During the past two years I have frequently taken the opportunity to post criticism of the certification process on the Open Line as part of a continuing dialogue and debate between members who support the “correct” method of certification and those like myself who feel that it is so extensively flawed that its present form must be either profoundly altered or abandoned entirely. I base my position on the methodology of certification and the unfortunate impact of the past and current procedures. Despite the assertion by those who defend the case report method of certification that it is a positive educational experience, it is my contention that the process as practiced by the Committee on Certification ultimately has a negative impact upon the analyst's ability to think independently and utilize his or her theoretical and personal impressions while conducting psychoanalytic work.
Graduates of our institutes who intend to apply for certification get a sense that the analyses they conduct should be performed with the intention of satisfying the committee's definition of psychoanalysis rather than following their patients' needs. This creates a split between the analyst's role responsiveness in regard to the patient's best interest and the committee's apparent role as protector of psychoanalytic purity. In this role as protector of a definition of what constitutes true or authentic psychoanalytic treatment, the Committee on Certification becomes — unwittingly, if not purposely — a deterrent to the development of theory and technique in the interest of greater therapeutic effectiveness of analytic treatment and experience for both patients and analysts.
The current methodology has nothing to do with protecting patients and insuring the increasing relevance and effectiveness of psychoanalysis. Rather, it aims to make certain that all treatments called psychoanalysis conform to what the committee decides is correctly psychoanalytic. If analysis is viewed as a treatment modality where the process is essentially pre-determined as a series of transference interpretations, and where the analyst's aim is legitimate only if he or she stays within the bounds of interpretations and perspectives agreed by the committee to constitute psychoanalysis, then our ability to contribute to the development of psychoanalysis as an evolving clinical discipline will be severely restricted, if not eliminated.
“Graduates of our institutes who intend to apply for certification get a sense that the analyses they conduct should be performed with the intention of satisfying the committee's definition of psychoanalysis rather than following their patients' needs.”
Under these conditions, psychoanalysis is a set piece in which certain assumptions must be honored by those conducting it. The committee members then elevate their subjectivity regarding the patient over that of the treating psychoanalyst, who may well have deviated from standard or even modified conventional wisdom in the service of actually helping the patient.
Historically, I believe, 50–70 percent of applicants have been rejected initially. [Editor's note: Friedman could not supply TAP with the source for his assertion that there was a historical 50–70 percent first-time failure rate, though he asserts that this number was the one he always heard used. Figures from Singer (see page 11) indicate a 42 percent first-time failure rate consistently between 1991 and 2001.] The Open Line debate has called attention to this fact and may be a crucial factor in the recent increase in percentage of initial passes. More or less all of those who persistently re-apply subsequently pass, after the actual work of analysis has been completed. This means that the applicants have merely reformulated or re-written an already completed treatment to meet the requirements of the committee as they are presented to the rejected applicant, who is now a supplicant to the committee's judgment.
The negative effect of these circumstances is clear. Many applicants simply aren't willing to re-submit because they feel it would be degrading. They feel that it is unacceptable and untrue to agree with their examiners that their own subjectivity about patient and treatment was inaccurate. I have heard many individuals who were turned down on the first round explain that they won't go further with the process of certification for these very reasons. Others proceed with more cynical intention to meet the desired changes requested by the committee.
This has led to courses designed to teach potential applicants how to write up their cases, as well as remedial “tutoring” of those who have failed and need to be taught how to write and say it so that the Committee on Certification will be satisfied. At individual institutes, certain training analysts have been identified as being able to tell the applicant how to write things up so as to sail through the committee process. An atmosphere of uncertainty has been introduced by the refusal of the committee to describe concretely what is an acceptable write up and what fails to meet the criteria. Avoiding humiliation and damage to one's career becomes a motivating force in a procedure for which there is no way to study or prepare.
The net result of these formidable problems with the process and its dubious validity and reliability has been that increasing numbers of our graduates decide against applying to be certified. [Editor's note: Figures made available by Singer, comparing the four-year periods from May 1991 through May 1996 and December 1996 through December 2004 (see page 11), indicate that increasing numbers of members have applied for certification.] They choose to avoid a test that isn't a test in the true sense. The work has already been done. The committee is cast as the guardian of the purity of that work and the ultimate judge of whether the applicant is truly a psychoanalyst.
The process is intrinsically destructive to morale. This is unavoidable because the fixed definition by the Committee on Certification applies to work already conducted. There is no room for anything to actually be changed. All the applicant can do is pledge to think the way the committee wants him or her to think about work already done.
It is plausible that applicants who have labored through many rejections in the end will try to work in a fashion they have learned from their examiners. But can this actually be the case, and how do we know that the
Henry J. Friedman, M.D., is an associate clinical professor of psychiatry at Harvard Medical School. He is a member of the Boston Psychoanalytic Institute and Society and a teaching and supervising psychoanalyst at the Massachusetts Institute of Psychoanalysis.
quality of the applicants' work will really have been improved?
Mike Singer, as chair of the Committee on Certification, insists that those applicants who require repeated submissions before passing have done more than merely comply with the demands and clues of their examiners. He believes that real learning has taken place through repetitive questioning and directing of the applicant in the direction of true psychoanalysis.
It is important to note again that these are completed analyses. While it is possible that the applicant has seen finer points of both analytic technique and theory or recognized that he or she has missed the opportunity to analyze an interaction or misinterpreted a dream, I suspect that the majority of applicants will simply have complied by providing the correct responses to the clues they receive from the examiners.
Many applicants who have required repeated examination may come to believe that only a constricted analytic responsiveness is compatible with the idea of a competent psychoanalyst. This may contribute to our profession's image as constricted, unresponsive, and remote. It may also decrease many psychoanalysts' efforts to engage patients in a relationship that makes psychoanalysis possible for a larger population of individuals.
A true test of psychoanalytic competence cannot be based upon a review of the cases conducted in the course of training. It would need to be based on a comprehensive oral examination dealing with such issues as the indications for psychoanalysis as opposed to psychotherapy, the appropriate use of medications with psychoanalysis, familiarity with competing established theories, and awareness of emerging ideas and theories. Applicants could be asked to respond and discuss analytic material drawn from casebooks of various psychoanalytic schools.
Such a test would focus on the applicant's ability as a psychoanalytic clinician. It would test for competence regarding patients, not competence regarding a favored image of what constitutes proper psychoanalysis on cases already completed.
I believe that whether we choose to insist on a test of competence beyond the criteria of graduation from a local institute should be determined by the membership and not imposed upon us by BOPS. If we should choose certification as a means of testing for clinical competence, then any test — preferably administered by an independent agency — must be a test of knowledge and competence applied to new material and not merely proof of loyalty to a committee's definition of psychoanalysis.