts of the world, psychoanalysis in America remains traditionally tied to medicine and psychiatry.
Three committees of the American have studied various aspects of the question of nonmedical training since 1975. The Committee on Prerequisites for Training (chaired by Homer Curtis) was established by the Board in 1975. This committee first differentiated personal qualities, such as the character or analyzability of a potential candidate, from qualifications based on educational and other practical experience. Regarding the latter, it recommended that major prerequisites should include experience in human caretaking, in the scientific method, and in social and humanistic studies. It also stressed the importance of prior socialization into a professional identity that reinforces standards of responsibility and ethics. The committee believed that the medical-psychiatric track best fulfilled the requirements, but that another possible track was through a doctorate in clinical psychology or in mental health.
The Committee on Feasibility for Nonmedical Training (chaired by Kenneth Calder) was established by the Board in 1978 to study these recommendations, to determine whether it was feasible to train nonmedical applicants in our institutes according to them, and to suggest specific guidelines for selection and training. This committee
concluded that it was feasible to train nonmedical candidates and concurred with the prerequisites of the prior committee. It also recommended that a minimum of two years postgraduate clinical training with a broad range of cases be required. It recommended a quota on the number of nonmedical candidates to be trained and, after study and consultation, concluded that it would be legal to establish such limits.
At the spring, 1981 meetings, the Board accepted and approved these reports, and affirmed the goal of developing such programs for consideration by the membership. A third committee, the Committee on the Desirability of Nonmedical Training (chaired by Richard Isay), was established at the same time, this time by the Council, where many felt that in addition to the scientific and educational issues already explored, we must also consider the impact of proposed changes on psychoanalytic practice, on the American itself, and also the political, social, and economic impacts on the membership. That report is in the form of listings of pros and cons—best and worst forecasted long-term outcomes and effects in five major areas: the profession of psychoanalysis, psychoanalytic training, the American Psychoanalytic Association, the public, and the financial status of members. It is a summary itself and cannot be summarized here, but is available to all members. The report brought many questions of significance into focus, such as: effects on the power, prestige, image, and viability of the profession; the possible political, social, and personal effects of decreasing or appearing to decrease our links to medicine and psychiatry; questions regarding the prestige and even the professional survival of the American, its institutes and their training programs, and in what form or forms this might be; questions regarding our relationships to other fields and our place within governmental, medical, academic, or other power structures, and questions regarding such things as our patient pool, referral sources, and our incomes.
The members of the Spruiell committee (in addition to Dr. Spruiell: Drs. Kenneth Calder, Philip Holzman, Richard Isay, Charles Kligerman, Robert Michels, and Herbert Schlesinger) were instructed not to advocate one or another point of view. They were to develop proposals that would present the issues honestly and clearly, so that the membership could determine by discussion and vote its own destiny. In the preliminary report to the Board in April, the committee proposed three possible models for the implementation of full clinical training for nonmedical candidates.
Model I involves minimal changes in bylaws, no new committees, and no administrative and evaluative functions beyond that already established for all institutes and candidates. The bylaws would be modified to include Ph.D.'s in psychology or mental health with appropriate clinical experience as an appropriate prepsychoanalytic pathway in addition to the present medical-psychiatric path. Quotas for this new category would define the allowable percentage of these candidates in a given class or institute. (All but one committee member believes that our legal advisors are correct in their view that such a quota would be legal.) The Board would monitor institute programs through its existing Committee on Institutes.
… many felt that in addition to the scientific and educational issues already explored, we must consider the impact of proposed changes on psychoanalytic practice, the American itself, and the political, social and economic impact on the members.
The models are in order of an increasingly active and detailed role by the Board in the ongoing monitoring and evaluation of institute programs and individual nonmedical candidates. Model II proposes a new standing Board committee which would recommend to the Board whether given institute programs should be approved, then periodically reexamine ongoing programs, much as the Committee on Institutes now does for existing programs. Nonmedical graduates of approved programs could apply for certification and automatically be qualified for Active Membership as any other graduate. Regarding individual applicants, such a committee could advise or consult, but would have no official evaluative function. As with model I, the bylaws would be modified so that being a physician was no longer the sole path to candidacy or membership, and a quota for nonmedical candidates would be set. An individual waiver would be unnecessary. Once programs were accepted by the Board, nonmedical and medical candidates would be treated exactly the same.
Model III proposes a new standing committee of the Board which, in addition to the functions of the committee in Model II, would be roughly analogous to CORST. It would evaluate individual applicants to ascertain that their qualifications were sufficient to recommend waiver of the requirement of medical-psychiatric training. The committee would also recommend waivers of the medical degree for application for active membership, unless a bylaw change or procedure were worked out to make such a waiver unnecessary.
The two-hour discussion at the Board meeting in April was complex and diverse and not easily reducible to brief position statements. In prior meetings, much time had been spent discussing broad, general questions, such as the scientific and educational appropriateness of training nonphysicians as analysts. Here, two large multifaceted areas of concern and disagreement which partially overlap, but to some extent can be separated seemed to emerge. The first is the question of the maintainence of the Association's standards; the second is the question of the importance of and necessity for safeguarding our medical identity and affiliations, and the only partially related subject of the value of a medical education to a psychoanalyst.
