APsaA members are discussing the subject of certification. This editorial by Arlene Kramer Richards gives us one person’s personal experience of the process, along with suggestions for the future. The piece was originally published in États Generaux de la Psychanalyse (2000) and appears here with the requisite permissions. The IP Blog looks forward to many comments so that people can reflect, with open minds, on their positions – whatever they may be.
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DISCUSSION OF THE CERTIFICATION PROCESS AT THE AMERICAN PSYCHOANALYTIC ASSOCIATION
By Arlene Kramer Richards
I became a certified member of the American Psychoanalytic Association in 1998. My experience in becoming certified has caused me to think long and searchingly about the purposes and the consequences of this process. The personal pain induced by the process is the spur for my thinking, but the thinking has gone on long after the pain was assuaged by the concern and sympathetic listening of a few close friends and many colleagues. The process began when I decided to attend a meeting at which prospective candidates for certification were invited to discuss the process. The members of the committee who were present at the meeting assured the prospective candidates that the process would be collegial and that they wanted to use it to get to know the candidates and their way of working as analysts. This sounded good to me. They also gave details of how to write up cases for certification and, most importantly for me as someone who had trained long ago and outside the institutes of the American, said that they were willing to accept a selection of cases from senior people rather than demand that we write up all the cases we had ever had. That was reasonable. I wrote the cases as I would for scientific papers. I tried to spotlight the difficulties that arose in the analyses themselves and the thoughts that had occurred to me as I wrote them up now, many years later. Informed that they had been insufficient, I was encouraged to go to Toronto in May 1998 to present my work in person. This time, I was to bring process on current hours. I was shocked to find that the small subcommittee that interviewed me at that time did not believe that I had presented to them well enough to show that I understood the analytic process. After another write up and another interview, I was told that I had now shown that I did understand the analytic process. For a senior analyst who had done many analyses and supervisions and had been the co-chair of an IPA pre-congress on analytic supervision as well as having been a training analyst so long that some of my analysands were now training analysts, this did not feel good. Was the problem me or was it the process? Or was it both? Much of my thinking about this has been in the service of figuring this out. To begin at the beginning, there was the case write ups.
The case history is a picture of something that has happened to an analyst as a result of what has happened in the life of her analysand. Like every picture, a case history contains both positive and negative space. The positive space is the register of what happened. The negative space is the emptiness where whatever happened has been not recorded, expunged or erased. Like the report of a dream or any other narrative, the case history can be distorted by commission or omission. In the instances described by Michels, both commission and omission are strongly motivated. The case histories written for the purpose of certification in The American Psychoanalytic Association are prime examples of work motivated by external rewards for conformity to a standard. The purpose of a case report in the certification process of the American is to show that the writer is an analyst as defined by the standards of the certification committee. This is a definition that does not have a behavioral analogue. Writing up case reports is part of the specification for being an analyst as is (now) meeting with a two person subcommittee that hears whether the writer of the reports also sounds like an analyst. My understanding of my own experience in the process was that the reports had to show that the writer understood defenses as mechanisms of the mind especially used for the purpose of keeping some other mental contents unconscious. In addition, the report had to show resistance and the analyst’s work to overcome the resistance.
The committee stated in a message to potential candidates that the candidates were not asked to present a particular kind of analytic work. “Just”, as one member put it: “show that you know the alphabet.” The standard would seem to be consensual, but it as Michels so clearly shows, is not at all consensual. And the way of meeting the standard, therefore, is to eliminate anything that goes beyond the consensual and established. This is the negative space, the unsaid. In advising candidates for graduation who were required to present cases I have suggested that medication not be mentioned since some colleagues still believe that it is not a truly analytic process of the analysand is so ill as to require medication. To others I have suggested not mentioning the method of referral, since some think that referrals have to be for analysis and that taking a parent who comes into treatment because the child is having difficulty is not legitimate. I have heard other advisors advise candidates not to mention projective identification as a defense because that could cause some colleagues to object. Others have been told not to mention their self psychological concepts because they could be objected to. Interestingly, but bewilderingly to the candidates, the acceptable terms change over time and members of the overall committee change in their views while the people on the committee change as their terms expire or they tire of the work or other activities require more of their time. The shift in people, ideas and standards presents the candidates with a kind of lottery. They must write their cases for a very small audience and the audience is unknown to them as are the standards that they will use.
