No one owns psychoanalysis: a plea for ecumenical cooperation
An editorial by Jane S. Hall
I am dizzy, perplexed, confused, and distracted by all the debates on standards and credentials taking place in the United States. At APsaA there is something called certification after graduation that many see as unfair and archaic; at CIPS people have differing opinions about the NAAP inspired licensing bill; at NYFS there are some (not many) who disagree with the new, non-evaluatory policy about selection of training analysts; in California, a state where people have to drive sometimes long distances for therapy, some analysts in training wish that three times a week was acceptable for a training case; and surely, there are other debates I know nothing about. Instead of focusing on the facts that psychoanalysis is far from the public’s mind and that there is a dearth of candidates, too much energy is being spent on deciding just how many hoops one must jump through to call themselves an analyst and then a training analyst. My plea is for ecumenical cooperation to replace the infighting that is draining our field of the energy needed to re-build the reputation of psychoanalysis as a valid form of treatment and study.
The reality is that psychoanalysis belongs to everyone. In New York (and in several other states) a group called NAAP, started by Phyllis Meadow in reaction to the American’s exclusionary practices years ago, has successfully lobbied the legislature to pass a licensing bill that on the one hand, prevents just anybody from hanging out a shingle, and on the other hand, has lowered the requirements in education that the IPA and other groups require at this point in time. One major change involves frequency of analytic sessions for candidates and their training cases.
Had another group raised the money to lobby over a long period of time things might be different in New York. However, now that the train has left the station, it would be wise to focus on finding alternative routes of transportation on the journey of refining educational standards. One option is to better educate those interested in pursuing education in psychoanalysis about the choices available.
Using law school as an example, we know that some schools have reputations of excellence and others do not. After graduation from any law school, passing a bar exam is required. If passed, the lawyer is allowed to practice independently. Her success depends on her skill and dedication. When the dust settles, some lawyers achieve more success and serve their clients better than others. The question of which schools turn out better lawyers is tough because the cache of attending Harvard or Yale, along with the contacts and networks involved, make scholastic measurement secondary (our president being a prime example).
Why can’t psychoanalysis have its own ‘bar exam’ based on demonstration of the applicant’s establishment of a psychoanalytic process with several cases. Whether oral or written – such demonstration could be presented to an audience or readership of 10 to 20 or more analysts from various institutes with the aim of collegial dialogue. I believe IPTAR does something similar. What a rich opportunity this could be – sharing different ideas in a nurturing atmosphere. The decision when to present would be left to the applicant when she/he feels competent. Consultation with supervisors and peers help the analyst in making this decision. Transparency and collegiality would diminish the humiliation and anxiety now suffered in evaluatory processes.
Here are my ideas (certainly up for dispute) about what psychoanalysts must possess regardless of their theoretical slant and training requirements:
1. A deep understanding, gained by one’s own analysis, that each person is unique and has an unconscious that exerts great power.
2. An ability to effectively recognize and respond to transference phenomena, positive and negative, idealized and hidden, with the patient’s best interest in mind, eventually leading to an internal shift or change. This includes establishing a safe haven for expressions of rage, despair, confusion, profound sadness, which require both parties’ courage and strength.
3. Alertness to countertransference and enactment, and skill in using what we learn from them.
4. Respecting that each patient has a complex past that is in some way repeated in the present. Whether reconstructions and/or here-and-now relational observations are used, they must reach the patient in a healing manner.
5. An understanding of the brain’s plasticity.
6. All of the above for the purpose of enabling the patient to: correct distortions that prevent a fuller, richer life; experience a life unencumbered by crippling compromise formations and derailed development; transform the ghosts that continue to haunt the patient into ancestors laid to rest. (Loewald’s idea from his 1960 paper The Therapeutic Action of Psychoanalysis
Each analyst must find, with each individual patient, the treatment plan that will be most effective. This involves the number of sessions per week, the important setting of boundaries for both parties, the wisdom of flexibility, an assessment of the individual patient’s fragility and strength, defense system, capacity for reflection, and motivation. If we believe in the uniqueness of a patient, we cannot use a cookie cutter approach. This means that every patient will respond differently to frequency of sessions, the couch versus the chair, the activity and silences of the analyst, and other techniques. The term ‘analyzability’ is relative and the concept of ‘parameters’ has hopefully been retired.
