The controversial educational topic discussed at the Department of Psychoanalytic Education’s Educational Forum on June 19, 2019, was the place of psychotherapy training in the education of psychoanalytic candidates. Three pragmatic realities in contemporary psychoanalysis have converged to raise the pedagogical question of whether it would be wise to train candidates in psychotherapy during their formal years of psychoanalytic education. These current exigencies are: (1) the clinical inexperience of candidates; (2) the survey data indicating that psychoanalytic graduates spend the bulk of their days doing psychotherapy, not formal psychoanalysis; and (3) the contemporary trend in APsaA institutes to combine psychotherapy students and psychoanalytic candidates in some percentage of courses in their curricula.
I introduced the forum by reviewing these trends while emphasizing the importance of deeper pedagogical issues when considering the value and wisdom of offering some training in psychoanalytic psychotherapy to candidates. One of these underlying issues is psychoanalytic identity. If a goal of psychoanalytic education is to foster a psychoanalytic identity, it would be useful to consider the impact of psychotherapy training on such an identity.
Another underlying issue is how to differentiate psychotherapy from psychoanalysis. In general, there are two main schools of thought about this distinction. The more common approach is to view the two therapeutic modalities as being on a continuum. This perspective views both techniques as sharing the same essential elements but in different proportions or intensity. The other approach, less widespread, describes the two techniques as qualitatively different. It states that there is a psychoanalytic process and a psychotherapy process, each very different despite their common usage of psychoanalytic concepts about mental functioning, pathogenesis, and therapeutic change.
No one present found the idea of providing some psychotherapy training to candidates a worrisome idea.
As usual in Education Forums, the discussion was thoughtful, respectful, and intense. Most interestingly, however, was the notable lack of controversy about the central question. No one present found the idea of providing some psychotherapy training to candidates a worrisome idea. Rather, all were explicit that the days of viewing psychotherapy as some impure alloy in contrast to the purity of psychoanalysis are long over. Even when invited explicitly to differ with the apparent acceptance of the value of psychotherapy training by the group, no one stepped forward.
Instead, the guest participants, as well as the institute representatives, found it more useful to consider the deeper pedagogical issues and questions involved. This trend was particularly notable in the discussions of analytic identity. A consensus emerged that an analytic identity involves an internal process, not behavior, such as treating many patients with psychoanalysis. In general, an analytic identity was thought to involve certain ways of thinking about and listening to clinical material. It also involves remaining open to various ideas and possibilities rather than foreclosing understanding by insisting on excessively specific ways of formulating and organizing the clinical material. The IPA emphasis on the
formation of an analyst was mentioned as an example of this emphasis on the development of such an identity. Some thought it more accurate to call this openness an analytic attitude rather than an analytic identity. Most, however, used them interchangeably.
This deeper way of thinking about the issue was also notable in the discussion of the distinction between the two technical modalities. No one emphasized external criteria such as frequency, activity, or the couch as differentiating the techniques. When mentioned, these variables were said to be important only insofar as they impacted the sort of process that occurred, not as differentiating factors themselves. For example, some emphasized that greater frequency and less therapist activity could promote the emergence of deeper material, greater regression, and greater distortion within the transference. These latter phenomena are what distinguished the two techniques to these participants. Another distinction mentioned was the expectations of the patient. Patients in once weekly psychoanalytic psychotherapy have different goals and often speak differently than the free association and self-reflection that occurs more prominently in analysis. Others challenged this difference. It was reported that efforts to differentiate the modalities by examining process notes generally failed. Interestingly, Ralph Beaumont reported that examining two sequential sessions had been more successful.
A gradual shift to making the distinction based on therapist variables occurred. For example, it was suggested that someone working therapeutically listens differently than someone working analytically. The former tends to focus on manifest content whereas the latter attends more to deeper, latent content. In this vein, it was mentioned that Fred Busch had once distinguished the techniques by stating that therapists try to relieve symptoms while analysts strive to create a psychoanalytic mind in their patients. This distinction complemented the comments of some that one has different expectations when doing psychoanalysis versus psychotherapy. An interesting compromise was suggested by Charles Fisher who emphasized that all analytically informed treatments could be thought of as involving both therapeutic and analytic interventions. These go on simultaneously. Hence, it could be more fruitful to study specific interventions and discuss whether they are therapeutic or analytic.
Eventually it was noted that the distinctions were clustering around the mind of the treater. This raised an interesting question about psychoanalytic education: Should we be emphasizing technique in our training programs or should we be focusing on learning to think psychoanalytically? Many participants thought the latter should receive greater emphasis than it traditionally has. I related this point to one made at the September DPE 2018 Regional Education Workshop in Los Angeles. In that discussion of psychoanalytic supervision. Howard Bacal mentioned the Hungarian school of psychoanalysis had always insisted the supervisor could only help the candidate think about the patient and the analyst-patient interaction; the supervisor could not make technical suggestions because technique arose out of this unique interaction. Based on that perspective, the Hungarian school insisted the first control case be supervised by the candidate’s own analyst. That approach was eventually forbidden by Ernest Jones. But it seems to fit with the idea developed at the forum that analytic education should prioritize learning to think analytically over the learning of technique.
Ways of teaching this ability to think analytically and distinguish the techniques were also discussed in some detail. Two interesting approaches were recommended. One would involve two different cases being presented by different presenters. One would be a midphase analytic one being seen 4-5 times a week. The second case would be a once-a-week psychotherapy patient in midphase. The class would look at the types of interventions made and examine the qualitative difference between interventions. In particular, the psychotherapeutic interventions in the analytic case and the analytic interventions in the therapy case could be studied in an ongoing way.
Another teaching strategy to address the complexity of teaching differences between analysis and psychotherapy would be to have three students present in a class. The first student would bring material to illustrate an analytic process in order to demonstrate the action of an analytic intervention. The second student would be assigned the same requirement for a psychotherapeutic intervention with a psychotherapy patient. Student number three would be asked to bring a difficult clinical dilemma, in which the analytic or therapeutic intervention is not yet defined. Discussion of that dilemma would consider questions like: What should be done here? Why? To what extent is that analytic or nonanalytic?
By the end of the forum, the participants had expanded their discussion and debate to include broader considerations of psychoanalytic education. In this way, the forum had provided the impetus to creative and disciplined thinking about how to promote excellent training. Once again, those present had experienced a meeting of their analytic minds. They were all encouraged to take this discussion to their home institutes to promote the same useful meeting of the minds there. This forum, as the others have, exemplified the DPE’s vision of inclusive and collaborative work, where ideas are discussed critically with a focus on advantages and disadvantages, not correctness or incorrectness. As such, the forum embodied the DPE’s commitment to creativity and flexibility in education.