In December, the Board and Council continued to deliberate the issue of external credentialing. The Board Committee on External Credentialing, chaired by Gerald Margolis, submitted a comprehensive and sophisticated report that contained much new information and new levels of analysis. Among the most salient new areas of information that were contained in this report are:
The realistic feasibility of modifying the Board on Professional Standards to enable The American, based on its experience of accreditation, to attain external credentialing within an approximately two year time frame. The committee suggested that this may be a possibility for providing public recognition of psychoanalysis as a respected profession among other professions. Such recognition may be important for the future of the profession not only for the American but for psychoanalysis in general.
The lengthy path and uncertain outcome of an effort to pursue external credentialing with the Psychoanalytic Consortium organizations (estimated at over ten years);
The complexities of the structure and divisions within other Consortium organizations quite aside from their differences in standards from The American;
The possibility of exploring alliances with the Independent Psychoanalytic Societies (the non-APsaA United States IPA institutes whose educational processes are very close to ours);
The complexity, and perhaps impracticality of obtaining student loans as part of the external credentialing.
The information from the Board committee suggests fresh possibilities for the futures of our members, our organization, and our profession. Obtaining recognition by CORPA (Committee on Recognition of Post-secondary Accreditation), and perhaps DOE (Department of Education), of The American's accreditation functions may be important to our survival, and may be a turning point in our efforts to restore respect and prestige for psychoanalysis.
Our accreditation processes are a unique achievement. They firmly establish that a central basis for being considered a competent psychoanalyst is the achievement of a set of educational requirements and goals whose rationale and outcome we are constantly evaluating, revising and testing. Such ongoing self-scrutiny is our best guarantee to patients and the public of the quality of our graduates. This protection of the public welfare is what makes The American's accreditation processes attractive to CORPA and DOE. Recognition of our accreditation by these agencies will be of great value to patients searching for quality treatment and to an expanding governmental and private provider network.
External credentialling has been discussed predominantly on the basis of the peripheral issues rather than the central issue: the core functions of education and accreditation which protect the public welfare by developing well-trained psychoanalytic practitioners who meet high standards of clinical competence. I do not mean by this that peripheral is unimportant — it is important to make sure that NAAP does not achieve legitimacy; it is important to maintain alliances with colleagues; it is important to obtain loan money for students.
The American has chosen accreditation of institutes as a central organizational instrument in the process of providing quality psychoanalytic education. We accredit via a process of peer review and collegial consultation because of its essential value to our candidates and their education and to assure of the highest level of patient care. We must consider the value of accreditation within our Association and the potential to lose the form and spirit of what we have achieved.
At the last Board meeting, David Carlson, the outgoing chair of the Committee on New Training Facilities spoke eloquently about our unique accreditation activities. I quote at length from his extremely relevant remarks. “The early years of accreditation were often stormy ones as BOPS and its committees struggled to define their procedures around a unifying concept of standards; and the hurt feelings and resentments from struggles of those years still surface in some of The American's debates…. [At this time] site visits, though still an ordeal for those who must organize them, have become seen as the collegial, facilitative events that they can be…. Years of working together around the Board's minimum standards gradually produced consensus on their implementation in the concrete procedural aspects of analysis, in the role of training analysis and supervision, and in the general extent of necessary curriculum; and has resulted in shared standards around which a wide variety of institute structures adapted to local circumstances and philosophies can adhere to our national program. Until a generation of analytic educators shared that set of standards and recognized a range of interpretation of those standards the sources of fights and misunderstandings were many, and the Board's attempts to help the development of psychoanalytic training were often seen as intrusive and even as authoritarian.
From the perspective of CNTF, each new facility's staff can be seen to struggle with a complex series of issues in developing policies that suit changing needs. CNTF advises on what has been helpful or destructive elsewhere and is always intent on helping the new facility and its sponsor institute take those actions that will facilitate productive development and move toward independence of the new facility. What from one perspective is an accrediting process is from another an attention to administrative practices that can facilitate or retard growth.
For instance, the study of new facilities whose growth has stalemated has sometimes revealed that the original facility was launched by a handshake deal between leaders of the sponsoring accredited institute and one or two analysts locating in the new area. In such circumstances, unless the new facility has matured very rapidly, a new generation of leadership in the sponsor institute will tend to feel burdened by sponsorship and uncertain about the quality of the new facility, and members of the new facility will feel looked down upon and blocked by the sponsor. From this kind of experience we have learned that agreements between two organizations must from the very beginning be broadly based: the whole membership of both sponsor and
new facility must be invested in the process and be fully alert to the demands the arrangement may make on them in years to come. Similarly a whole range of predictable questions can be faced and agreed on in advance, including how expenses will be underwritten, the participation of new facility staff in the teaching of the sponsor, the times of joint classes, procedures for faculty appointment, etc.
