A generation ago, graduates of psychoanalytic institutes did not feel that developing an identity as a psychoanalyst was a problem. After completing training, young analysts were accepted into a professional group of colleagues who had a definite sense of their professional identity. They might practice in different settings; some few did research or went into academia. For others, there were potential analytic patients on the waiting lists of clinics and institutes. In recent years, changes in the field of psychiatry and in the composition of the group of trainees have made consolidating a professional identity as a psychoanalyst much less clear and more uncertain.
The Committee on Associate and Affiliate Members has devoted considerable effort to issues of interest and importance to candidates, recent graduates, and younger members of The American. It has developed a number of programs to meet these concerns.
An increasingly prominent problem was the difficulty candidates had finding suitable control cases for supervised analysis. As this problem became recognized, the Committee sponsored a workshop to which members from institutes across the country were invited to describe and assess the extent of the problem. The workshop confirmed that the problem was widespread. As an outgrowth of the workshop, a survey was conducted among the 26 institutes of The American.
In the fall of 1984, a questionnaire was mailed to all the institutes, and responses were tabulated in June 1985 to determine how long candidates have to wait for control cases. Results were analyzed and presented at the Scientific Meeting in Montreal. This study was spearheaded by Marvin Wasserman, who analyzed the data with David Jimerson. There was considerable agreement that the problem of finding control cases was almost universal.
Three separate analyses of the data were made. The first analyzed the 27 sets of responses as a single group; the second divided the institutes into the 13 largest and the 13 smallest and compared them in a number of ways; the third divided the institutes into the 11 with the longest waiting times for the first case and the 11 with the shortest waiting times for the first case. The mean total time spent by candidates waiting for their first three cases is 63 weeks following approval. Many candidates actually wait longer because they have more than one case in each category. The waiting times can be even longer if an individual candidate's waiting time is longer than the mean. This questionnaire did not distinguish between delays caused by unavailability of patients and delays caused by candidates' special needs. Nevertheless, the impression from the responses is that the great majority of delays were the result of the unavailability of patients.
There was a statistically significant relationship between institutes that had short waiting times for the first case and both the size of the institute and the number of patients they evaluated per year. Institutes with shorter mean waiting times for the first case had more candidates and evaluated more patients than did those with a long wait.
These data suggest that, at least in some instances, a “critical mass mean phenomenon” may exist, and an institute's ability to attract more patient applicants depends partially on its having a sufficient number of people associated with it to create a large enough network of contacts in the community at large. Such a network would maximize the possibility of tapping into the pool of suitable training cases in a given community.
A second factor important in the length of time candidates wait was the institute's role in finding cases for advanced candidates. It appears that the wait for the first and second cases is shorter than that for the third and subsequent cases. Our impression was that the institutes frequently take a more active role in finding first and second cases than in the later ones.
The third finding related to the fees charged by candidates. There was an inverse relation between the institute size and the lower end of the range of fees charged for all training cases. That is, the candidates in larger institutes would see patients for lower fees. This difference was statistically significant for the third and fourth cases, with fees for the third case considerably lower for the large institutes than the small institutes. These findings may reflect a need or willingness of candidates in the larger institutes to accept patients at lower fees to expedite their training. There are also important regional differences in fees. In certain institutes, candidates charge higher fees than in others.
There was no meaningful difference between the long- and short-wait institutes in relation to whether the institute permitted the candidates to convert patients from psychotherapy to psychoanalysis. Both long- and short-wait institutes permitted candidates to convert patients from psychotherapy to psychoanalysis. More institutes with the long wait advertised than did those with short waits, perhaps because of the former's awareness of the problem.
It appears from these findings that local circumstances at an institute may be as relevant to the amount of time candidates spend waiting for the cases as is the national trend. It is hoped that these findings will stimulate institutes to reevaluate their procedures for assisting candidates in finding control cases and to implement changes when they are appropriate.
The workshop that was originally convened to learn about the problems concerning control cases continued as an active forum for candidates and younger members from across the country to meet and discuss issues of practice, share methods for developing and consolidating a practice, and share views on other problems.
These concerns, namely ones of professional identity, developing a practice, the character of psychoanalytic work and how it fits into other aspects of the professional career, also form the subject of an ongoing discussion group in the scientific program at each semiannual meeting of The American. Titled “Becoming a Psychoanalyst in the 80s” (and now “Becoming a Psychoanalyst in the 90s”), the program is chaired by Eric Gann and has as a guest at each meeting a senior analyst who provides a resource and opportunity for younger members to interact with an older colleague. Guests have included Leo Rangell, Charles Brenner, Sam Ritvo, Theodore Shapiro, Robert Wallerstein, and Selma Kramer. The discussion groups have been well attended and evidence the participants' interest and their wish for a context to feel connected to one another and to The American.
Dr. Notman is a Clinical Professor of Psychiatry at Harvard University and is a Training and Supervising Analyst at Boston Psychoanalytic Institute.
Another part of the scientific program sponsored by the Committee is the Psychoanalytic Forum. This was originally designed to provide an opportunity for a senior psychoanalyst to present and to interact in a discussion with younger members. This forum has taken place during the meetings on Thursday afternoons at a time in the scientific program that does not compete with other major presentations and precedes the Thursday discussion groups. It has been very well attended both by Association and Affiliate members and others and has prompted lively discussion. In addition to exploring and representing the interests of Associate and Affiliate members, the Committee has involved members in the activities of The American by appointment to committees, participation in scientific programs, and indirectly by communication and personal contact; for example, the Psychoanalytic Forum has been chaired each time by a member of the Committee.
The younger members of The American feel the need for a professional organization to represent them and to help provide a psychoanalytic presence in their communities, particularly those that are not in large cities where there are many analysts. There is often a gap between the local institute and The American, and The American appears as a distant and often mysterious organization. The Committee on Associate and Affiliate Members is a source of communication within the American Psychoanalytic Association. This function is in some ways analogous to the activities of CAPE, the candidates' organization, which has been more or less active over the years. Since the Committee operates within The American, however, there are informal contacts with other elements of the organization and the opportunity for invaluable participation and sharing of ideas. The Committee has also worked with the officers of The American to develop communication with candidates at the points of entry and graduation.