My hope is that a would-be psychoanalyst explore in her own analysis what works best for her. As long as we have training analysts wed to a particular mode of analysis, the personal analysis of the candidate will be affected. This is natural but when the candidate/analysand completes course work, supervision, and analysis, she is free to find her own voice largely by listening to her patients with benign curiosity. This ‘own voice’ is in my mind the true measurement of an analyst and when achieved it makes the title ‘training analyst’ obsolete. The voice gets stronger with experience. Jurgen Reeder discusses this in “Hate and Love in Psychoanalytic Institutes: the dilemma of the profession”.
Arguments about setting standards and rules are often persuasive and I agree with those who insist that in depth work eventually requires a minimum of three sessions a week, but I would like to see more elasticity, more exploration, more experimentation, and more focus on the individual dyad taking the journey – because each psychoanalytic journey is unique. This is why scientific measurement is so difficult. Standardization also inhibits many from presenting work honestly. How quick we can be to say: “That’s not analysis!”
The question that continues to haunt us – one that might shed some light on standards – has to do with how one perceives the difference between psychoanalysis and psychoanalytic psychotherapy.
Is there always a difference?
Is there sometimes a difference?
Is it a cut and dried issue?
Is there a continuum?
And finally, why do we persist in labeling psychoanalytic work?
In today’s world few people come to the analyst requesting psychoanalysis and the analyst trained to deepen the work will do just that. How many institutes teach such a course?
John was referred to me by a friend of a former patient. After a period of consultation I felt that due to his turbulent childhood and presenting problems, along with his intelligence and sensitivity, he would be best served by intensive psychoanalytic work. My recommendation was rejected with John insisting on once a week. I agreed, but said that I believed increasing the number of sessions was in his best interest, encouraging him to explore his fear of it. His stated reason for seeking therapy was that he wanted to get married but his girlfriend was unsure because of his behavior which at times was possessive and volatile. After about 6 months he and his girlfriend decided to go ahead and a wedding was planned. At the last minute John panicked and cancelled the plans. During this time the treatment was based on psychoanalytic principles. I reflected to John that closeness was frightening and connected this to his childhood marked by violence and neglect. We both realized that a long treatment would be necessary to modulate his fears but he had to test my reliability and constancy first.
Three years into treatment, John, while functioning well in work and improving his relationship with Mary, is bringing his conflicts and fears into the treatment, working in the transference and experiencing both rage and longing. He is facing and reworking his past. The twice weekly treatment which began after one year has increased to three times a week. The option of four or five sessions is open and will depend on our timing and fortitude. We are working at his pace.
Most would say that this is an example of preparatory psychotherapy. I would not. John and I have been working psychoanalytically from the beginning. Connections are made, patterns identified, transference used, countertransference recognized and the enactments that we spot are analyzed. My point is that differentiating between psychotherapy and psychoanalysis misses the important point that psychoanalytic work is being done tailored to this particular patient and not to some learned stricture, never proven, that couch plus 4 weekly sessions equals psychoanalysis.
A case like John’s seems far richer an opportunity to teach and do the psychoanalytic work, with the central focus on the patient rather than on requirements based on institutional, standardized thinking.
In sum, the notion of standards, while understandably present in our thinking, has a potentially destructive influence on creativity and individuality. Our focus on whose standards are best takes us farther and farther away from improving our individual work with each of our patients.
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August 7th, 2007 at 10:29 am
Jane Hall’s eloquent plea is relevant, important, and an essential read for every psychoanalyst!
August 7th, 2007 at 7:54 pm
Jane Hall describes the current dilemma in psychoanalysis very accurately. I would add that this is not a new dilemma, but has become urgent because of changes in health care, in society in general, which has become much less “psychoanalysis friendly” and much more “quick fix seeking.”