“We have learned that clarity at the beginning of a sponsoring agreement, explicitly spelled out terms, and widely shared knowledge of the arrangement and support for it are the best guarantee of new facility development, and that much of the grumbling about the ”standards“ of one party or another that we used to hear can be obviated by openness and ensuring broad support before launching any venture. In fact, when there are complaints about standards it is common to find that the issue is really one of administrative procedures that have been unclear or have been skirted.”
As a former chair of COI, I know how difficult it is for an institute and COI to make a site visit into a productive and constructive experience. Our accreditation processes have become facilitative, and collegial peer review processes in which the authoritarian application of rules has been replaced by careful discussion and reflection. These processes are a learning experience not only for the institutes but for the members of the site-visit committee who can apply their experience to their own institutes.
What does it mean to have effective and truly useful site visits? Generally, external accrediting agencies gravitate to check lists that regulations has been met. Those of us who are familiar with JCAH or residency site visits are aware that they involve chart checks, verifications that one or another regulation has been met. Since educational achievement (graduation) as a prerequisite for membership and professional certification would not be the purpose of a Consortium-related Board such an outcome is more likely. What may happen, is that standards qua numbers and requirements could become rigidified, i.e., “higher”, whereas evaluations based on a deep understandings of analytic education will be lost, quality will go down while “standards” go up. The entire history of the Board, as the accrediting arm of The American, has been to move away from such “standards” to a principle based approach. This is nowhere more evident than in the subtlety and complexity of our site visiting processes.
The most likely outcome of the Consortium-Board option is that our internal accreditation would either end or become a shell of itself. Pressures on our current accreditation processes will arise from the fact that the new institutes (non-American Psychoanalytic) that might be accredited by a consortium-related accreditation board would still have to develop their own educational requirements and procedures which could be at significant variance from ours. The new board itself would also have to develop its own accreditation processes and philosophy in order to accommodate the wide range of educational procedures that such a diverse group of institutes would have.
The degree of energy, dedication and self sacrifice shown by the Fellows and members who perform site visiting accreditation work will be profoundly affected by a vote of their own Association to put external credentialing entirely in the hands of a Consortium-Board. Such a vote is an either or choice.
It is our processes of self-scrutiny that are impressive to agencies like CORPA and DOE which are concerned about the protection of students, patients and the public. They see our standards of education as an expression of a guarantee of protection. Dr. Dorothy Fenwick [the Executive Director of CORPA] emphasized “the higher standards the better” when she met with our representatives, and explained that this is because “we are dealing with peoples' health.”
Some do not agree that there is reason to be concerned about the maintenance of our accreditation procedures. The report of the then Joint Ad Hoc Committee on External Credentialing, in December, 1995, stated: “any proposed Consortium developed accrediting body will not replace our in-house accrediting, but will be in addition to it, an option that our component institutes may choose to pursue.”
In my view, this is not realistic.
Whether or not such an optional choice of accreditation by a Consortium-related Board is possible depends on the requirements of CORPA and DOE. The BOPS Committee reports that any new accreditation board would have to develop its own separate experience and record of site visiting and cannot “piggyback” on the previous experience of one of its components. This opens the definite possibility that our institutes would have to endure cycling repeatedly through two site visits, coordinating two views of institute development that might not be totally consonant. If seeking recognition from this Consortium-related Board would be “optional” for institutes, such a board would not achieve bringing meaningful order to the profession. Under such a scenario the public would not gain the quality assurance that our accreditation now offers nor would the profession gain the respected, independent status that it could if we sought recognition alone.
Since graduation from accredited institutes would not be a condition for designation as a psychoanalyst nor be a requirement for membership in some of the Consortium organizations, the nature of the accreditation relationship between institute and membership organization for such a Board would be essentially different from ours. For The American, a defined and rigorous psychoanalytic education built upon prior professional education and training is a necessary requirement for designation as a psychoanalyst. For other Consortium organizations, e.g. Division 39, a doctoral education alone suffices, not graduation from a psychoanalytic institute. Even in the uncertain scenario of BOPS conducting site visits for The American's institutes, the accreditation activity of BOPS would be under the aegis of a Consortium-related Board which would not have as its central purpose the accreditation of institutes for the sole purpose of certifying that only graduates of such institutes would qualify as psychoanalysts. After all, the public is interested not in where we graduated from but whether we are “board certified” or credentialled.
