The time has come,” the Walrus said,
”to talk of many things:
of shoes—and ships—and sealing wax—
of cabbages—and kings—
and why the sea is boiling hot—
and whether pigs have wings.”
The time has come, not to reprise recent goings-on in The American, as I have done in this column for several issues now, but to air some tensions that disturb many of our members. These tensions date back as far as the association's founding in 1911, when it was decided that only those holding M.D. degrees could enter training in accredited institutes, and that only their graduates were eligible to become members. Almost all psychoanalysts were members also of the American Psychiatric Association, and a significant number were certified in psychiatry by the American Board of Psychiatry and Neurology.
From the 1940s to the early 1970s, psychoanalysis strengthened its position both with the general public and with related professions. Medical schools sought out psychoanalytically trained psychiatrists to chair their departments of psychiatry, and invited analysts to join their faculties. Psychosomatic medicine was of particular interest in these departments.
Unfortunately, the influence of psychoanalysis began to ebb in the 1970s, a trend that continues to the present. Today few analysts head departments of psychiatry, and rarely are they appointed directors of education. In many medical schools, residents in psychiatry receive almost no instruction in psychoanalytic ideas or their therapeutic application. Instead, a major shift toward neuroscience finds departments of psychiatry headed by physicians with reputations earned in academic research.
Curiously, while the physician analyst has largely been eclipsed in the world of academic medicine, a reverse trend has developed in university departments of psychology, at both the undergraduate and postgraduate level. In addition, schools of social work have expanded their curricula to include courses in clinical psychoanalysis and psychoanalytic therapy.
Thus, even as medical interest in psychoanalysis flags, psychologists and social workers are embracing it enthusiastically as a science of the mind and a major therapeutic tool. Increasingly, they are developing analytic curricula in their training facilities, and regularly schedule scientific meetings that are impressive and scholarly. At present there are four societies in the United States (each with an affiliate training institute) consisting predominantly of psychologists and social workers with Ph.D. or Sci.D. degrees. These societies, two in New York and two in California, have been granted recognition by the IPA as provisional or fully accredited component societies and among them can boast at least three hundred members.
Several years ago, considerable pressure was brought to bear on The American—particularly by Division 39 of the American Psychological Association—to open our institutes to psychologists with doctoral degrees and to establish their parity with M.D. applicants. Division 39 and three psychologists brought a lawsuit against The American, despite a growing consensus among members that psychologists be admitted for full training on a parity with physicians. Although patience and mutual respect might eventually have accomplished the same results, there is no question that the lawsuit accelerated the necessary change in the bylaws.
An unfortunate side effect of the lawsuit is that since then other organizations and individuals have for various reasons, threatened legal action involving The American. For instance, a group of psychoanalytic organizations has insisted that the frequency of training analysis sessions can legitimately be reduced to three times weekly from the required four, and that recognition by the IPA should be accorded institutes following that practice. Were they to bring a suit, IPA component institutes would have to bear the expense of mounting a defense. Since The American, through its dues, underwrites at least a third of the cost of running the International, any additional financial burden the latter assumes would weigh heavily on us. However, if we can move away from the legal aspect of the training analysis question, I see no objection to engaging in serious dialogue and study regarding the issue. Matters of this kind should be settled collegially rather than by nonscholarly confrontation.
As we live in litigious times, however, we must take a serious look at the legal issues that confront us. The American acts not only as a sort of ombudsman to its component societies and institutes, but also as a “regulator.” We accredit institutes and certify our members; we set up standards for the admission of candidates to training, for training curricula, and for graduation; and we approve the appointment of faculty and of training and supervising analysts in the institutes. The American also sets standards for clinical practice and ethical conduct. These “regulatory” functions always involve a degree of liability. For instance, lawsuits have been brought by persons who have been refused admission to an accredited institute of The American, or who for various reasons have not graduated. Questions arise here as to the responsibility and liability of the national body for actions taken at the local level. (For that matter, whenever an institute or individual member is sued, for whatever reason, questions arise as to the liability of the national body.) Although the institutes have insisted upon autonomy in matters of curriculum, admission of candidates, and graduation, areas of tension will always exist between the local level and the national body regarding accrediting procedures and the certification process, tensions exacerbated by the requirement that faculty appointments and the selection of training and supervising analysts must be formally approved by BOPS. However, these inevitable tensions may be regarded as a “creative dialectic” and must be tolerated in any case.
During the formative years of The American, it was necessary to maintain close ties between local groups and the national body in order to prevent “wild analysis,” both to protect patients and to differentiate psychoanalysis from less intensive forms of therapy. It was in that context that the Board on Professional Standards assumed the important role it plays today.
Over the past twenty years or so, an apparent decline in the number of patients seeking classical psychoanalytic treatment has been matched by an increase in the numbers and kinds of mental health professionals offering psychoanalytic psychotherapy. Already a number of our institutes are providing courses in psychotherapy to non-physicians below the doctoral level. This gives rise to the question of whether institutes should develop a complete curriculum for psychotherapy, in addition to their programs for psychoanalysis. If so, should criteria be established for the admission of candidates in psychoanalytic psychotherapy? Another issue involves the establishment of standards of practice for psychotherapy.
Frequency of visits, use of the couch or not, use of medications concurrently, considerations of transference-countertransference in psychotherapy vs. psychoanalysis—these are all questions to be considered.
The effects of this “new culture” in psychoanalytic therapy must be carefully addressed, especially in light of the impending health care reforms. Since the expanded class of mental health providers includes not only physicians and Ph.D. psychologists, but persons holding masters degrees and perhaps other credentials, the issue of “external credentialing” takes on new importance. Several years ago a joint committee of Board and Council was created to examine this question, and we have continued to support its work. Donald Burnham, who originally chaired the committee, conducted surveys of Board and Council committees, and received overwhelming support for pursuing an external credentialing body that would both accredit institutes and certify individuals. The current task of this committee, which is now chaired by Allan Rosenblatt, is to explore ways of establishing a body independent of The American that would accredit institutes and certify individuals regardless of affiliation. This body, which would not replace BOPS, would offer our members recourse to a respected body outside The American in the event that third-party payers (insurance companies or government agencies) require credentialing from an agency that is not also the training body.
Hoping that we can continue to deal creatively with the tensions I have discussed, I look forward to seeing all of my colleagues at the December meetings—and please attend the business meeting, where we will discuss some very crucial issues.