To readers of Kafka, this baffling lottery in which half the entrants are expected to lose is familiar in feeling. But the people administering this procedure are members of a helping profession. So they provide help. The committee suggests to candidates that they get outside readers , preferably former members of the committee since current members are not supposed to be biased in favor of particular candidates. This advice does contradict the initial intent of the committee to get to know the candidates in depth as the committee members do not work with the candidate to prepare the case reports, but only see the end product.
Thinking about the process as I went along, it seemed more personal to me. But at the end it seemed as it had in the very beginning, an institutional attempt to insure the organization cohesiveness, to make sure that the “certified” members shared a set of values and standards that the organization wished to preserve. The case reports, then, were to contain evidence of those shared values and standards. But the committee stated that they did not simply want the candidates to tell them what they wanted to hear. They were not so naive as to think that the candidates would deliberately hurt their chances of passing by saying what they really believed when it contradicted the expectations and values of the committee. To prevent having the candidates simply mouth what the committee wanted to hear, the values and standards had to be unstated. The ambiguity and opportunity for misunderstanding resulting from this process with unstated standards would increase the likelihood that the candidates were not just complying with the requirements, but really believed what they were implicitly stating in their case reports. At the same time, it was possible, and indeed did happen, that some candidates would write their reports in a way that would emphasize their current concerns beyond the defense and resistance paradigm. Those candidates could be seen as arrogant or insubordinate.
This state of affairs had the candidates required not only to figure out what was wanted in the case report, but also to affirm that the case conformed to the unwritten standards. The case was then not an opportunity to think about the analytic process or the analytic outcome as problematic, but to make an affirmative statement of the process. In other words, the candidate had to state what were her interpretations and how they changes the analysand’s understanding of himself and his behavior as a result of that changed understanding. The positivist stance required a corresponding modesty so as not to sound grandiose.
An example of a case report unacceptable to the committee included a description of a comment by the analyst that the patient was worried about becoming less connected to her parents if she signed something that they wanted her to sign accepting an annuity. The analyst believed that she would be less dependent when she did not have to ask them for money each time she needed it. The committee believed that the analyst was acting in her own interest since she would no longer have to negotiate with the parents about the patient’s fee. In the event, the statement that it was the analyst’s counter transference rather than the patient’s interests that determined the analyst’s interpretation of the patient’s hesitation to take the money was required for the case to pass muster. Was it so? Perhaps. But the report had to state that it was the counter transference rather than that it was a decision that would free the patient even though it did, in fact, free the patient from having to negotiate with her parents every month for her living expenses as well as the analytic fee.
The outside consultant thought that another case was not accepted for two reasons. One was that the analyst reported her concern that the termination decision may have been contaminated by her counter transference concern for the male patient’s parents when he had reached a compromise that would keep them out of his life forever and would not permit them to know of their daughter-in-law or their grandchildren. The analysis was terminated successfully after the analyst did a piece of self analytic work on her counter transference and reported that in the case. That case had another problem in that the patient reported a bizarre memory which the analyst believed to be the conscious counterpart of his core unconscious fantasy but presented as if it were a memory. The memory was confirmed by the analysand’s mother, but the case report did not include the idea that this real memory could be the nucleus of an unconscious fantasy while still being “factual.” The consultant thought that I would run the risk of seeming to accept a naive view of trauma if I presented this material.
For at least one member of my subcommittee the standards included the idea that defense mechanisms were ubiquitous and could be found in the data of the analysis. As it happens, I do not think in terms of defense mechanisms, but rather of how anything can be used as a defense when it is available. I have had the experience of being told dreams so long and complex that the telling prevented understanding. Like many analysts, I have had people talk about the most intimate details of their sexual behavior in order not to talk about the analytic fee. Does this mean that they are using the defense mechanism of self revelation? I think it more parsimonious to conclude that any mental content can be used to defend against the emergence of any other. But this is unacceptable to those believe that making the analysand aware of his or her defense mechanisms is analysis.