The report of the Board Committee on External Credentialing addressed the issue of establishing an external credentialing board with the Consortium which proposes to create an external authority that will accredit the same institutes that the BOPS currently accredits in an ongoing manner in this way: “The Ad Hoc BOPS Committee on External Credentialing is concerned that the effort to maintain the consistency of our rich history of quality accreditation procedures may be so disrupted by the decision now to pursue recognition of accreditation authority exclusively through the Consortium that the quality accreditation program we would need ten years or more down the road might no longer exist. In such a scenario …our application to CORPA and DOE would be jeopardized, leaving our
[graduate] psychoanalysts with a weakened option to seek external recognition of our accreditation methods…. Over the course of the approximately ten years required for the Consortium board to become accredited, The American and its institutes will possibly be burdened by site visiting from two accrediting bodies, accrediting according to differing requirements, each submitting site visit reports whose recommendations may differ on salient points. The scope of this burden will include the expenditure of financial, administrative, and emotional resources attendant to the sensitive nature of the site visiting experience.“
Thus, to enter into an agreement without full exploration, understanding and evaluation of the complexities and problems of uniting organizations with such disparate structures and educational requirements would be tantamount to entering on the basis of a “handshake” agreement, not broadly based within all the Consortium organizations. Given the potential advantages to the profession and to our members of attaining external credentialling now via BOPS, this would entail a needless threat to the futures of our members and our profession.
Without educational quality that can gain and maintain the respect of professional colleagues and the public at large, it is not likely that the profession can be viably maintained. As the Board report says, “CORPA's ethos is consumer oriented in a broadly societal way: they are vitally concerned about health and public safety… CORPA's recognition of an accrediting body for psychoanalytic educational programs will further the process of establishing respected independent status for psychoanalytic education and psychoanalytic professional practice. This is an increasingly important endeavor, because psychoanalysis cannot continue to rely on the umbrella of a related specialty to provide this educational and professional status and respect.”
Those who advocate a credentialling alliance with the Consortium, emphasize that this will bring order to psychoanalysis, as the Flexner report brought order to medicine. I do not believe this would actually occur. One reason is that some organizations of the Consortium adamantly refuse to allow the IPS to join the Consortium. There is much reason to believe that the IPS would apply for, and be successful in attaining, independent status as a credentialling board! Thus, there would be two boards, just as there would be if there was an APsaA-IPS alliance, and a second alliance between the Consortium. Joining with the Consortium organizations would not simplify the landscape.
According to the report there is much potential for confusion and complexity in working out arrangements with organizations that have radically different viewpoints than ours. It reports that the largest other Consortium organization, Division 39, does not have an integrated position about what a psychoanalyst is. Division 39 is composed of around 4,000 members, only around 500 have training from a psychoanalytic institute of any kind. Members of Division 39 are eligible to be “diplomated” in psychoanalysis by entering an examination process that does not presuppose graduation from a psychoanalytic institute or specific standards of frequency. Some of the members of Division 39 can qualify for Section 1 that does have educational and practice standards. Presumably, some of the members of Division 39 will ultimately be graduates of any future “Division 39 institutes” but these graduates would not necessarily be the same group as the diplomates or even members of Section 1.
Furthermore all the other Consortium organizations have explicitly indicated that they have no interest in the development of external accreditation of institutes as the basis for the development of an external board to credential graduates. External credentialing of graduates is the basis for the American considering external accreditation of institutes.
No other Consortium organization is officially associated with psychoanalytic education institutes which it accredits and graduation from which institutes is required for designation of its members as psychoanalysts. Nor is this interlinking the goal of a Consortium-related Board. The central purpose of our accreditation is to ensure that graduate psychoanalysts have received rigorous psychoanalytical education before being designated a psychoanalyst. That would not be central purpose of a Consortium Board. In fact, it is even unclear such a Board would actually represent the organizations of the Consortium.
All of the above questions are thorny, complex and time-consuming issues that would have to be struggled with internally and externally with the other organizations before application to CORPA can be made. In contrast our current accreditation processes are in place and appear to face a relatively uncomplicated course over a minimal period and appear to have a likely positive outcome.
One of the options considered in the Board report is for The American to apply for recognition by CORPA and DOE at this time and simultaneously work with the other Consortium members to establish their own accreditation board. This option, suggested by CORPA, allows the possibility that these two boards might enter joint or cooperative activities at some future point. Another advantage of this approach is that it would allow all of the Consortium members to continue to work together on other issues of mutual concern. This option might allow the Consortium members room to focus more energy on public education, lobbying, and other endeavors which naturally bring us together rather than drive us apart, and in the process, to get to know each other better and develop better working relationships.
Much of my thinking has derived from the report of the BOPS Committee on External Credentialling. I recommend this excellent report to your attention and study. The issue of external credentialling is one that can vitally affect the futures of our graduates and our future as an organization and as a profession.