The recent vote of the membership of the American Psychoanalytic Association to permit its affiliated institutes to admit psychologists to clinical training, without further recourse to a waiver process, is a landmark event in the history of psychoanalysis. Presumably this change means that in the future psychologists will be able to play an equal role with their medical colleagues in all aspects of their participation in their local societies and within the APsaA. In light of these truly extraordinary and welcome developments the question can be asked, “What more do psychologists want?”
It would appear, on the face of it, that everything we as a discipline have strived to accomplish during the past several decades—and most pointedly in the past ten years—has been achieved. Psychologists can now be trained, if qualified, freely in institutes of the American Psychoanalytic Association or in institutes that they have begun to develop on their own in several metropolitan areas in this country. These free-standing institutes are now able to recruit faculty from the societies of the APsaA without those who choose to teach feeling that they will be ostracized for working with us. Moreover, independent non-medical institutes can apply directly to the International Psychoanalytical Association without being required to be members of the APsaA.
A number of complex factors were involved in shaping these developments. Foremost among these, from the perspective of psychologists, was the filing of the antitrust lawsuit against the APsaA and the IPA. The simple act of filing the suit emboldened psychologists not only to seek training through institutes of the APsaA but also to establish programs of their own in areas were none had existed. Moreover, it brought the question of training psychologists to the center of attention of the APsaA, where otherwise it might not have been. Clearly, the increasing turn of psychiatry back toward “biology” in the past decade or two, alongside a decreasing interest in psychoanalysis among psychiatric residents, was an additional factor that made movement toward opening training fully to psychologists likely, if not necessary. Training institutes that are unable to offer classes for one or several years, or whose classes are reduced to two or three candidates when they do run, are obviously placed in a position—if they are to survive—of rethinking their pool of candidates. Although some of my medical colleagues have asserted that the APsaA was headed in this direction anyway, I believe the lawsuit and the increasing paucity of highly qualified medical candidates played an important role in forcing a change. These “coercive” factors aside, I am aware that there were always voices in the APsaA that recognized the obvious clinical competence of psychologists and knew that they were at least as prepared intellectually and clinically to undertake full psychoanalytic training as were medical candidates. However, I doubt that these voices would have prevailed at this point in time—even though they may have represented the “silent” majority—had the “coercive” factors not been operative.
A clear assessment of all the elements that have led to these changes awaits whatever historians may choose to interest themselves in them. The question remains, however, is there anything more that psychologists want? Obviously, a great deal has been achieved and there is no question that many psychologists feel that we have accomplished exactly what we wanted, perhaps even more than we had hoped—assuming, of course, that these changes are implemented fairly and objectively. Given our experience, we have learned that it is wise to not leap to the conclusion that problems are resolved until several years of monitoring justifies such a conclusion. In any case, I think it correct to say that some in our Division feel that we have what we want and that there is nothing more to ask for.
Nevertheless, although I cannot speak for all psychologists, I think there are some other things that at least some psychologists want. These have to do both with the APsaA itself and with fundamental issues at stake in psychoanalysis today. On the most immediate level, I believe some psychologists would want to be assured that if any independent, freestanding institutes with which they might be involved wish to apply for accreditation by the APsaA—a not unlikely event within the next few years, in my estimation—they will be fairly evaluated on substantive educational grounds. This does not imply any change in fundamental standards. Rather, it would be important to know that arbitrary, ritualized, or educationally insubstantial issues will not be raised if an otherwise well-qualified institute were to seek accreditation. Such an institute should not be disqualified because it did not develop through the “normal” study group process under the tutelage of the APsaA (which, of course, it could not, precisely because it was non-medical), and its training analysts should be judged on the basis of their experience and depth of knowledge, not automatically rejected because they did not have their analyses with training analysts of the APsaA (which they could not, again, as a result of the prior exclusion of non-medical analysts). These are the sort of “catch 22” situations some previously excluded institutes are currently facing in seeking affiliation with the IPA. So when in future an independent institute applies for accreditation, we want to know that it will be evaluated in terms of educationally relevant criteria. Educational programs, including psychoanalytic ones, should not be evaluated on the basis of spurious standards, such as tracing one's “analytic genealogy” (the virtually episcopal process instituted by the IPA in evaluating some of the free-standing North American institutes, to see if it can be determined that one's training analyst had in turn been analyzed by a “kosher” training analyst). A fair process to examine applications from independent institutes to the APsaA—based on truly substantive educational criteria—is something most psychologists, I believe, would want.