These standards would exclude some of our most prominent and eminent analysts. Brenner, for example, would object to the idea that defenses are specific mechanisms of the mind. When I talked about defenses as being variable with any idea, thought or fantasy usable to defend against any other, the examiners nodded in, it turned out later, solemn disagreement. The more senior of the two interviewers declared himself satisfied when I gave this understanding of defense. I thought that he was satisfied that I had a reasonable understanding of defense, even if it differed from his.
When it later turned out that he had chosen to fail me, I protested this to the chair of the overall committee, saying that my examiner had said he was satisfied. The committee chair replied that the examiner meant that he was satisfied that he could not go any further that day and was not going to pass me. This still seemed to me an unusual way to express the feelings of an examiner who had the purpose of passing the examinee. If one wanted to pass a candidate, one would not be satisfied with failing her. It seemed to mean that he would have been happy to have had me go away. Because he would not meet my gaze from the beginning, I believed that he had made up his mind to that before I ever entered the room. The younger colleague who was the second member of the subcommittee that was examining me seemed bothered. He reminded the senior man that I had come a long way for the interview. (It was a thousand dollar round trip to Toronto since I had to leave to go back to my practice the same day.) His concern for me seemed to be that I was not getting a fair hearing. He succeeded in prolonging the interview for another hour by having me read case material from a current case to them. It was, however, an empty exercise.
And all of the contacts I had with the chairs of the committee had the same tone. They were careful to express regret and to assure me that they would understand if I decided to abandon the process and protect myself from further disappointment. They clearly wanted to be good interviewers and good examiners.
The exam had a failure rate of 50%! This is the kind of rate that is unacceptable in colleges and universities around the world. No teaching institution that produces 50% failures would ever be considered worth attending. None of the examiners would send their children to a kindergarten that had such a failure rate. Yet the candidates for this examination are highly trained, very sincere, selected from the intellectually gifted and have all been successful in schools, colleges and graduate schools. How half of them could be failures is something to be pondered. When I asked the chair of the committee about this rate, he said that he did not consider it failure, but part of an ongoing process. A member of the committee itself explained that he thought there would be no purpose in doing all that work of reading cases if they just passed everybody!
This understanding of the process makes sense. The committee on certification takes pride in working hard. Therefore the hard work must be justified as being valuable. No one wants to think that her or his hard work is the equivalent of carrying stones back and forth across a prison yard. Everyone wants to think that his hard work is also valuable to the world. Carrying the rocks is all right if there is an esthetic, moral or utilitarian purpose in it. The members of the committee on certification put in so much time and effort that the activity must be seen to be essential to the functioning of the organization. Is this way of seeing the process wild analysis? I mean it to justify the position of those who have sincerely and honestly served on the committee over the years. If I have it wrong, I would like to hear from members of the committee who see it differently.
The purposes of the certification process are many. Some committee members emphasized the importance of making sure that the applicant knew psychoanalytic theory, at least in its rudiments. Some emphasize the idea that the applicant must know how to write a case so that the committee may be convinced that the applicant has really carried out a full analysis and knows the stages of the analytic process, especially the termination phase. Some accentuate the adherence to certain basic psychoanalytic principles, especially transference, resistance, defense and counter transference. The idea is that the applicants may not have learned these things in their own analyses or at their own institutes, even though the local institutes of the American have graduated them. The certification process is there to insure that the graduates of institutes really know their stuff and can show it in writing, and, if necessary, in an oral interview.
The certification process has changed. It no longer is a write up of the cases and an interview only if the cases do not pass muster. Now all candidates must have an interview as well as presenting cases. What purpose could the interview serve? Does it make the candidate more knowledgeable? Does it serve as a getting acquainted meeting? Can the same interview serve as a gate keeping and an acquaintance function? The purpose of the case write up is to demonstrate a certain sort of competence, ambiguous though that may be. The purpose of the interview is more ambiguous yet. In addition, the current process is supposed to be anonymous. But how can a process be anonymous and include an interview? Do the interviewers know the name of the person they are interviewing? Can the continual patching up and revising of the system really improve it? Or is it fundamentally flawed?
