As members of the American, we find ourselves confronted by a sweep of changes, many imposed by forces outisde of psychoanalysis, some springing from within, but all sharing implications for the future of our field and of the American. The beginning of nonmedical clinical training by our institutes, slightly more than three years ago, is a notable recent change. The implementation of this program, through the Committee on Non-Medical Clinical Training, was a major topic of review at the December 1989 meeting of the Board.
The program represents a departure from the tradition, which has been followed since 1911 and codified in our bylaws, of limiting psychoanalytic education to medically trained persons with psychiatric backgrounds. The training of nonmedical clinicians is now fully accepted. The Board believes that the admission of qualified medical and nonmedical persons to our institutes is one of the ways the field will be enriched. A high level of national educational standards in all our accredited institutes remains the essential reason that admission to our institutes is valued by the most able and promising clinicians and researchers.
The institutes' selection processes and the educational value of the Association give credence ultimately to graduation, certification, and membership in the American. These credentials yield a number of professional and practical advantages to the members and will assume even greater significance with the proliferation of institutes outside the aegis of the American.
To provide analytic education for those who are not psychiatrists and who wish to be practitioners, the American has appointed some five committees since 1975. The report of the fifth committee to study nonmedical training, the Ad Hoc Advisory Committee to the Executive Committee of the American, known as the Gaskill Proposal, was adopted by the membership of the Association in 1986. Since the by-laws and standards limit analytic training to physicians with psychiatric training, the proposal called for the establishment of a national waiver committee to waive this requirement Acceptance of the Gaskill Proposal by the members necessitated the establishment of new procedures and new responsibilities for institutes wishing to accept nonmedical applicants.
Waivers were to be given to institutes, not to applicants; and institutes were obliged to select for training those persons who had the potential for excellence as analytic practitioners. Such persons should have “achieved identity as human caretakers through therapeutic clinical activities of proven excellence.” The committee was to review applications to determine how institutes applied the assessment procedures. The proposal also directed the committee to study how nonphysicians are integrated into institute educational programs and to offer assistance to institutes wishing to make application for waivers. The drafters stressed, in conclusion, the need to implement the program gradually and noted that standards and principles of the American have evolved over time as part of the Association's heritage.
The charge to the new committee by the BOPS was, in effect, to implement the proposal. The fledgling committee prepared the procedures, explained them to the Board and the institutes, formulated a schedule for the evaluation of many potential applicants, and began recommending waivers for the training of nonphysicians in May 1986. Including those of the December 1989 meeting, the committee has recommended waivers for 115 applications; 22 applications and reapplications have been deferred.
This is an account of a successful enterprise, but there have also been growing pains. Each new committee of the board historically is greeted with some degree of confrontation until an accommodation between the relative autonomy of an institute and the relative authority of a national committee can be achieved. Such debate occurred in the early 1960s, after the inauguration of CORST and again following the formation of CNMCT. These periods of confrontation helped balance the emphasis of the committee's function and assure acceptance of the committee's work.
Lively discussion concerning CNMCT took place at the December 1988 Board meeting and escalated by May 1989. Some institutes expressed concern over the considerable work such applications for waiver entailed. Others viewed the CNMCT evaluations of the applications as an infringement on institute autonomy. A number of Fellows wondered whether different procedures for the assessment of medical and nonmedical applicants might lead to charges of discrimination. Other institutes were satisfied with the procedures and noted that they were equally valuable for assessing traditional medical applicants. One institute, following the May meeting, appealed the CNMCT's action after the committee did not recommend waivers for three of its four applications. The institute cited its concerns about the possibility of legal reprisals.
For all of these reasons, it seemed timely to review the CNMCT process so that the BOPS could discuss the issues more fully in an effort to achieve a wider agreement. The CNMCT reviewed the implementation of the Gaston Proposal twice between the May and December meetings. It also reevaluated all the institute applications that had failed to receive a recommendation for waiver at the May meeting. The committee requested institutes wishing to have their applications reviewed (not all chose to do so) to submit new material supplementing areas of the application that needed clarification. Review of these applications, in turn, facilitated the committee's self-study of its own procedures.
Institutes were invited to send their views. The Executive and Coordinating Committees discussed the issues in October and December, and vigorous discussion took place at the December meeting of the Board.
A surprising degree of concurrence was expressed by the institutes, the CNMCT, the Coordinating Committee, the Executive Committee, and the Board itself. This consensus was crystallized in
the Topeka Proposal, which was adopted by the BOPS.