I agree with the set of prerequisites she mentions, which to me have always been self evident. However, she asks:
‘Why can’t psychoanalysis have its own ‘bar exam’ based on demonstration of the applicant’s establishment of a psychoanalytic process with several cases. Whether oral or written – such demonstration could be presented to an audience or readership of 10 to 20 or more analysts from various institutes with the aim of collegial dialogue.”
Ideal as this sounds, we are all too aware of how training analysis of analysts does not necessarily always make for ability to engage in a “colleagial dialogue”, which implies acceptance of differences in style, etc. I think that Jane’s hope is that the applicant would be treated differently by a group that she suggests, but what would make that group composition different from the current certification committee of BOPS?
My suggestion would be that the TA system as such would be abolished and that any graduate analyst after 5 years could analyze a candidate if he/she wanted to. It seems only sensible that we consider analysts good enough to treat the public to be good enough to treat our candidates. The proviso I would introduce is that once an analyst treats or supervises a candidate, he/she should be mandated to participate in a peer supervision group on an ongoing basis. I believe this is a variation of what is being done at the NY Freudian Institute.
I hope that Jane will correct me If I am not right about this.
Finally, Jane’s lovely case is illustrative of what a number of us have been doing for a long time. Like Jane, I am not sure that courses are being taught in other institutes on “deepening” therapeutic work. Many years ago I taught a seminar at PINE on “Conversion” of therapy cases to analysis. After a few year hiatus, the seminar is being given again in a somewhat altered form. Incidentally, when I supervise psychiatric residents, I teach them a similar technique. This has a dual purpose. It introduces their patients to psychodynamic treatement, but it also inspires the residents to enquire about and be interested in psychoanalytic training.
Alexandra Rolde, M.D.
August 8th, 2007 at 10:30 am
This comment was received via email from Herb Gross:
Jane Hall has outlined the essence of a psychoanalytic identity and how it is developed. She includes an understanding of the plasticity of the “brain in analysis” which implies an opening to neighboring disciplines that I applaud. I wish we could find a way to openly include and credit our partners, the analysands who are our best teachers and evaluators. The evaluation of training analysts by candidates is an information stream shared by the candidates themselves. What would happen if this information stream was used more systematically?
August 9th, 2007 at 9:46 am
Quid custodiet ipsos custodies: Who will watch the watchmen? Certification: boon or bane? Who needs it: the providers or the people?
I concur with Jane Hall’s plea for ecumenical cooperation. Ecumenical is a Greek word from church lore: it means world-wide, encompassing all the churches, cosmopolitan, all-embracing. In the church it would mean a world-wide unification of the Catholic, Protestant, and Orthodox churches. It ain’t happening yet. In the smaller psychoanalytic world it is already happening in the US, with some private rapprochement initiatives between the American Academy of Psychoanalysis, the split off the American in 1956, and the American; in Germany it is the rapprochement between the DPG and the DPV, long last putting their rivalries to rest.
But Jane has something else in mind: the issue of certification, which is currently splitting the American. It is not a world-wide issue: it is an intramural fight and what is at stake is the shape of the American in days to come in the USA, given the facts of the standing of psychoanalytic treatments in the population at large, demographics of the analytic clienteles, the HMO’s and the rest of the reimbursement policies by insurers, the competition from other organizations in the marketplace, and last but not least: what does the client or patient want and what does the provider or analyst want.
Certification, also called BOPS standards, is thus the matter that Jane would like to be solved by ecumenical consensus. It ain’t happening. The “conservatives” and the “liberals” are at each others’ throats. Habit? Human nature? Hubris? Take your pick. But as noted, what is at stake is what kind of organization do we want to be. Jane compared it to law school, I compare it to medical school. Medical schools train doctors who have a valid state-approved license with various reciprocities within the 50 states. A medical school sows to all winds. Medical school exams and board certification exams are standardized, administered and proctored, and has a legal standing. The American is a totally self-styled body and has no legal standing, only long-standing pretensions of being a certifying body whose mandate is strictly intramural.
