The history of the Committee on Non-Medical Clinical Training begins with the history of psychoanalysis. In the earliest days, candidates for psychoanalytic training were self-selected. About the only qualification needed was motivation. The training consisted primarily of a personal analysis and supervision, for, as Freud noted, “this technique cannot…be learnt from books…it is to be learnt from those who are already proficient in it.” This meant that for Americans to learn psychoanalysis they had to travel to Europe to learn from Freud or his early colleagues.
Europe, in the meantime, had been facing the problem of “wild analysis,” the idiosyncratic application of psychoanalytic ideas by untrained practitioners. A concern not only for the rights of patients treated by these individuals, but also for the scientific integrity of psychoanalysis, led to formation of the International Psychoanalytical Association in 1910, membership in which distinguished trained from untrained practitioners. However, wild analysis continued, and in 1918 Europeans and Americans took divergent approaches to the problem. The Europeans set up training institutes, while their American colleagues restricted eligibility, ruling that only individuals who had completed medical school and a psychiatric residency could travel abroad to learn psychoanalysis and return to practice and teach. As institutes were established in America, the same rule was then applied to persons coming to them in search of training. Rightly or wrongly, this arbitrary decision was made on the basis of a recent standardization of medical education across the country. Training in psychology and social work had not yet undergone an equivalent process. The early analysts believed that standardization of prior training would insure that the highest standards were maintained in the psychoanalysis practiced in America.
And so began a bitter struggle, particularly as nonmedical psychoanalytic leaders in Europe immigrated to the U.S. only to find themselves ineligible to join the psychoanalytic movement. Some concession was made in 1957, with the establishment of the Committee on Research and Special Training (CORST), whereupon it became possible for certain individuals, either strategically well placed in their communities, or because they had an established reputation in research, to gain access to psychoanalytic clinical training. Still, training remained generally unavailable to nonmedical clinicians.
By the mid-seventies, support had grown within The American regarding the training of nonmedical clinicians, and a series of committees—a total of four over a ten-year period—met to study the possibilities. But progress was slow and opposition high. In December 1984, following a failed proposal at the previous meeting, Edward Joseph and Homer Curtis (then president of The American and chair of BOPS, respectively) appointed Herbert Gaskill, Justin Krent, and Robert Gilliland as a Special Advisory Committee. Chaired by Gaskill, the committee was to review the work of its predecessor committees and prepare a statement to reopen the discussion. In the meantime, three psychologists filed an antitrust suit against The American, adding a sense of urgency to the search for a viable way of offering training to nonmedical clinicians. By October 1985 the report was completed. It contained the proposal that a special waiver of the medical education requirement be granted, in individual cases, to institutes wishing to offer full psychoanalytic training to gifted and experienced nonmedical clinicians. The proposal, supported by both BOPS and the Executive Council at the December meetings, was then put to a vote of active members. By February 1986 the “Gaskill proposal” had been overwhelmingly ratified by a two-thirds majority. Following this, Shelly Orgel, who had succeeded Curtis as chair of BOPS, appointed Gaskill, Krent, and Gilliland, along with Gerald Adler, Stephan Levitan, Phyllis Tyson, Dale Boesky, and Stanley Goodman, to the newly formed Committee on Non-Medical Clinical Training (CNMCT), with Carl Davis as chair. The committee met for the first time in May 1986 and again at a special meeting held in September.
The first task facing CNMCT was to identify categories of individuals without medical training who would be appropriate for selection by institutes. The second task was to forge a set of procedures for institutes to follow in applying for the waiver. By December 1986 the committee had concluded that individuals holding the highest clinical degree in their field, and who had demonstrated excellence in clinical work, could be considered. In addition, the committee had in place a preliminary set of procedures, however flawed, for institutes to follow. In the first round of applications, 24 requests for waivers were received, and at the May meeting Davis recommended that BOPS grant waivers to 11 institutes to enroll a total of 18 individuals in full analytic training.
What quickly became apparent to CNMCT was the vast discrepancy among the assessment procedures used by the institutes, and the vast differences in what they required in the way of documentation from their interviewers. Institute procedures ranged anywhere from as few as two interviewers, one interview each, with a brief one-paragraph report, to as many as six interviewers conducting three or more interviews each and submitting an extensive and comprehensive report. In addition, in some institutes a thorough discussion of the findings was undertaken; other institutes made decisions by a simple vote of the Education Committee on having read the reports of the interviewers. In still other institutes, no matter how much discussion went on, the final “decision” appeared to amount to a rubber-stamping of the wishes of the most powerful members, or the decision was in fact made by a small, never changing, never challenged group.
