Since 1977 several committees of our Association have studied proposals to change standards for admission to training in our institutes to permit psychologists with a doctoral degree to apply for training. Some have proposed a quota. I will attempt to summarize the arguments against making such changes. The arguments tend to fall into a few groups:
The value of medical training;
Arguments concerning our relationship with medical colleagues;
Consideration of a threat to the identity of the American Psychoanalytic
Association as a primarily medical organization;
Organizational difficulties in monitoring the suitability for training and subsequent training in institutes.
None of the arguments is without bias. I am mindful that scholars in other disciplines are interested as we are in understanding the human mind, in psychological research, and in concern with examination of human experience. From this point of view psychoanalysis may be considered as belonging' to the humanities. But as Hans Loewald points out in Psychoanalysis and the History of the Individual, “Psychoanalysis is by its origin and specialized function in society a medical or therapeutic art.” Tradition has given us the responsibility to relieve human suffering, whatever other purposes we may serve in our studies and investigations.
The stimulus for consideration of training nonmedical candidates seems to come from concern about a decrease in the number of applicants for psychoanalytic training. The positions vacated by psychoanalysts and psychodynamically trained psychiatrists in departments of psychiatry have been replaced by biologically trained psychiatrists for teaching and research. The question, then, is: Do we need to find candidates from other disciplines in order to keep our institutes active and to provide pychoanalysts for the future? This question is addressed only indirectly and implicitly in the various proposals to train nonmedical candidates.
The core issue of the debate is whether, in spite of the declining influence of psychoanalysis in psychiatric education, there is value in maintaining that a degree in medicine and residency training in psychiatry is the most important requirement for admission to training in our institutes, and, secondly, whether the American Psychoanalytic Association is to continue its identity as a medical association.
A medical education has particular merit in the preparation of a psychoanalyst. The tradition and discipline of
the training as a physician who takes responsibility for the life of the patient has no parallel in the training of other disciplines. Such training has a psychological effect on the identity of the physician, and also is part of the expectation in the prospective patient which has a profound effect on the transference processes.
Training in medical sciences makes a significant contribution to the future psychoanalyst. These provide insights into the physiological processes related to anxiety, to psychophysiological reactions, and to stress. The clinical years of training provide access to patients of all economic classes and ethnic groups from which one can gain sociological and anthropological knowledge. Finally, the clinical experience of a psychiatric residency is invaluable and cannot be duplicated. In the hospital, as resident, the psychiatrist observes a range of psychological disorders, of the disruption of family life by the development of a major psychiatric disorder. Inpatient and outpatient experience should provide important information about diagnosis, etiology, psychopathology, and socioeconomic factors in psychiatric disorders. Such experience is invaluable in the education of a psychoanalyst.
Not everyone agrees with this argument, of course. We have received the benefit of significant contributions in our field by exceptional psychologists who have not had medical education. These have been exceptional people, and the mechanism for inviting and receiving the contributions of such exceptionally gifted scholars is still available to us without change in our admission procedures. This fact, in my opinion, does not alter the significant value of medical education for the talented psychoanalyst as clinician, therapist, and teacher.
Many members of our Association do not work full-time in psychoanalytic practice. Some teach in medical schools, engage in general psychiatric practice including psychotherapy, crisis intervention, group and family therapy, admission and treatment of patients for short-term hospital treatment, and so forth. For these colleagues, identification as psychiatrist in the medical community is as important as identity as psychoanalyst. I will not discuss here the difficulties of the different roles. For many, it is a necessity of life; for some, it may be choice. The respect these members receive as psychiatrists and the role that many of them have played in the larger organization of the American Psychiatric Association have been an enormous advantage to the American Psychoanalytic and its members. The APA in various of its committees has assisted our small organization socially, politically, and economically. Through the APA our small number has a much larger voice on many issues of significance to us—like confidentiality, for example, or negotiation with insurance companies. The assistance is not one-sided, however. We have articulate, intelligent, aggressive members who have been willing to devote enormous energies in the committees and council of the APA, which has been of benefit to both of our organizations. Our influence has extended beyond our numerical representation in the APA.
The tradition and the discipline of the training of a physician who takes responsibility for the life of the patient has no parallel in the training of other disciplines. Such training has a psychological effect on the identity of the physician, and is part of the expectation which has a profound effect on the transference …
Many of our members feel that if we change our admission procedures to train nonmedical candidates we will damage the thread that supports our respect in the psychiatric and medical community. There have been and will continue to be elements that are suspicious and hostile to psychoanalytic concepts in some medical centers. We have a singular contribution to make to medical education. Wherever our members can participate in medical schools, in departments of psychiatry or medicine on the undergraduate level, or in the teaching of residents on the graduate level, we can and will stimulate interest in psychoanalysis. Some of these students will seek training in our institutes, if we can demonstrate that the training is important enough to make such a big commitment worthwhile. We will not attract as many students as we did twenty years ago but, while small in number, the discipline of psychoanalysis as a significant subspecialty in psychiatric medicine will continue to survive.
In the discussion at the Board on Professional Standards in April, it was pointed out that there are difficulties in evaluating the training of a Ph.D. psychologist applicant, in contrast to an M.D. Further, there are great problems regarding the providing of adequate clinical training for a nonphysician candidate; still further evaluation of the progress of nonmedical candidates would tax the capacities of the Board. These may not be insurmountable difficulties, but I think it should be stated explicitly that the presentation of the alternative models for nonmedical training that were reported in the last Newsletter implicitly convey the existence of these problems.