The question is: does the American want to be ecumenical in the sense of embracing other models, other viewpoints, and grow in size, or does it prefer to stay small and elitist. Both choices are valid. For example, the present Vienna Psa. Association is very small, klein aber fein, small but it has it all. What do we want? We have to consider the needs and wants of those who would like to join us.
The same applies to who wants to lie on our couches. Who needs those standards? Whom do they serve? Directly and concretely they serve the American alone. Ethical behavior by doctors and, by extension, psychiatrists, psychologists, analysts, social workers, is based on the Hippocratic and other ethical codes. BOPS have not invented them, their mandate is to make to hold institutes and individuals to ethical standards and take disciplinary action when required. They do not stand to societies like medical board exams to medical school exams. They are an intramural device for eliminating undesirables from the halls of power and influence.
The people who come to us for treatment do not care two hoots about our internecine quarrels. A person wants to know whether the analyst can be trusted, whether he will be in his corner, whether the analyst will be loyal to him and to his interests, whether he will get love and learn to love. These are minimal requirements.
The patient wants to be served, not used. To understand this principle is already a big step in understanding what counter-transference is about.
August 12th, 2007 at 10:42 am
Jane Hall says many important and pertinent things about what psychoananlysis is and what it requires from the analyst and analysand.
However, I have reservations about her proposal for a “bar exam” to demonstrate the capacity to facilitate the development and evolution of a psychoanalytic process. There is no general agreement about what a psychoanalytic process is. In his research, Stuart Ablon has found that there are multiple psychoanalytic processes.
I fear that the natural perfectionism and obsessive search for flaws will always enter any evaluation of the clinical work of others, and will sooner or later fail to accept analytic processes that do not follow the concept favored by the examiner, evaluator, or colleague, which ever term is selected for these people.
This problem has waxed and waned within the certification process in the American Psychoanalytic Association and will, I predict, also occur within the NYFS process, as collegial as it presently appears to be.
I agree with Jane that there is little to gain from sharp or arbitrary definitions of psychoanalysis versus psychoanalytic psychotherapy, or by defining psychoanalysis in terms of frequency of sessions per week.
Analysts frequently conduct treatments that we would consider to be non-psychoanalytic psychotherapy. Our work is not psychoanalytic just because it is done by an analyst. But, we also do know that the interventional options available to us at any point in the course of a psychoanalytic encounter are multiple and varied, and, in general, that they fall into the categories of supporting defenses, or of learning to see what is being defended against, and how this is being done.
I hope that no analyst today would claim that he or she does not support the defenses at certain points in the course of any analysis, or that such clinical choice does not narrowly define the treatment for him or her as either psychotherapy or or psychoanalysis. The important issue to my mind, is that the analyst understands the full range of options available to him or her, is able to explain the reasons for the choices he or she makes, and to recognize the effects of these various choices over the course of the work.
But I do not think this can be evaluated in any standardized and satisfactory way that selects for competency at any level that is desired, from minimal to master. For this, if it must be measured, I would favor an objective standard exam, preferably given during the course of education, or at most, could include standardized clinical vignettes with multiple choice answers, to level the playing field.
And one more concern, one which was recently pointed out to me by a highly respected colleague: Who would make up the questions?
Ralph Fishkin
August 14th, 2007 at 6:20 am
Jane Hall has done an excellent job of presenting a number of the current controversies integral to our efforts to assess psychoanalytic competence. Inherent in many of these discussions is the very difficult issue of “standards”.
It goes without saying that the overwhelming majority of us support the concept of standards, indeed even very high standards, for our field. There is just no serious argument with this issue. We all would like nothing more than to be part of a profession that receives enormous respect from the general public, the scientific community, and the general mental health field because of the presence of such very high standards.