Needless to say, the discrepancy among applications led to confusion and disagreement among members of CNMCT. Although recognizing the important career implications for the individual on behalf of whom the waiver was requested, and the pain that deferral would induce, in both the individual and the institute, members were troubled by the incompleteness of certain applications, or by applications that presented contradictory information with no clues as to how the contradictions were resolved. This state of affairs often made it difficult for the committee to recommend waivers, and when they were not granted, tension grew between BOPS and the local institutes. The continuing lawsuit added to the tension.
Meanwhile, the chair of CNMCT rotated; in December 1988, after three ground-breaking years, Carl Davis stepped down and John
MacLeod took over. Hailing from an old Scottish clan known over the centuries for their skills as Highland warriors, MacLeod moved quickly to unify the committee. Recognizing that CNMCT had by now gained considerable experience in processing waiver applications, he attempted to distill from that experience a more objective and explicit description of the types of documentation found most helpful and necessary in gaining a comprehensive view both of an applicant and of the institute's processing of the application. Unfortunately, in asking for this documentation, and using its adequacy in evaluating applications, CNMCT only exacerbated tensions, which began to grow also between BOPS and CNMCT. Both BOPS and the institutes began to suspect CNMCT of using the documentation to create and uphold a “national standard of excellence,” thereby compromising institute autonomy and second-guessing the institutes' evaluation of their applicants. CNMCT came to be viewed by some as obstructing the very process it was created to facilitate.
By this time the committee had processed 101 waiver applications and approved 77, a figure in excess of 75%. CNMCT considered this proof of its commitment both to the spirit of the Gaskill proposal and to exercising the oversight function that document mandated. Nonetheless, it did not seem to instill confidence in CNMCT, as certain institutes were quite upset at having their applications turned down. The ensuing debate led to a sense that there was overlapping authority and responsibility between the institutes and CNMCT, particularly in the areas of suitability and the evaluation and documentation of clinical aptitude. Finally, in December 1989, the issue was resolved by the passing of the Ross amendment to the Gaskill proposal, which more clearly defined suitability and eligibility. The amendment determined that local institutes would be responsible for determining suitability and clinical aptitude, whereas CNMCT would be responsible for determining educational eligibility. In addition, CNMCT was to monitor the evaluation process of the institutes by determining that documentation was complete.
The next major change came a year later. The membership approved a bylaw amendment extending eligibility for full clinical training to all individuals holding a Ph.D. or Psy.D. in clinical psychology, a doctorate in mental health, or a Ph.D. or D.S.W. in social work. This historic step, effectively reversing a policy that had been in effect since 1918, was taken a scant five years after institution of the waiver program. Never before had change come so quickly within The American.
Adoption of the amendment was followed by significant changes in the functioning of CNMCT, and in August 1991 Phyllis Tyson was appointed chair. Passage of the amendment decreased the enormous volume of applications to be processed,
while continuation of the waiver option provided a mechanism whereby gifted clinicians from a variety of educational backgrounds could qualify for psychoanalytic training. In order to identify such individuals and come to a consensus about their eligibility, however, CNMCT had to find a different way of working with the institutes. The committee wished to avoid, to the fullest extent possible, the tensions and hurt feelings of the past. It wished also to avoid the imposition of laborious efforts on institutes preparing applications, long deliberations by CNMCT itself, and the disappointments and antagonisms arising in the event of unfavorable outcomes. Working more closely with institutes to ensure that applicants are eligible and ready for psychoanalytic training at the time of the waiver application, and that applications are complete, became a priority.
To that end, CNMCT has initiated a liaison system. Each institute has been assigned a committee member who is available (as is the chair) for direct consultation at any time during the application process. Many institutes now routinely telephone their liaison member to discuss eligibility before the individual is fully evaluated locally. If the individual is not yet eligible, various ways are discussed in which eligibility might be achieved. In those rare cases in which an individual seems clearly not eligible, even potentially, that opinion is discussed. Through this process, disappointments are avoided, and the success of the waiver program assured. Already it has shown good results. At the May 1993 meeting, for the first time ever, all applicants were recommended for waivers, a trend that continued in December.
A review of CNMCT statistics shows the progress that has been made. Since 1986, 188 waiver applications have been processed, of which 45 were initially deferred. Of those with deferred applications, 30 were later granted waivers, and one became eligible without waiver. Most of these deferrals occurred in the early days of CNMCT, when it was struggling to find a fair and objective process and institutes were struggling to ascertain the criteria for suitable and eligible candidates. To date, 26 institutes have participated in the nonmedical clinical option and are training waivered candidates. Fifty candidates at 20 institutes are currently participating in psychoanalytic training who have master's level degrees (mostly the M.S.W.).