What kind of changes could make the certification process a more clear cut one? When advising doctoral candidates about their proposals for dissertation research, it is customary to ask them to formulate their purpose in a short paragraph. This then gets elaborated with the goal of their original purpose as the test of the reasonableness of any procedures that will carry out in order to investigate their topic. The same ought to apply to any project, whether research or application, whether carried on by students or by experienced professionals. Of course, there is no such thing as pure research in the social sciences just as there is no pure research in the physical sciences. The ideal of pure research in either field was effectively shattered in the wake of atomic physics, Nazi racial science research and the boom in revelations of the non-disinterestedness of other branches of science. In the social sciences, for example, the mass testing methods and procedures used today were originally developed for military use in the second world war.
So the testing for competence in psychoanalysis has not been disinterested either. In addition to its purpose in eliminating the people who do not understand analytic concepts (if there are any such among graduates of accredited institutes, there are also more political agendas. Screening out those who the current holders of the standards believe to be indifferent or even antagonistic to the current standards is another agenda. This specifically was addressed by some of the contributors to the recent e-mail discussion of the certification process. They believed that they were screened out because they were too rebellious or too independent, or too arrogant. They had been deemed to be unreliable as upholders of the current standards.
Competence and reliability were not the only standards to become apparent in the e-mail discussion. A third standard that was stressed and the appeared to be important in my own experience was that of persistence. After my disastrous interview in Toronto I was assured by the then chairman of the committee that everyone would understand if I did not wish to continue the process. I took this to be a gentle nudge toward giving up and going away. Others on the e-mail network mentioned being told the same thing. No one would blame anyone who wanted to withdraw from the process. This message was, it seemed to me, to serve two purposes: it showed the compassion of the committee members, but it also had the probably unintended consequence of establishing an easy way for the candidate to be in charge of failing himself or herself rather than having the onus put on the committee. The final decision was the candidate’s own.
The process was a potential bonding experience for the committee members. It made them a band of brothers and sisters, not unlike the members of a military organization or a fraternity or sorority when potential new members are inducted by hazing. It also served to make the new members a part of the process. Once having passed, I found myself seeing the process in new terms. Maybe it was not so bad. The second committee had accorded me the courtesy and collegiality that the first had not. There were good guys as well as bad guys in this group. I would like to be friends with the good guys.
The temptation to do nothing further, to say nothing and let those with longer tenure in the American debate the issues was strong. Why should I take on another battle? I had several papers in the works, a very busy practice, lots of friends and some relatives to be involved with, why did I need to make trouble? At the end of the day, it was because I read the e-mails over again and thought that there were several points I could add to the discussion. One was the matter I began with here. The matter of how cases need to sound in order not to ring any alarm bells in the minds of any committee members. This includes the idea of negative space, the events, coincidences, insecurities and doubts that occur in any analytic relationship. The idealizations that our patients form around us, the demonizing images they have of us are acceptable. The moments when we actually take on these qualities are not. One analyst lends his patient subway fare after her wallet has been stolen, another takes a fainting patient to the hospital, another offers to lower the fee if the patient will agree to being a training case, another feels sympathy for the parents of a patient who is about to deprive them of their grandchildren. The list of “transgressions” people actually commit in the course of an analysis is both large and diverse. How can the candidate for certification know whether it is acceptable to do or even feel any of these things? Better to omit them from case presentations; better to relegate them to negative space.
The result of doing this is that the candidate believes that the committee is correct. A real analyst would not have such unruly patients. A real analyst would be willing to do only what previous analysts had determined was a really analytic intervention, not what the momentary inspiration seemed to dictate. The true analyst would not be so impulsive as to respond to her patient, nor would she be so vulnerable as to feel unacceptable feelings. And if she did feel or do those things she would at least have the discretion to conceal them. Therefore she must be a fraud, a pretend analyst at best. She must conceal this from others in the future by showing them that she has high standards, that she is a real analyst after all. Maybe the problem was just that she had a bad patient. Maybe with a better analysand she could have been a real analyst. Maybe getting on the committee herself would prove that she was one of the best, the people fit to choose who was in and who was out. Psychological research into this area has shown that when people act against what they believe to be right, they then justify their actions by believing that they are doing the right thing. Was I fooling myself this way?
