Wednesday, May 14, 1997, marked a historic moment in the history of the American Psychoanalytic Association. At the annual meeting in San Diego, the Board on Professional Standards ratified a COPAP proposal for a revised approach to selecting candidates for psychoanalytic education and clinical training. (For more on this subject, see “BOPS Accepts COPAP Recommendation to Reduce Waiver Criteria,” page 6, and “Revised Selection Criteria Reflect New Awareness of Psychoanalytic Qualifications,” page 8.)
The new proposal delineated The American's principles of candidate suitability, outlined a more objective yet universally applicable approach to eligibility, and extended eligibility categories. All categories of clinically trained mental health professionals at the doctoral level will be eligible to apply. In addition, mental health professionals who have completed the highest masters level clinical degree generally recognized in their field, as well as at least two further years of didactic education and clinical training, will be eligible to apply.
This extension calls for a change in the by-laws of the Association, since by-laws stipulate eligibility categories. Once approved by the Executive Council, the proposed bylaw change will be sent to all certified members for approval. We are optimistic that our members will agree with BOPS that the time has come to extend eligibility categories.
If the certified membership approves the by-law change, it means greater autonomy for institutes with regard to selection. Those institutes wishing to do so could select candidates from larger categories of mental health professionals. This extended autonomy would at the same time challenge institutes with greater responsibility, for they would be almost entirely responsible for maintaining standards within the candidate body — BOPS would relinquish more of its oversight function.
An understanding of the history of selection enables one to fully appreciate the magnitude of this achievement.
In the earliest days of psychoanalysis, candidates for psychoanalytic training were self-selected. About the only qualification needed was motivation. Training consisted primarily of a personal analysis and supervision. Americans traveled to Europe to learn from Freud or his early colleagues. It was not long, however, before “wild analysis” (the idiosyncratic application of psychoanalytic ideas by untrained practitioners) became a problem. Concern for the rights of patients and the scientific integrity of psychoanalysis led to the formation of the International Psychoanalytic Association in 1910. Membership in the IPA distinguished a trained psychoanalyst from an untrained practitioner. Nevertheless, “wild analysis” continued, and in 1918 Europeans and Americans took divergent approaches to the problem.
The Europeans organized training institutes so that the special training necessary for the practice of psychoanalysis could be made more available and more standardized. The Americans restricted eligibility, maintaining that a medical understanding of mental disease was essential to the practice of clinical psychoanalysis. Thus only individuals who had completed medical school and a psychiatric residency were eligible to travel abroad to learn psychoanalysis. As institutes were established in America, the same rule was applied to persons seeking training at the institutes.
Freud did not agree with restricting training to psychiatrists. From as early as 1913 until the end of his life, he held strongly that psychoanalysis should not be regarded as purely a concern of the medical profession. This divergence was the subject of serious debate, and in 1927 a series of position statements from 28 analysts from various countries was published.
Reading the position statements is humbling, for many of the points made over the last ten years in favor of or against extending categories of eligibility repeat the arguments of 1927. The arguments are well known — fear of lowering standards; fear that the medical identity of the profession would be lost (and thus that an M.D. would be less likely to apply for training); conviction that a knowledge of human physiology, anatomy, and pathology are essential in order to fully understand mental symptomology; conviction that the rigor of medical education provides invaluable mental training to integrate complex questions and complex data.
In the 1927 review of position statements, two important points were made that were not subsequently developed in any systematic manner. The first addressed preparedness. Muller-Braunschweig, among others, pointed out that “the true significance of the question of so-called ‘lay analysis’ can be appreciated only when it is considered as part of the more comprehensive question, What is the most suitable preparation and training for the prospective analyst?”‘ He thought that while medicine may provide a certain knowledge base and instruction in disciplined thought, other subjects were also important. An introspective psychological attitude needed to be cultivated.
The Hungarian Society reframed the issue:
The center of gravity of medical studies lies in anatomy and physiology, that of psycho-analysis in psychological subjects; a qualified physician is therefore scarcely better fitted for psycho-analysis than an educated layman. The unessential question appears to us to have displaced the essential. The kernel of this question is: How are analysts, whether medical or lay, to be trained?
The society recommend that if anything were to be regulated it should be training, not eligibility, and selection should be made on the basis of personal suitability. The society felt that curriculum development should be emphasized, with attention given to both the individual needs of physicians and non-physicians and the subject matter of psychoanalysis (which would be identical for both groups).
This emphasis on curriculum was more in accord with Freud's sentiments. He maintained that the important question was not whether an analyst possessed a medical diploma but whether he had had the special training necessary for the practice of analysis. Freud also recognized that denying access to training inadvertently increased rather than decreased the risk of illegitimate and unscrupulous use of psychoanalytic ideas and risked injury to both patients and the “good name of analysis.”
Phyllis Tyson chairs the Committee on Preparedness and Progress. Sources for quotations and historical information in this article can be obtained from the author.
