Only two years ago, the Board on Professional Standards adopted the most comprehensive revision to our Standards in Education and Training in Psychoanalysis since 1938. This document was thought to be a unifying compromise between two fundamentally different positions pertaining to both educational and professional matters. Since that time however, the fault lines between these two positions have broadened and deepened, but they have also become clearer. In this sense, the recent crisis in governance is a blessing in disguise because the disagreements that have plagued and crippled our organization for decades are now so starkly clear that we can no longer ignore the critical decisions we have managed to avoid, the most fundamental one being what kind of organization does APsaA want to be?
The future of APsaA and psychoanalysis is too important to be determined by reactive solutions and unintended consequences of piecemeal changes. The silver lining in our organizational struggles is that APsaA now has a valuable opportunity to carefully think about and thoughtfully decide what it wants to be. In this article, we will present our perspective on what these fundamental fault lines are. In the most general sense, they seem to fall into three categories: 1) national standards vs. local autonomy, 2) formal peer review of clinical faculty, and 3) separation of membership/guild issues from professional credentialing and accrediting functions.
The specific issue that precipitated the compromise of 2010 was the requirement that certification in psychoanalysis was a prerequisite for an analyst to be appointed as a training and supervising analyst. The establishment of the developmental pathway at first appeared to solve the problem by integrating the processes of certification and TA/SA evaluation. It appears now that the true fault line still remains. To ensure that the credential of certification in psychoanalysis would have a single and uniform meaning, the Standards Review Committee delineated the specific roles of the national participants and local participants of this integrated evaluation process. This respects the fact that certification is, as for all professions, a blind evaluation of core and clinical competencies.
By contrast, an evaluation for TA/SA appointment is a local institute's process of vetting and requesting the appointment of an analyst who will perform a clinical function. Put simply, the compromise of 2010 was not intended to change the meaning of certification; it created a different but equivalent process through which it could take place. This highlights the first fault line; for some the preservation of this distinction is essential, while for others it diminishes local autonomy. This disagreement raises a critical question: Is this a problem that can be solved, can such different ideas of professional credentialing co-exist in one organization?
Over the past year, the Board on Professional Standards has been under increasing pressure, first by individual members and most recently by the Executive Council itself, to change or eliminate some of the criteria that qualify individual analysts to be appointed as training analysts. The proposals have had many iterations, but the most recent version is to eliminate the practice of having those applying for training and supervising appointment present clinical material to the local TA/SA Selection Committee or its functional equivalent.
Historically, and still today, all training and supervising analysts have had two processes of formal peer review. The first is during the certification process and involves presenting clinical material to members of the Certification Examination Committee, who are unknown to the applicant and who are trained to evaluate the core competencies for independent practice in psychoanalysis. The second is the TA/SA evaluation process, part of which is a presentation of clinical material to the Selection Committee of the local institute or a neighboring institute. The evaluation of clinical work is only one part of the TA appointment procedures, which also include assessment of personal suitability, being five years or more past graduation, analysis of both genders, and with termination of analysis as well as 3600 hours of clinical immersion in psychoanalysis.
The second fault line concerns the proposal to eliminate the evaluation of clinical work of an analyst who will be analyzing and supervising candidates in training. Some argue that graduating from an APsaA psychoanalytic institute and minimal post-graduate immersion should suffice. We believe that this would be problematic for educational and professional reasons.
APsaA institutes as well as IPA institutes require candidates in training to be in analysis with a TA while seeing control cases. This is not suggested or encouraged, it is required. This means that the institute assumes both the responsibility and the liability not only for the candidate but also for the control cases that they treat under the auspices of the training program. TA/SA appointment is a clinical appointment comparable to an attending in a residency program or clinical faculty in an internship program or fellowship.
Colleen L. Carney, Ph.D., is chair of BOPS.
Lee I. Ascherman, M.D., is secretary and chair-elect of BOPS.
Elizabeth A. Brett, Ph.D., is co-chair of the Committee on Institutes and secretary-elect of BOPS.
In other health care professions clinical preceptors are routinely, if not exclusively, board certified in their specialty and vetted by the program for which they will perform a particular function. Graduation from their own residency program or doctoral internship is a necessary but not sufficient criterion for clinical appointments. Eliminating formal peer review processes would not only render institutes more vulnerable, it also distances our psychoanalytic institutes from mainstream standard practice in allied health care training programs.
In addition, each institute has the obligation to ensure the integrity of its own training program. Because the training analysis is required, it is incumbent upon the institute to provide TAs whose own clinical work is consistent with the educational philosophy of its educational program. Most of the integration of psychoanalytic learning happens in the candidate's own analysis and supervisory relationships. How would an education committee know if an analyst is prepared to perform these functions without some formal evaluation of the analyst's own clinical work?
We know that psychoanalytic competence is not something that ends at graduation; this is the valuable point of the developmental model championed by both the San Francisco and Chicago Institutes. At the same time, psychoanalytic competence does not automatically happen because of graduation and it does not develop in a vacuum; it evolves through continued clinical psychoanalytic experiences. This suggests that those analysts with more immersion in psychoanalysis are probably more prepared to perform these clinical functions than those with less.
While our standards require 3600 hours of analytic immersion for training and supervising analysts, the Committee on Institutes reviews this criterion on an ongoing basis. The question of the quantity and quality of clinical experience that is optimal for TA/SA appointments as well as other criteria for these appointments is an ongoing question under constant review by the Committee on Institutes. It is also being studied as a part of the Training and Supervising Analyst Development Project. This study is one part of the larger Psychoanalytic Development Project, initiated in 2010 and is a series of studies intended to develop benchmarks for psychoanalytic competence at a number of key points in any analytic career: admissions, progressions, graduation, certification, and TA/SA appointment.
The third fault line has to do with the multiple functions APsaA as an organization embodies. It is a membership/guild organization, but it also sets training standards for institutes, certifies/credentials individual analysts, and approves training facilities. Other health care professions would see that we have the missions and work of three separate organizations in one. There are not only legal reasons why other professional organizations separate these completely, each having its own board of directors, there are also professional reasons for doing so. Standard practice is that membership concerns are kept separate from credentialing and accrediting functions, and certification and accreditation are still further separated from each other. It is a wonder that APsaA has survived this long given the precarious cauldron it tries to contain. Our recent vote to externalize certification is a step in the right direction as is our support of institutes applying for accreditation from the ACPEinc.
However, the recent crisis in governance betrays the true fault line. When our bylaws were written, the authors separated the membership, professional credentialing, and accreditation functions. How and if we can reconcile these internal tensions will determine the nature of our organization as well as the integrity of our profession.