It seems to me that a major problem for us is the way in which we try to set, measure and evaluate standards. The assessment of tolerances for O-ring seals or of the integrity of the thermal protection systems for our space shuttles will be subject to a very different kind of review than the way in which Gustavo Dudamel or Alan Gilbert will be evaluated when they assume the helms of the LA and NY Philharmonics respectively. In all of these circumstances the level of performance expected will and must be extremely high but the way in which the engineering and safety needs of the shuttle must be assured are quite different from that required for the stewardship of the interpretation and preservation of classical music.
Jane addresses the very differing needs encountered in each psychoanalytic treatment, how each patient represents a unique situation and how the concept of standardization can be very problematic in a situation as variable as the psychoanalytic endeavor. I join her in urging that we seek the greatest degree of flexibility in our efforts to utilize the concept of standards within psychoanalytic treatments. I would also suggest that any ideas about standards should be considered fluid, always subject to reconsideration and reevaluation as our concepts about analysis itself have changed, even remarkably so, over time.
August 14th, 2007 at 1:11 pm
Jane Hall is to be commended for her wish to challenge a false elitism that has stunted the growth of psychoanalysis. She identifies the certification issue in APsaA as an important example of an inadequate way to measure competence. Her collegial method of assessment for training analyst appears to work on the local level, but Ralph Fishkin fears “that the natural perfectionism and obsessive search for flaws will always enter any evaluation of the clinical work of others, and will sooner or later fail to accept analytic processes that do not follow the concept favored by the examiner, evaluator, or colleague, which ever term is selected for these people.” How much more true would this be if applied on a national level?
She correctly identifies some of the false distinctions between analysis versus four times per week versus three times per week. Her wish for collegiaity and open discussion of clinical material is admirable even though she insufficiently address problems of confidentiality. There is much to be admired in her open-minded attitude toward new ideas.
Despite this her solutions may go too far in decredentialing psychoanalysis as something special, applicable to few people, learned with difficulty and worth preserving as a preliminary achievement to working as she does. If this is the case, then there would inevitably be some who can do it and others who cannot. In this same sense, there are lawyers who cannot pass the bar exam and doctors who cannot pass state or national exams. In order to preserve psychoanalysis as a special skill that can be evaluated, I suggest Jane’s approach should include at least two further matters. First, psychoanalysts need to decide if there is a psychoanalytic method that must be mastered. If so, tests can be devised to evaluate whether or not this has been accomplished. Second, psychoanalysts must define what is not psychoanalysis by describing the basis for failing evaluations. It is insufficient to test only for various versions of what psychoanalysis is; it is necessary to state what psychoanalysis is not. Difficult as this may be, it should not be impossible as there is a wide experience in analytic institutes and in the Certification Committee that can provide examples of why people are deferred. In the long run, psychoanalysis cannot be just anything that is therapeutically intended, but must have its criteria for exclusion. Hopefully, this will not result in false elitism, but elitism based on merit that is not always achieved.
August 15th, 2007 at 2:27 pm
I agree with Jane Hall that a crucial issue for revision should be the rigidity of standards because of its centrality in psychoanalysis.
I have extensive experience – as I presume most contemporary clinicians have- on successful analytic work done three, but also two or one weekly sessions. In fact when the patient shows good ability to contain the psychotic areas of his or her personality, an experienced analyst can reasonably agree with the patient’s request for reduced frequency of sessions and psychoanalytic work proceeds very satisfactorily. Shouldn’t we question whether in our contemporary world the rigidity of standards seems more a legacy of hypnotism than from evidence of real clinical needs. “That’s not analysis” is the refrain, as Jane reminds us. And if an original approach is clinically successful: ”That’s psychotherapy! It works with that patient, but isn’t analysis”.
Unfortunately rigid parameters seem untouchable and so is the case with the “power elite” of local institutions, where, in some more than other, debate about the matter of standards is non existent. The blindness about the rigidity of criteria and analytic standards and the lack of adaptability to the single clinical situation parallels the blindness with which the candidates and members relate to psychoanalytic local authorities. In this sense, standards seems to have, among others, the specific function to protect a blind and rigid authority. A critical institutional super-ego prevails and impedes the development of the candidates’ ego and their scientific attitude of inquiry and creativity. In this context, we miss the opportunity to help younger analysts conduct in a more learned and rigorous way those analyses which –for different reasons- need to proceed with less frequency of weekly sessions.
