We are faced with a serious issue—whether or not our psychoanalytic institutes should offer formal training in psychoanalytic psychotherapy to nonanalytic candidates. I want to speak against our doing so.
Many psychoanalysts are concerned by the large cutbacks in teaching time that dynamic psychiatry (and the teaching of psychotherapies) has suffered in psychiatric residency training programs. I, for one, have even feared that the teaching of psychodynamic therapies to psychiatric residents and graduate psychiatrists might eventually be left solely to our analytic institutes. While there has been some redress of these cutbacks, there is still much cause for concern. I think this problem has fueled interest in some of our institutes' faculties to bring some psychotherapy teaching into our institutes.
Also contributing to this issue is that the “widening scope” of psychoanalysis has brought with it patient-appropriate modifications in analytic technique, led to identifying such techniques as psychoanalytic psychotherapy, and raised the assumption that one can teach such modified analytic techniques to clinicians not in analytic training. There is, I believe, a large problem with this assumption.
My opposing the teaching of therapies other than psychoanalysis is not one of unyielding opposition, but rather of serious concern. Can we do it satisfactorily? If we can, should we? And if we can and should, are we ready to do so?
I will not, by the way, address the question of teaching psychoanalytic psychotherapy to analytic candidates, except to state that I doubt that they need special training for psychoanalytic psychotherapy. The requirements of the Board on Professional Standards make for training that is long and taxing. This training should ordinarily make it possible for the clinician to eventually learn to introduce variations of psychoanalytic technique where needed; these may be in the form of parameters or of psychoanalytic psychotherapy where an analysis-near experience is warranted and feasible. On the other hand, I believe that seminars in comparative analytic psychotherapies can be useful and clarifying, and that these can accelerate the development of expertise.
Can and should we teach psychoanalytic psychotherapy to nonanalytic candidates? This question has been considered at length within the American Psychoanalytic Association. For example,
both the Board on Professional Standards (BOPS) and the Committee on Child and Adolescent Analysis (COCAA) have recently devoted much time to it, and some of my remarks will draw on these discussions.
I am among those who find that distinguishing psychoanalysis from psychoanalytic psychotherapy is a complex problem in the adult therapies, and this is even more so with child therapies. All psychotherapists assume a distinction between psychoanalysis and other psychotherapies, but this distinction is insufficiently conceptualized and not satisfactorily committed to paper. Where such efforts have been made, there is significant disagreement. Nonetheless, I believe that despite our in-house disagreements, we analysts can and should put forth well-enough conceptualized differences between psychoanalysis and psychoanalytic psychotherapy before considering to undertake to teach the latter to nonanalysts.
Even if we had clearly conceptualized formulations of these therapies, I think that most therapists not trained in clinical psychoanalysis (the analysis of the transference neurosis) will not be able to competently distinguish between psychoanalysis and psychoanalytic psychotherapy. For example, I heard one professional trained in dynamic psychotherapy say that to psychoanalyze her patient she need only increase the frequency of visits from two times a week to four. Such misunderstanding is not uncommon. This person had undergone nearly two years of training in a program taught by one of our institutes.
But even if nonanalytic trainees had well defined conceptualizations of such things it would not remedy what I believe to be the major obstacle to teaching such therapy to nonanalytic clinicians. My foremost concern is this: I find it difficult to believe that a psychotherapist who has not undergone a personal analysis and been trained in the conduct of analyzing the transference can actually carry out psychoanalytic psychotherapy. Psychoanalytic psychotherapy is an application of psychoanalysis which arose out of its “widening scope.” To me, this means that such a therapy must ride on the experience and analysis of the transference. This being so, nonanalytic clinicians will generally not be able to carry it out satisfactorily.
Recently, a well trained mental health professional, several years in practice, wanted supervision with a borderline psychotherapy case. Because this person was past training, and was not currently in a postgraduate training program, I agreed to do so. The problems arising out of the intense transference experience and the clinician's difficulty in dealing with them were large. This is common, in my experience. If I am mistaken in my understanding, and analytic psychotherapy does not ride on the analysis of the transference, then why call it “analytic” and why should our institutes teach it?”
If the time comes that psychotherapies are no longer taught in psychiatric and other clinical programs, then the question of our institutes' undertaking that kind of training can be brought up. But this would be the separate question of whether to teach psychotherapy to our own analytic candidates.
It is not my intention to promote notions of an exclusive elite of psychoanalysts. What I am emphasizing is that one cannot know certain phenomena without fully experiencing them. When it comes to knowing how to analyze transference, having no training in doing so becomes an insurmountable obstacle. I remain skeptical that professionals who have not consciously experienced being a transference object in a deep sense and analyzed their patients' experiencing him or her as such will have sufficiently acquired the ability to appreciate the rigors and technique of analyzing the transference.
Let me add this. Carrying out psychoanalytic psychotherapy where it is most often currently done, with borderline patients, brings with it significant transference difficulty. Indeed, the transference in borderline patients tends to be more intense and difficult to work with than with neurotic patients. Could such a treatment, then, be taught to professionals who have no experience conducting the comparatively less complex analyses of neurotics?
If we agree to train nonanalytic clinicians to surmount this obstacle and include a personal analysis and supervise their analyzing the transference, why not bring them into the full analytic training program? If we feel they do not qualify by capability to become psychoanalysts, do they qualify to carry out analytic psychotherapy? And if the answer is that the American Psychoanalytic Association does not allow us to train these clinicians, then the question must follow: Is this a way of getting around the American's training standards and what will it do to our profession?
Assuming that the reader disagrees with the insurmountable obstacle I have noted, and believes there is a way to train such nonanalytic clinicians, what image will these trainees have of themselves? Will they experience, convey, and perhaps even assert that they are psychoanalysts?
Distinguishing analytic from nonanalytic candidates trained in our institutes would be feasible within the institute walls. But outside those walls at least two problems might emerge which might cause our institutes, our Association, and psychoanalysis itself to suffer. First, patients or referral sources might not be sufficiently informed of these distinctions and of their meanings. Second, because they were trained in an analytic institute, some of these trainees might be tempted to misrepresent themselves as psychoanalysts. After all, it is prestigious to be a psychoanalyst, even in these days of backlash against it. It is even more prestigious to be one trained in an institute of the American.
Another concern shared by many colleagues is that the promise of bringing more cases to analysis by those trained in our institutes' psychotherapy programs has generally not materialized. Yet another concern regarding this issue is whether such added training might drain institute faculties of energy and time needed to maintain high caliber analytic training. Of course, different institutes would feel the burden differently, with the large ones faring better than the small. But the burden on the already overworked executive and education committees of even the larger institutes would be increased by such additional responsibilities.
In summary, in regard to training nonanalytic candidates in psychoanalytic psychotherapy, if I am correct in defining psychoanalytic psychotherapy as a therapy that rides on analyzing the transference, I doubt that we can do it satisfactorily. If we do not want to breach the standards of the American, I think we should not do it. Given these thoughts, I think we need to talk more before we undertake such programs in our Institutes.
Despite the conservative tone of my commentary (a tone which I believe does not prevail in major aspects of my work), I think caution on this matter, at this date, is warranted.