American psychoanalysts confront challenges that demand a concerted response but disunity, confusion, and pessimism can compromise our thinking and paralyze our collective will. Necessity compels us to examine the organizational structure of our professional enterprise. In my view, we must decide whether we shall function as a specialty of the mental health professions or a specialized profession in our own right. This article is intended to further the discussion by providing a sociological perspective on the nature of professions, with special reference to the issues of credentialing and the social status of professions.
Social scientists employ the term “profession” to denote an occupational group, formed around a specialized knowledge base and expert skill set, that acts collectively to establish its standing in society, including basic institutional arrangements that govern the transactions of its members with the public. These arrangements are established because the nature of professional work demands protections for the public as well as the professional group itself.
Professional work is the application of specialized knowledge to the important problems of life. Because of its inherent or “legitimate” complexity, professional knowledge is inevitably a “mystery” to the laity. A prospective client cannot measure a practitioner's competence or assess the suitability of a proposed service. The more personal the service, the greater the client's vulnerability, and the greater his or her need for some form of protection. Professions are thus occupations in which the prevailing business norm of caveat emptor (let the buyer beware) cannot apply. The professional cannot market his services without having the public trust, and the public cannot utilize the professional's skill without confidence that the professional will render competent and ethical service. Both the prospective client and the practitioner need an institutional structure that will ensure the quality and safety of the service and thereby promote public trust.
Professions secure the public trust by establishing programs to advance professional knowledge; training institutions with minimum standards for training; high standards for competent and ethical practice (practice in the client's interest); disciplinary codes to enforce standards; and recognizable credentials to distinguish those professionals to whose competence and good character the profession attests. In a fully formed profession, the profession negotiates with the government to establish licensing laws that protect professional titles, define a professional “jurisdiction,” and restrict practice within that jurisdiction to those who are licensed.
Together, these arrangements constitute a social contract or “corporate bargain” between a profession as a corporate whole (a single body) and the wider society: The profession guarantees the competence of its members and the containing community reciprocates by recognizing the profession's expertise, conferring special respect and status, and granting legal protections through licensing laws. The existence of this corporate bargain constitutes the essential characteristic of a profession. It serves both the profession, whose social status and market prospects are enhanced, as well as the public, whose welfare is protected.
Any occupational group seeking to establish itself on a professional model must establish boundaries that define a professional community. A professional community may be represented by more than one professional association, but those associations, whatever their differences, must be able to agree on a coherent set of inclusion criteria for membership in the profession. Minimum requirements for membership are ordinarily based on the attainment of basic competence to practice. Practitioners who fulfill those requirements are “certified” by the professional community, and that certification is signified by a recognizable credential.
The establishment of a professional community, with boundaries based on minimum qualifications for membership, is predictably controversial because it requires a painful differentiation between the “qualified” and the “unqualified.” Intense conflict can result which may obstruct professionalization or produce schisms and competing communities, a situation that damages social credibility and undermines the effort to professionalize the occupation. Any occupational group that wishes to attain a professional status must come to terms with the issue of boundaries in order to secure a social contract with the community at large. Put simply, there can be no profession without a defined community of professionals.
Once basic inclusion criteria are established and the professional community is defined, the community can establish a credentialing system. This may begin with a single credentialing program, like the accrediting of training programs, and may take years to develop as
Fredric T. Perlman, Ph.D., F.I.P.A., is co-chair of the Committee on Government Relations and Insurance and chair of the IPA Committee on Psychoanalysis and Government.
an occupation progresses on its path toward full professionalization. A complete credentialing system includes three fundamental components: accreditation of educational programs, basic certification of qualified members and, ultimately, state licensing.
These three components—accreditation, certification, and licensing—together compose an interlocking system. Certification and licensing are both typically based on graduation from an accredited training program, and employment criteria may be based on all three. Although standards for certification and licensing may differ somewhat (certification requirements are sometimes more rigorous than licensing criteria), the successful system is coherent and assures prospective employers and clients that an individual is both qualified to practice and bound to standards of competence and ethical conduct that are enforceable by the profession as well as the state.