As a result of the adoption of the Topeka Proposal, the institutes have primary responsibility for assessing the analyzability and the clinical competence of applicants, and the CNMCT monitors eligibility and evaluates the thoroughness and documentation of institute applications. The areas of autonomy of the institutes are more clearly defined than previously.
The Board recognized that some of the primary areas of responsibility of the institutes and of the CNMCT may overlap or may not be readily delineated, but such gray areas in individual situations should be resolved by committee and institute. The CNMCT has in the past furnished consultative help to institutes and will now augment this assistance. The committee, along with the Committee on Institutes, will begin to evaluate the effect of the nonmedical clinical training programs in the institutes, which is one of the stipulations of the Gaskill Proposal. The CNMCT also expects to define more clearly factors to be considered in the determination of eligibility.
At the December 1989 Board meeting, before discussing the legal ramfications of the CNMCT process, Joel Klein, the Association's legal counsel, stated that he did not want to be seen as attempting of influence the Board's course with regard to the future role of the CNMCT. He did want the Fellows to know that he usually refrains from giving legal opinions in open forums, since such a practice does not protect confidentiality. Nevertheless, inasmuch as confusion existed in people's minds about the legal issues, he agreed to share his opinions with the Board.
He stated that the CNMCT proocess is a well-established part of the settlmenet agreement in the recent lawsuit and that it was his opinion that the procedures are not in violation of the agreement. The agreement specifically covers PhD psychologists. Other groups of applicants, therefore, are not governed by the agreement. It was his opinion that legal arguments about discrimination are misguided and ill founded. He said that, to the extent that academic groups are prohibited from discriminating with respect to applications, those prohibitions have to do with gender, race, and religion, and not with academic credentials or background. He stressed that the Association would be well served to debate issues forcefully, intelligently, and on their merits, and not to be concerned with unfounded legal issues.
I believe the deliberations in anticipation of the meeting and at the meeting itself achieved a consensus that will serve the Board and the institutes well. The shared understanding of the principles involved in the implementation of the Gaskill Proposal should foster a better accommodation of both committee and institutes in the CNMCT endeavor. The legal clarifications were helpful and should dispel uneasiness with regard to the process.
What had seemed settled by the time the Wednesday meeting concluded appeared on Thursday at the Executive Council to be in question. An amendment to the by-laws, nullifying the requirement of a medical-psychiatric background, will be discussed at the next Executive Council for possible submission to the membership for ratification. The Coordinating Committee had discussed the feasibility of such an amendment in October and December and concluded that although such an amendment ultimately may be appropriate, passing it at this time would not be advisable. Members of the committee pointed out that the Gaskill Proposal for nonmedical training had been passed by more than the necessary two-thirds vote of the membership, presumably because of its stipulation that the nonmedical clinical program would be monitored by a national committee that would assess the results of such training.
The program has been in effect only a little over three years. We are still learning how to evaluate the academic and clinical preparation of nonmedical applicants, to determine the equivalence to the medical psychiatric background. We also need to determine how our more biologically oriented candidates from psychiatry interact with those from a nonmedical background in our educational program. More thought and discussion of the advisability of amending the by-laws appear to be needed before definitive action is taken.
Martin Stein, Chairman of the Ad Hoc Joint Committee on Membership and Organization, presented the committee's thoughtful report to the Board. The committee agreed on the need for procedural changes in the Committee on Certification, changes that they hoped would lessen some of the adverse reactions that at times accompany deferment Their suggestions were to have been discussed with the Committee on Certification, but at the time of the report this discussion had not yet taken place. The committee members had not achieved a consensus on the linkage of certification and membership but were in the process of discussing the ramifications of such a change.
The BOPS voted to accept the report. Some may have voted to accept in the hope that the committee would be able to make further recommendations on the substantive issues. The next day, the Executive Council voted not to accept the report. Consequently, the committee was relieved of its responsibilities.
The Task Force on Amending Active Membership for Non-Certified Graduates is now exploring ways to separate the certification requirement from membership while at the same time protecting the Board's primary responsibility to foster analytic education with the Association. The separation of membership from certification would cause a major change in the future of the organization and affect both how it functions and how it is perceived. One of the goals of those hoping to separate certification from membership is to encourage more graduates to be involved in the work of the Association. Various approaches to achieving such participation need to be explored.
Justin Krent