According to information currently available, at least 23 waivered individuals have already graduated. In addition to practicing clinical psychoanalysis, many of these graduates are teaching in medical schools or advanced university programs, some are on the faculty of their local institutes, and some are serving on committees at the local or national level. One is already certified.
Of great concern at the time of the Gaskill proposal was the effect this group of nonmedical clinicians might have on The American and the institutes. However, a recent survey indicates that institutes have for the most part perceived the training of nonmedical candidates as an enriching experience. Generally, once classes begin, individuals become known on the basis of their individual talents; differences due to educational background quickly fade. While the medical ambience in some institutes and in The American has begun to shift, the changes are seen mostly as positive, allaying the fears of those originally skeptical about the training of nonmedical candidates.
Although most are encouraged by these statistics and changes, others are distressed. They fear that the high standards of The American are not being maintained, and that waivers are too freely dispensed. Master's level candidates (mostly M.S.W.s) seem to arouse the greatest concern. Whether this concern is based more on old stereotypes than on firsthand knowledge of the current situation in the social work profession is hard to say.
In any case, CNMCT has begun to work more closely with the Committee on Psychoanalysis of the National Federation of Societies for Clinical Social Work. This group was particularly disappointed in being omitted from the category of clinical specialties for which a waiver is no longer necessary. The CNMCT chair and officers of Board and Council have met regularly for the past two years with senior leaders of this group to share and discuss mutual concerns. Far from the old stereotype of welfare workers, this is a dedicated group of highly trained and sophisticated clinicians specializing in the study and practice of psychoanalytically oriented clinical work. Many have been trained as psychoanalysts, mostly in institutes not affiliated with The American, and they practice as such. In the course of these contacts, the delegation from The American has familiarized itself with the American Board of Examiners and its accreditation procedures for granting the Board Certified Diplomate (BCD), a credential that guarantees a certain level of clinical immersion, maturity, and expertise. The Federation hopes that in the not so distant future social workers with a B.C.D. will be eligible for
psychoanalytic training without a waiver. Of social workers already accepted for training by The American, over 60% hold the B.C.D., and most of the remainder are Board-eligible.
From work with the Federation and with member institutes, CNMCT concludes that statistics do not reflect any lowering of standards consequent to the training of nonmedical candidates, including those with degrees at the master's level. CNMCT concludes also that when institutes apply for a waiver, they are reasonably assured, from firsthand contact with the individual and conscientious assessment thereafter, that the applicant is both suitable and eligible for psychoanalytic training. They then stand behind their assessment and do whatever is necessary to obtain the waiver.
Members of CNMCT feel that these statistics reflect positive changes in the course of its development as a committee. In the early days, when the waiver process was still largely unformulated, both CNMCT and the institutes were groping to find workable methods of evaluation. Mistakes were made, sometimes communication broke down, and a lack of trust developed. For the most part, that has been turned around. By working more closely with institutes, CNMCT has come to feel that standards are being maintained at the local level, and that a greater feeling of mutual trust is growing between institutes and the committee.
The future of CNMCT is of great concern to many. Some institutes are of the opinion that the sooner they have local autonomy with regard to eligibility, the better, and that a national committee to oversee the work of local admissions committees is no longer necessary. They feel it is time The American prepared to hand over to institutes the entire task of selecting candidates, and to place the task of maintaining standards in the hands of the educational process within each institute. Other institutes are of the opposite opinion, that eligibility criteria should not be broadened and that BOPS should continue to exercise an oversight function. This is not the first, nor will it be the last, issue over which institutes distrust one another's judgment. With the range of opinion so wide, however, it seems that now is not the time to consider the dismantling of CNMCT.
Nonetheless, the committee has begun to consider other ways in which to make a useful contribution. While consultation with institutes before and during the preparation of waiver applications, facilitation of waivers to qualified individuals, and consultation with institutes during the education of wavered candidates will remain priorities, there is a need also for outreach and for research. CNMCT is looking for ways of helping institutes reach out to groups in their communities in order to attract eligible or potentially eligible candidates. In addition, selection procedures will be examined to determine how best to identify psychoanalytic potential and to better define what it is that makes a good analyst. Is it prior education, prior clinical experience, education during psychoanalytic training, one's personal analysis, supervision of control cases, or psychoanalytic clinical immersion after graduation? These are questions CNMCT will be considering as it shifts more and more to a role of study and facilitation.
In the meantime, CNMCT remains dedicated to the principle that given the present professional climate, with all the difficulties facing the field, all persons with a sincere desire to study psychoanalysis, who are willing to make the commitment and personal sacrifices this entails, should be seriously considered and judged according to their individual merits.