There is a general tendency to equate political power with scientific quality: this dangerous identification of power with science brings about a dogmatic stance in psychoanalysis and in training criteria. For example the current criteria do not question an obvious aberration of common sense: the same group of training analysts who analyze candidates also evaluate candidates along their training. This implies that the outcome is subjugation of candidates and paralysis of their ability to form individualized perceptions and judgments. The consequence is that subjugation to dogmatic standards and dogmatic authorities result in a chronic desire for power and control of the next generation and to a pathological level of competition and envy within analytic societies!
One of the most urgent steps toward change and growth in psychoanalysis should be to put a realistic limit to the idealization of psychoanalysis, by revising our actual idea of analytic standards, and by actualizing it as a science open to the increasingly complex demands of our contemporary reality.
August 27th, 2007 at 5:25 pm
I have been reading various comments online about psychoanalysis and wanted to add the following:
In my mind an analyst is someone who, in his or her work, thinks of resistance, transference, and countertransference as the guiding principles in day to day work with patients. Therefore the essence of analysis is not couched (pun intended) in terms of frequency of sessions of patient or of the analyst’s training analysis, or whether an analyst’s patients lie prone on the couch, etc., but whether one thinks of analysis of resistance, transference, and countertransference as primary in conducting therapy. I intentionally say therapy here because the long-standing debate that psychoanalysis is in some way deeper than psychotherapy is not helpful. For instance quoting Pete Wolson’s remarks “Effectively, psychoanalysis is a form of psychotherapy, obviously more intense and deeper than psychoanalytic psychotherapy and other forms of psychotherapy. In large measure. this is due to the frequency of sessions (4 to 5 sessions per week), as well its focus on unconscious psychodynamics and transference-countertransference processes. In my opinion, this distinction needs to be preserved for psychoanalysis to continue to exist in any meaningful way.” I have worked over 30 years and have treated many patients. I have yet to find psychoanalysis necessarily any deeper than psychoanalytic psychotherapy. For instance, working through and resolving a narcissistic transference with pre-oedipal patients is very deep. Yet traditionally these patients would not have been considered suitable for analysis. I have found my 1x a week work with many borderline narcissistic patients as deep if not deeper than patients coming 3x a week. Frequency of sessions is not necessarily the issue in terms of how deep a therapy may go.
In my experience (over 30 years) often patients are rejected from psychoanalysis because the analyst does not have the skills, or is consciously or unconsciously frightened of these patients.
I think we can agree that an analyst, trained in analysis 5x a week, may be less competent than an analyst having a personal analysis of 1x week intensity. Just the fact of frequency of sessions does not necessarily make a competent analyst. I consider all my work psychoanalysis because I think of analysis of resistance, transference, and countertransference. Frequency of sessions is not a factor.
Throughout the years we have seen groups attempt to exclude others from the practice of psychoanalysis. First psychiatrists wanted to own the club, then once psychologists got in then they wanted to limit the club and social workers had to fight to get in. Further attempts to excluded others in my mind is fruitless and alienating. I think of the groups outside the USA who have a commitment to the study of psychoanalysis but for whatever reason may not define the essence of psychoanalysis as having to do with frequency of sessions.
I am not a “sour grapes” analyst. I am speaking from the experience of having a 4 time a week analysis, and treating patients 3-4-and 5 times a week. I have all the credentials that I could ever have and still believe that NAAP analysts and those outside the USA (and outside the IPA) be given the respect as practitioners and not have to fit into the mainstream of what some groups say psychoanalysis is.
This is a plea: Let us not define the essence of our profession in terms of frequency of sessions. This will exclude students who can not financially afford this frequency, limit patients who could be considered analytic patients if we had a broader definition of a psychoanalytic patient, and include those groups falling outside the perimeter of IPA but are competent psychoanalysts nevertheless.
Mark Sehl
drsehl@aol.com