“If it is impossible to prevent the lay analysts from pursuing their activities and if the public does not support the campaign against them,” Freud asked, “would it not be more expedient to recognize the fact of their existence by offering them opportunities for training? Might it not be possible in this way to gain some influence over them? And, if they were offered as an inducement the possibility of receiving the approval of the medical profession and of being invited to co-operate, might they not have some interest in raising their own ethical and intellectual level?”
Finally, in a somewhat whimsical yet challenging statement, Freud wrote,
Our civilization imposes an almost intolerable pressure on us, and it calls for a corrective. Is it too fantastic to expect that psycho-analysis in spite of its difficulties may be destined to the task of preparing mankind for such a corrective? Perhaps once more an American may hit on the idea of spending a little money to get the ‘social workers’ of his country trained analytically and to tum them into a band of helpers for combating the neuroses of civilization. ‘Aha! a new kind of Salvation Army!’ Why not? … One thing I do know. It is by no means so important what decision you give on the question of lay analysis…. But the things that really matter — the possibilities in psycho-analysis for internal development — can never be affected by regulations and prohibitions.
The decision of the American Psychoanalytic Association to restrict eligibility remained steadfast despite this extensive debate. This policy became a matter of some concern for the IPA, but because of the intervention of Anna Freud, consideration of disciplinary measures was postponed — indefinitely, as-it turned out, as World War II brought IPA activities to a halt. Maintaining standards in the practice of psychoanalysis continued to be an issue of concern, and the selection debate re-emerged within The American in the late 1950s. Many were convinced that excellence in the practice of psychoanalysis could be guaranteed only so long as high selection standards were maintained. These debates served to reinforce the conviction that restricting training to psychiatrists guaranteed at least some standardization and quality of background.
As the debate continued, access to psychoanalytic clinical training through any member institute of The American remained unavailable to non-medical clinicians, although in 1958 access to training became available to researchers or those in influential political or community positions. But the world of psychotherapy and psychoanalysis was changing, and pressure grew to find a feasible avenue whereby well qualified non-medical clinicians could gain access to quality psychoanalytic training. Finally, in 1985, the Gaskill proposal was agreed upon, providing for a waiver of some of the requirements. It also provided a mechanism for gradual change within The American.
In May 1986, the Committee on NonMedical Training was created and met for the first time. This new committee was charged with the task of developing criteria and a procedure for a waiver process. The going was rough in the early years, as the CNMCT tried to find a feasible process, evaluate applications (some of which were more than 200 pages long in the early years), and find ways of working with institutes and with BOPS. A second CNMCT charge was to study the progress of accepted candidates and the impact of this new category of candidates on institutes. This second mission led eventually to CNMCT's being renamed the Committee on Preparedness and Progress.
As a result of the pioneering work of CNMCT/COPAP, a large number of well qualified and talented individuals have been selected· and are in the process of (or have completed) full psychoanalytic education and clinical training. Some of these graduates are well regarded members of institute faculties, some have become child or adult supervisors, and some are on the way to becoming training analysts.
A very important finding emerged as a result of the Gaskill process. COPAP gradually became aware that academic degree does not indicate psychoanalytic aptitude. Academic credentials are no longer reliable or sufficient indicators of theoretical knowledge, of a foundation of clinical experience, nor of a readiness to begin psychoanalytic education and clinical training. Furthermore, success in psychoanalytic training cannot be predicted on the basis of education, degree category, or years of clinical experience. It also became apparent that as medical education changes and alternative educational routes are sought, The American must no longer rely on prior education and other educational institutions to ensure the maintenance of standards. The only way to ensure high standards of clinical psychoanalysis among members of The American is to maintain high standards of psychoanalytic education.
This realization led COPAP to propose a different philosophical approach to the selection of candidates. While mental health degree categories remain an important part of an applicant's background, much more must be taken into consideration. This philosophical position is captured in the first paragraph of the current proposal:
A fundamental requirement for psychoanalytic education and clinical training is an established identity as a professional whose principles of ethical conduct mandate a firm, enduring, and uncompromising commitment to patient responsibility and a genuine concern for the welfare and optimal mental health of every patient seen. Selection for psychoanalytic education and clinical training is based on an evaluation of the total person. Strength of character, integrity, personal attributes and weaknesses, and evidence of ethical conduct provide indications of the applicant's suitability. The nature and extent of prior education, clinical training, clinical immersion, clinical aptitude, maturation within the profession, and potential for psychoanalytic competence determine eligibility and readiness to begin psychoanalytic education and clinical training.
It is this change in philosophy that is so exciting and monumental about the acceptance of the proposal in San Diego, and we are optimistic that the certified members will ratify the proposed by-law change.
With the burden of waiver application evaluation somewhat lifted, COPAP could take on more of a consultant role. It could also turn its attention toward psychoanalytic education and curriculum development. We look forward to developing more effective liaisons with member institutes and, in the process, learning more about the special needs of all candidate groups.