The Board discussion was complex and diverse and not easily reducible to brief position statements. There appear to be two large multifaceted areas of concern and disagreement which partially overlap.
Regarding standards, the various proposed models differ in the degree of caution and constraints they impose upon institutes or individuals and the degree to which they directly delegate to the Board a role in determining whom institutes can accept, evaluating their subsequent training, and then the suitability of such candidates to become members. Although most discussants agreed that Ph.D.'s in psychology come from a wide array of backgrounds varying from excellent to shoddy, many felt the Board could or should not play a role which might confusingly duplicate the functions of the Committee on Institutes and the progression or education committees of individual institutes. Further, any “monitoring” might inevitably lead to a perception of nonphysicians as a separate, special group, rather than integrated into the institute and Association membership, as they should be, once accepted for full training. Some felt that model I was the least deceptive and gave members the clearest choice to accept or reject. Physicians also come from backgrounds of widely diverse experience and quality and institutes generally are conscientious in their concern for quality. Others felt strongly,
however, that it was unrealistic to burden the Committee on Institutes or admissions committees with decisions for which they had neither sufficient expertise nor the time to develop it. Even were it to be only a committee to “advise and consult” (a proposed alternate model), the Board should develop a group well qualified and experienced in evaluating the background and possible special problems of such candidates, as well as to assess (at least in a general way) the fate of such candidates should we accept them.
The most cynical position was concerned that some institutes needed to be monitored to guard against lowering standards in order to get sufficient candidates for their classes. The most ideologically pure position echoed Freud's arguments: We must not let political, economic, or other practical expediencies dilute what is necessary to maintain the quality and breadth of psychoanalysis as a science and a discipline, which is to obtain the best people possible, whatever their background and training. The creative thinking, passionate interest and other special and sometimes idiosyncratic qualities in the background and makeup of analysts who can most enrich and advance the field are not confined to those with medical training; in fact, such qualities are sometimes not found in them, or are discouraged by the medical training itself.
There were strong arguments to counter this idealism, however, which came out in discussing the question of the importance of our medical identity and affiliations. What good do our ideals do us if we lose physician applicants to our programs and the special respect, position, and legitimacy in the eyes of the public, medical colleagues, and the government, as well as academic and other important societal groups. Might we naively suppose to retain our ideals while losing the power to implement them and actually be doing damage to ourselves, our science, and our profession?
Although some argued for the unique value of medical training to psychoanalytic practice, it was such sociopolitical and organizational issues that dominated this part of the discussion, and many felt that these were the core issues that underlay the debate about quality. There is a wedge in American psychiatry between biological and dynamic psychiatry which we might deepen by disidentifying ourselves from medicine. Psychiatric residents will find our institutes less appealing, less prestigious, and less worth the financial sacrifice. Our influence will wane in psychiatry and medicine. Our interests will be less well served by affiliating ourselves with psychology and the humanities, and those outside the field will no longer have a basis to know we are “different,” that we are the best. What good will being the best be, if it cannot be perceived? Proponents of these positions were said by others to be overconcerned with image rather than substance. Quality is its own reward and will eventually have its impact and recognition. We should be concerned with what is good for psychoanalysis as a science and for society as a whole, rather than narrower personal and organizational concerns.
Every member has something at stake here, and must therefore struggle with the complexity of the issues … and know as far as possible the implications of their eventual vote.
One strongly voiced position, however, maintained that with a mechanism like model III (or even with no change, and an expansion of CORST's activities) we could open our institutes to a small, specially qualified group of nonmedical applicants, increase the quality (and size) of our classes, develop a collaborative, nonadversarial relationship to institutes, while safeguarding our basic unique medical heritage, identity, and image, with all that goes along with that. Others found this belief possibly naive, however, and even misleading. They say that this is possibly a misleading reassurance designed to diminish members' fears of moving too far and too fast, but will actually gain votes for a change that is momentous and dramatic. Some of this group believes that even if quotas stand legal challenge (and some are skeptical of this despite reassurances from our lawyers) one cannot begin to foresee the sweeping changes in our organization that might and probably will occur once this basic differential between our own and lay analytic organizations is modified. One cannot change our basic definition as an organization, they say, and expect to be able to regulate the historical, sociological, and organizational forces that will ensue; these may lead us in directions we cannot control and may not like, once they occur.
This highly condensed report does not do justice to the range and complexity of the Board discussion, let alone to the historical, scientific, and sociopolitical context in which it occurs. Copies of the Spruiell Committee's reports and of Dr. Carl Davis's excellent, detailed summary of the Board's discussion have been sent to every society and institute. The Isay Committee's report has been previously circulated and is also available. It is hoped that these materials will be familiar to all and that discussions of them and the issues involved will be carried on locally by all members. It is important that every member be informed regarding possible options and their possible impact. Many feel that this discussion, the proposals that will emerge, and the eventual vote is of the deepest significance to our future as an organization, as a discipline, and as a science. Every member has something at stake here, and must therefore struggle with the complexity of the issues, participate in the discussions and know as far as possible all the implications of their eventual vote. The debate continues in December in New York.