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.