Late last year after the presidential election, the conservative writer Joseph Epstein unleashed a fury of criticism over his Wall Street Journal op-ed in which he took out after Jill Biden whose crime, according to Epstein, was to use the honorific “Doctor” when she had earned her doctorate in education and, in his view, the title should properly be reserved for medical doctors.
If you agree with Epstein about the sacred meaning of an MD, you would probably be inclined to agree with the way American psychoanalysis once valued the degree in its domain. Certainly, with the multiplicity of counseling degrees — LMFT, PhD, PsyD, MD, LCSW, PCPC and their local variants — it is easy to forget that, in psychoanalysis, degrees once dictated who had access to clinical training in the system of institutes certified by the American Psychoanalytic Association. As biographies of Carl Jung and Harry Stack Sullivan have pointed out, it was not uncommon in the early 20th century for non-medical would-be analysts — no less figures than Edith Rockefeller, the daughter of John D. Rockefeller, or the eminent University of Chicago political scientist Harold Lasswell — to travel to Berlin and Zurich for psychoanalytic training. But by the late 1930s organized American psychoanalysis had so thoroughly repudiated non-medical or so-called lay analysis that an official rift developed between the American Psychoanalytic Association and its international counterpart, the International Psychoanalytical Association. A separate system of non-affiliated institutes had to be erected for non-MDs seeking advanced clinical training in psychoanalysis.
For half a century, the MD served as the union card for psychoanalysis, this despite Freud's full-throated defense of lay analysis. In his famous 1926 paper “The Question of Lay Analysis,” Freud expressed a belief that “the practice of psychoanalysis has far less need for medical training than for educational preparation in psychology and free human insight” and that “the majority of physicians are not equipped for the work of psychoanalysis.” Still, today, there remain institutes that have not abandoned the exclusionary practice of requiring candidates to hold an MD or a doctorate in a clinical discipline. Even though, without some special accommodation, that would exclude many esteemed scholars of our time, who, while lacking clinical degrees, are able to maintain clinical practices through special psychoanalytic training.
Over the course of the 20th century, a handful of prominent lay analysts, such as Erik Erikson, who is regarded by many as the most prominent psychologist of the 20th century, made their way into mainstream psychoanalytic institutes. A parallel system of “independent” institutes also flourished to train non-medical professionals. However, these psychoanalysts were excluded from membership in APsaA. But in the name of maintaining the value of psychoanalytic training's “currency” – the cornerstone of Epstein's diatribe against the use of the term “doctor” by those outside the medical profession — medical doctors remained the only doctors welcome in APsaA-accredited training institutes until a 1985 court case pried open the doors. More than four decades elapsed before APsaA's leadership issued a formal apology for its exclusionary practice.
With APsaA and local psychoanalytic societies now examining the cost of the field's history of exclusion, whether by race, social class, gender, sexual orientation, or degree, Epstein's op-ed re-awakened the dysphoria I once experienced. As an academic-turned-clinician, I admit to cringing more than once in my early days of clinical work when patients addressed me as “doctor.” My reaction was not because I did not feel worthy of the honorific after six years cloistered in libraries and archives obtaining a PhD by preparing a work that sought to advance knowledge of the history of psychoanalytic education.
Perhaps because I grew up in a family of medical doctors and I was the only one to earn a PhD, the prospect of being mistaken as a member of the MD club seemed fraudulent. After all, my hard-earned doctorate was academic not clinical. I often disguised my degree dysphoria under the guise of alliance building, asking patients in the first session how they would like to be addressed and routinely informing them that I referred to myself by my first name. How they referred to me was their choice. Occasionally, a patient would discuss why he or she had selected me as a therapist, admitting that they did not really know what to make of all the different letters after therapists' names. If they went so far as to inquire, which some did, about the significance of varying degrees, I offered a brief explanation of the different pathways to clinical work, only occasionally getting far enough into the weeds to explain how someone with a PhD could also be designated a student intern for clinical purposes.
With pride, I identified myself as a social worker, which I told them meant I was called upon by the profession's code of ethics to explore their suffering not just within them, but also in their social surround. Only rarely have I ever shared how this ethical obligation might incline me in a particular theoretical direction on such questions as the origins of sexual trauma. Regardless of what I say, however, a surprising number still refer to me as “doctor,” even if some softened it to Doctor Flora.
Flora E. Lazar, PhD, LCSW, is a historian and psychoanalytic psychotherapist who has spent her professional career at the intersection of research, public policy, and clinical practice. She is editor of the Chicago Psychoanalytic Society News and lives in Chicago and Salisbury, Connecticut.
For years, I found the obstacles to communicating about my academic and clinical background unsettling verging on fraudulent. Only over time and with greater clinical confidence have I come to realize that being a “doctor,” even a “doctor of philosophy” as my PhD denotes, actually does have clinical value. But unlike what Epstein would have us believe, the value is less for me than for the patient. As Bruce Wampold, “an exponent of the common factors approach to psychotherapy efficacy research,” and others who subscribe to the “common factors” approach to psychotherapy have underscored, expectations of being helped play an important role in effective psychotherapy outcomes. Realizing that patients who are suffering and seeking help have a need to call me “doctor,” even the wrong kind of doctor, more than I have need to be called one, has helped me settle more comfortably.
Self psychological theory might understand this insistence on calling me “doctor” against my stated wishes as a need for an idealizing self-object experience, one that provides among other experiences, safety, calm, and reassurance. Honorifics confer authority and power, sometimes a power that patients need in order to consolidate their fragile selves. Turning someone like Epstein on his head, this view would suggest that the need for therapists to accept their patients' idealization through their use of honorifics would accrue more to the patients' emotional benefit than to the therapist's.
This recalls a pivotal moment in my life when I first began speculating over the value of an honorific. I had been invited on occasion to the home of a high school teacher whose husband was a member of the faculty and dean at the local university. After several anguished adolescent visits in which I sat uncomfortably silent on how to address this esteemed academic, I finally screwed up my courage to ask him how he would prefer to be addressed. His reply would probably not satisfy either Epstein or his critics and has certainly diminished my appetite for the term “doctor.” “Young lady,” he affectionately replied (in an era before it was taboo to use forms of address with behavioral rather than biological connotations), “Please call me mister. Anyone can earn a degree. It is a lot harder to be a gentleman.”