I re-read the paper by Steven Bernstein on how to write up a case for certification while thinking about my writing up my own cases. He was so reasonable, requiring merely that the writer show the reader how he thought about his interventions. And he allows for the possibility that the writer would have done it differently now. So where’s the beef? The beef is that the task is impossible. How can one ever recapture the details even of the conscious part of the process? And how much of the unconscious and preconscious processing of the interaction is missed? All one can do is fill in the negative spaces. One can say one thought this or that in order to avoid knowing that one did not know what one was acting on at the moment of an interpretation.
It was while in this frame of mind that I read about the problem of bi-lingual education in the New York Times Magazine on Sunday February 1, 1999. Because the bi-lingual programs were originally set up to address a political agenda, they had been supplied with an educational rationale post hoc. The idea of bi-lingual education provided a cohesive voting bloc to the Southwest states where a large proportion of the population was Spanish speaking. The Spanish speakers could be powerful in addressing their political needs by keeping the younger generations solidly Spanish in acculturation. This led to the idea that teaching the children other subjects in Spanish would enable them to learn math and science, for example, in a more effective way. As the students, parents and teachers in other ethnic groups insisted, however, the quicker children learn English, the more they are able to make their way in all the other subjects in school. Chinese children, for example, preferred learning advanced math in English rather than stick with the grade level math taught in Chinese.
We are in a similar position with the certification process and the cases write-ups and presentations used to determine who is a real psychoanalyst. The political purpose of having a cohesive organization with the power to set and keep standards of public expression of beliefs is served by the process. The idea that the process serves to safeguard standards of what people do in their private offices or what goes on in the privacy of their thoughts is not a tenable one. When there is that mismatch between the public assertion and the private doubt, the sense of untruthfulness takes hold. This parallels the political aim being set forth as an educational goal, another instance of something meant well but feeling bogus because it covers another agenda.
What are the alternatives? Here Bernstein is very valuable. He asserts that the supervisors know the candidates and their work better than anyone else does. He regards this as a disadvantage at the end of the process in that the supervisor cannot be objective in doing a final evaluation of the work on which he or she has been a collaborator. And I believe that he is correct. There should be some outside observer to correct for this investment of the supervisor in the process. It seems to me that one way to change the process to make it more meaningful would be to have the progress of candidates be overseen by a committee of all the supervisors who see that candidate and an outside person, preferably an analyst from a society other than the one the candidate and supervisors belong to. The outside person could meet with the supervisors once a year and could keep in touch by e-mail or telephone if necessary. Then the outside person and the supervisors, in conjunction with the candidate, could decide when that candidate is ready to be a real analyst in practice on his or her own steam. This model is drawn from the experience of the New York Psychoanalytic Institute which monitors progression in this way. It also conforms to the pattern used at the Baltimore-Washington Institute and may reflect the practices of other institutes as well. The difference from the current practice at these institutes is the addition of an outside member of the committee, the person from another institute. The idea would be to have the outside member as a representative of national standards. This would allow the committee to function as advisor and standard setter rather than its current function of gatekeeper. The gate keeper must show some of the candidates the gate in order to justify the time and work put into the process, so that under the current system failure to progress must be visited on as many as half the applicants for certification. But if the certification committee were to be involved with progress, it could set standards without inflicting the narcissistic wound of failure on so many colleagues.
By eliminating the stigma of failure, the committee could be a welcome part of the process of becoming a fully trained and accepted analyst and could instead encourage each candidate to learn as much as he or she is capable of learning. The case reports could be a legitimate record of the progress of the analysis, constructed over time in journal form rather than a construct made to please a committee by submitting to the standards set by the past. The idea would be to encourage innovative thinking, finding new ways to think about and describe what we do rather than to conform to a pattern.