A credentialing system is initiated by a professional group in the form of accreditation and certification, but professional status is only fully established when the state establishes professional licensure. In the U.S., licensure is a function of individual states, and so a profession must typically engage in a long succession of state licensing campaigns to establish licensure. A large proportion of an occupational group's resources may be devoted to this end because licensure is critical to professional viability. At a minimum, state licenses protect professional titles, which is essential for collective public relations and marketing, while more robust licenses also restrict practice within a jurisdiction to “licensed” practitioners. Licensure benefits the public welfare by empowering the state to enforce standards of practice while it simultaneously serves professional interests by enhancing social credibility and, in the case of robust licenses, by establishing a “labor market shelter” that protects practitioners against unfair competition (i.e., competition from practitioners who have invested less time and money in their training). Such labor market shelters constitute an important assurance to prospective aspirants that a large investment in professional training will be worth it.
Although psychoanalysis has the cognitive resources of a mature profession (e.g., specialized knowledge and expertise), there is no community of psychoanalysts in the United States that is sufficiently unified to establish a fully functional profession with a coherent credentialing system. A heterogeneous multitude of competing organizations and rival constituencies all claim to represent psychoanalysis. This state of affairs is the product of a historic scramble for control of psychoanalysis. The entrenched “medical orthodoxy” of the American Psychoanalytic Association, abandoned only after the Group for the Advancement of Psychoanalysis and Psychotherapy (GAPPP) lawsuit, prompted the formation of new analytic groups by social workers and psychologists who were previously excluded from APsaA. Most of these groups set up training programs on the Eitingon model, albeit with slightly modified frequency standards for training and control cases (typically three sessions per week). Most of these groups restricted training to licensed professionals in social work and psychology.
Psychoanalysis thus emerged as a specialty of the three mental health disciplines, each with its own separate organizations, and more recently, with its own separate discipline-based certifications. The new “tri-discipline orthodoxy,” however, eventuated in the formation of yet other psychoanalytic groups, formed largely by aspirants from outside the mental health disciplines, many of which featured vastly different theoretical models and training standards. These groups also have their own professional associations, most importantly, the National Association for the Advancement of Psychoanalysis (NAAP) formed in 1972. The notion of psychoanalysis as a specialty of the three disciplines has been further challenged in recent years as APsaA and other freestanding training programs have, like NAAP, opened their training programs to a growing number of aspirants from outside the three disciplines. The psychoanalytic enterprise has thus become more and more a multidisciplinary enterprise.
If we are ever to pursue a professional model of organization for psychoanalysis, we must establish inclusion criteria that define a viable professional community, take responsibility for the services provided in our name, and create a credible credentialing system for our profession. The formation of the Psychoanalytic Consortium, followed by the historic compromises with respect to training standards and the ensuing establishment of the Accreditation Council for Psychoanalytic Education (ACPE), may serve as a foundation for the establishment of a more fully functional professional community. While ACPE standards for the accreditation of psychoanalytic training programs may not satisfy everyone, a slowly growing number of institutes, both inside and outside APsaA, are pursuing ACPE accreditation and quietly forming the nucleus of a newly emerging professional community. If this trend continues, the ACPE accreditation program could produce a large and viable psychoanalytic community. [See TAP 45/2, “Accreditation for Psychoanalytic Education: Current Status,” page 24.]
As we confront one threat after another, we must address very basic questions about the nature of our enterprise. Do we wish to form ourselves into a fully functioning profession, with inclusion criteria, defined boundaries, and a functional credentialing system? If so, who shall be included within the professional community? What are the optimal inclusion criteria for the professional community we envision? With whom might we partner to create a true profession?
We need to address these fundamental issues now. The world around us is changing. We still have an opportunity to shape our future if we take a proactive approach to the kind of future we want. We may not have this potential forever.
Bibliographical material on request from the author at .