In a somewhat unanticipated change from the uncertain and divided attitudes expressed in San Diego last Spring, both Board and Council responded warmly and, ultimately, overwhelmingly approved the Gaskill, Gilliland, and Krent report on the acceptance of nonmedical candidates for training in institutes affiliated with the American.
The report was presented at the recent Denver meeting. It was acclaimed by Fellows and Councilors alike as lucid, elegant, forceful, measured, and concise. It proposes that the Board on Professional Standards create a national waiver committee to review institute-selected applicants from fields other than medicine, in order to approve their admission for full clinical training. In Executive Council, where the most strenuous arguments against nonmedical training had been heard in the past, the vote for approval was unanimous.
The report establishes that the purpose of this waiver committee would be to provide a means to evaluate the professional and personal qualifications of nonmedical candidates. The argument is that the prerequisite of medical-psychiatric education has built into it a screening which assures us of clinically excellent preanalytic training—that familiar high standards of educational and professional experience and socialization into a caretaking professional identity have been met. The waiver committee would provide an alternative means to assure that nonmedical applicants have similar qualifications—comparable clinically excellent educational and professional experience necessary in the background of a psychoanalytic trainee.
The widening of the prerequisites would be on the basis of potential for clinical excellence as analytic practitioners. The institutes would, as they now do for every applicant, be responsible to evaluate the personal character, motivation, integrity, and psychological mindedness of the applicant.
The report asserts that in general we would expect that if nonmedical applicants have achieved a professional identity as human caretakers through therapeutic clinical activities of proven excellence, many will likely have gained recognition as teachers, supervisors, and/or authors of scholarly publications, as many of our medical applicants have done.
Matriculation of the institute-selected applicant is to be delayed until such time as the national waiver committee has acted favorably, after which the training and the career goal of this individual would be identical to his/her medically trained colleague, allowing for full integration within the institute program.
High standards of excellence will assure that the numbers of such candidates will not alter the current character and ambience of the Association. Finally, the report emphasizes the importance of gradual rather than abrupt change in regard to implementing this proposal.
In the lengthy and active discussions that ensued in both Board and Council, it was stressed that the Gaskill report represents the fruition of a long history of attempts by the American to deal with the significant issue of lay analysis, and that it succinctly distills the best thinking on the topic stemming from the work of four committees and ten years of extensive effort.
Similarities to one of the three models proposed in the 1984 Spruiell report were noted by several discussants. That report, tabled in San Diego, was followed by the appointment in December of the Gaskill team, charged with arriving at a proposal that might be acceptable to the Board, the Council, and, ultimately, to the membership at large.
Many significant issues emerged along the way to affirmation of the proposal, and the Gaskill committee was instructed to incorporate this thinking in its final version to be presented to the institutes by September. Then, following institute-level discussions, the proposal will be brought to Board and Council again in December, and, finally, pending approval, be submitted as a referendum to be voted upon by the membership in January, 1986.
A significant benefit of this proposal is that owing to its utilization of a waiver procedure, no bylaws change regarding medical training as a prerequisite is required, thereby retaining the American Psychoanalytic Association's essential attachment to both medicine and psychiatry. Furthermore, the fact that no bylaw change is required obviates the necessity of obtaining a two-thirds majority vote of the membership for ratification of the proposal.
The fact is that no vote of the membership is necessary, as there is precedent for the Board on Professional Standards to initiate a waiver procedure on its own, exemplified by the waiver procedures of the Committee on Research and Special Training (CORST), as well as other waiver practices of the Board, such as the geographic rule training analyst (GRTA). However, it was the spirit of the Board that the proposal would not be implemented without a significant vote of approval by the membership.
A heated debate revolved around the issue of whether these new candidates would be perceived as second-class citizens. Does the establishment of a waiver procedure on a national level confront these individuals with an additional assessment of their capacities to which medical applicants are not subjected, thereby establishing a double standard,
a two-tiered candidate status? The argument that the committee intends a single standard —a background of education, training, and professional activities resulting in a potential for clinical excellence was persuasive to the great majority. The waiver review procedure would assure that nonmedical applicants had appropriate experience and training in the same way that medical schools and psychiatric residencies assure that standard for those with medical backgrounds.
Some feared the legal ramifications of the waiver procedure. They wondered if it was legal to bypass the bylaws and its two-thirds requirement considering the medical prerequisite is so basic to the identity of our organization. Additionally, some wondered if it might not be viewed as a response to pending lawsuits and threats of lawsuits against the American and its affiliate institutes.
This latter allegation was vehemently denied by the leadership, who asserted that the committee was appointed prior to serious threats and, in any case, was instructed to consider only what was right and good for the profession, rather than to consider issues of legality, economics, or expediency. Nevertheless, the question was raised: Does the proposal not place us in a more vulnerable position by an unstated agreement with those who are suing us?
Another important concern was maintaining psychoanalytic ties to medicine. The question of numbers was raised. On the one hand, balancing candidate classes and not overweighting them with nonmedical individuals is important to many. On the other hand, the concept of quotas was felt by almost all as necessary to avoid, as both impractical and immoral. Many expressed the view that the standard of excellence to be applied to all applicants would keep the numbers of nonmedical candidates manageable; not so many truly qualified individuals as some might fear will be interested in pursuing psychoanalytic training.
Some pointed out that should the proposal be implemented, the American would have to take responsibility for educating people who are not trained to make multiple diagnoses or to make appropriate referrals, as a psychiatrist can. This merely emphasizes, others thought, the need for the waiver committee, whose functions will include educating the affiliate institutes in the selection and training of appropriate nonmedical candidates.
On the other hand, it was also emphasized that gradually many of the functions of the waiver committee may be assumed by the individual institutes, thereby alleviating the concern of some that the institutes' autonomy might be threatened.
The relationship of the new proposed category of candidate to the research candidate was discussed. It was stated that the proposed category would clarify the research candidate's status, whose background of scholarship and research, and whose career goal of applying psychoanalysis to that research, is clearly distinct from the nonmedically trained individual whose background is clinical and whose career goal would remain so. Thus, the allegation that the research track can and has been misused as a back door to clinical practice will be effectively addressed if the Gaskill proposal is implemented.
One suggestion made by several members of both Board and Council was that the commitment to gradualism be emphasized by limiting, at the beginning, acceptance of nonmedical candidates to those who hold a Ph.D. in psychology. Others favored the wider latitude allowed by being able to consider an applicant from any field whose education, experience, and character satisfied our criteria for the potential for clinical analytic excellence.
Finally, as a part of the enthusiastic endorsement of this proposal, the Fellows of the Board and the Councilors were encouraged to exercise a leadership role in educating the members of their respective institutes as to the issues involved in this complicated and important matter. Almost all were convinced that, if all members were fully informed, they would be sufficiently persuaded to endorse the Gaskill proposal. To this end, it was determined that not only would the proposal itself be distributed to the membership and the institutes, but also that detailed summaries of the Board and Council discussions would be forwarded as well.