At the same time that some psychologists would want to insure fair evaluations, should their institutes wish to affiliate with the American Psychoanalytic Association, some psychologists, myself included, would like to see the separation of psychoanalytic scientific societies from practitioners guilds. In our view, the restriction of full membership in a scientific society to practitioners—who are trained in a professional school climate which places a premium on the learning of a received clinical wisdom—is not necessarily in the best interests of the development of that science. A genuinely scientific organization should welcome into its ranks thinkers from all points of view, who may bring an expertise and sensibility very different from that of the practicing clinician. And it should welcome the kind of controversy over fundamental issues that, most unfortunately, has not been characteristic of psychoanalytic organizations—precisely, I believe, because they have been too caught up with trying to control and regulate what is thought and practiced, to the detriment of the growth and vitality of their science.
Finally, I think what some psychologists might want is related to what may well be the inevitable outcome of the increasing number of non-medical candidates in the APsaA and the possible inclusion of non-medical societies—namely, the evolution of the APsaA away from a predominantly “medical” identity. The issue
here is how psychoanalysis itself is understood. I believe that psychoanalysis is enriched by the participation in its thinking and practice of professionals and scientists from several disciplines, including medicine and psychology (in fact, some psychologists would want their clinical social work colleagues welcomed equally, without the waiver ritual, and without the obviously magical reliance upon a doctoral degree, which in social work is usually a research degree insuring no greater clinical expertise than independent clinical licensure at the masters level). However, as long as psychoanalysis is thought of as a subspecialty of psychiatry, or as part of the field of medicine—which other clinicians may be allowed to practice with appropriate training—a bias is introduced into our understanding of what is fundamental to the psychoanalytic process as well as to psychoanalytic education. That bias affects our educational stance and our work with patients in a way which some psychologists and other analysts, including medical ones, believe is not to the ultimate benefit of the field.
In my view a “medical model” of education and practice clearly has benefits (as well as liabilities) for medicine and for medical education. Such a model emphasizes the passing on of clinical wisdom accumulated through the experience of one's teachers, diagnostic precision as a crucial aid to the treatment process, and the importance of precise, objective technical interventions and strategies that clearly relate both to one's diagnostic assessment and one's understanding of the etiology of the disease process. Such an approach has proven over time to be an effective way of thinking about bodily illness and treatment (although increasingly physicians are questioning the usefulness of a model of scientific precision that does not hold up in actual practice). In any event, a stance of first acquiring clinical wisdom before one questions the received knowledge is essential if one is to function adequately in emergent situations where decisiveness and clarify of purpose are at a premium.
In my view, however, it is debatable whether such a stance is useful in understanding the psychoanalytic process. Some psychologists would want this debate to be kept open. The substance of the issue is the degree to which these aspects of the medical model (i.e., the assumption of objectivity, diagnostic acuity, and technical precision) and the wish to apply it to the psychoanalytic situation creates a culture of presumed knowledge, and presumed technical clarify, that accords neither with the scientific level to which our field has attained nor with what at least some consider the most useful stance to take with patients. Put simply, this sort of model inevitably pushes toward a “one person” view of the psychoanalytic process, in which a presumably neutral, objective, outside observer applies a certain perspective, technical skill, and treatment to the individual being observed. In practice, I believe, most psychoanalysts, medical and non-medical, work much more implicitly in a “two person” scheme: very collaboratively with their patients and with a profound sense of the difficulties, ambiguities, and uncertainties inherent in this work. Some even welcome the uncertainty, the lack of clarity and objectivity, as inherent to what can be productive in the work. Nevertheless, as long as we retain assumptions derived from an overly medicalized view of what we think we ought to know and how we ought to stand vis-a-vis our patients, we will be unable to incorporate what we do in practice into a more sophisticated, less technicalized way of thinking about what is truly at stake.
I realize that these thoughts are very debatable and will certainly not be subscribed to by everyone, medically trained or not. Indeed, many psychologists, especially nonanalytic ones, subscribe to the same wished-for precision in diagnosis and treatment that is this version of the medical model. It is an extraordinarily tempting stance—were it only true. But whether one subscribes to some version of the medical model or to some version of the ideas I have alluded to regarding the nature of the psychoanalytic process, I think at least some psychologists would want the debate kept open and not too quickly resolved. It is important that in opening itself to psychologists, American psychoanalysis, as represented by the American Psychoanalytic Association, not try to resolve its anxiety by simply recruiting them into a preexisting medical perspective on the work. Psychologists will—and should—bring a different point of view that will eventually call into question the most fundamental assumptions in psychoanalysis. In my view, a truly vital discipline could wish for nothing more.