Edwin Fancher has responded to No one owns psychoanalysis (the first editorial posted on August 7th). He addresses the issue of times per week by giving us his history of Freudian psychoanalytic training starting with the Eitington model in Berlin. Mr. Fancher’s contribution is presented as an opinion piece rather than a comment because of its substance, as was Jennifer Harper’s piece, NAAP and Licensing: Fact and Fiction, (August 28th) because of its depth and breadth.
There are many schools of psychoanalysis. This Editorials section of the blog is open to all who are interested in writing Op-Ed articles and comments on them.
The Op-Ed format gives us a forum for exchanging ideas with each other and expressing opinions. The blog form is not impeded by space requirements so all opinion pieces and comments can be posted. Analysts have a tendency to talk past each other instead of listening with open minds. Vehemently defending our beliefs affects our ability to see beyond them. Civil dialogue leads to growth.
Write soon.
Jane S. Hall, Op-Ed Editor
——————–
An editorial by Edwin Fancher
a founding director, Washington Square Institute for Psychotherapy and Mental Health founding president, New York School for Psychoanalytic Psychotherapy and Psychoanalysis
I would like to support Rick Perlman on the issue of the inadequacy of the standards of training for the New York State Licensed Psychologist status, which are based on standards promoted by the National Association for the Advancement of Psychoanalysis (NAAP). I have many disagreements with the NAAP standards, but believe that the most important issue is the lack of a frequency in the requirements for psychoanalytic training, which I will address.
Frequency has a long and complicated history in psychoanalysis, but I believe it is worthwhile to review some of that history, and I will touch on a few points in regard to how the issue of frequency influences: 1, the definition of psychoanalysis itself, 2. the distinction between psychotherapy and psychoanalysis, 3. the controversy over lay analysis, 4. scientific research into clinical technique, and 5. political controversy between organized professional groups on a state and national level.
Since the standards for psychoanalytic training were developed by Eitingen at the Berlin Clinic in the mid 1920’s the requirements for a training analysis and for the required two or more supervised analyses have been four or more times per week at institutes affiliated with the International Psychoanalytical Association (IPA), including those of the American Psychoanalytic Association (APsaA). The Eitingon model also requires several years of seminars on the theory and technique of psychoanalysis.
When Karen Horney’s group, the Association for the Advancement of Psychoanalysis (AAP) split off from the APsaA in 1941 they followed the Eitingen model and maintained the four time per week standard, but when the Sullivan and Fromm group left AAP to form the William Alanson White Institute (WAW) in 1943, they also followed a modification of the Eitingon model in that they adopted a requirement of a minimum of three times per week for training analysis and supervised cases rather than four. They also became the first American psychoanalytic training institute to accept non-medical candidates, although only psychologists, and a limited number of them.
By 1948 the dispute over Theodor Reik’s status as a lay analysts was resolved when he founded the National Psychological Association for Psychoanalysis (NPAP), the first really independent institute open to training “lay analysts,” as Freud had wished, including artists, teachers, lawyers, and philosophers, as well as psychologists and social workers. The NPAP followed the modified Eitingen model, similar to WAW, in that they required three times per week for training analysis and supervised cases. Their charter with the Department of Education of the State of New York allowed them wide latitude to grant certificates in psychoanalysis to professionals other than the traditional members of the mental health professions.
Thus, by the 1950s all IPA affiliated training institutes, and the most prominent non-affiliated institutes in New York based their training on a common assumption that psychoanalysis represented a special form of psychological treatment requiring a psychoanalytic process, and that this process requires a patient who is appropriated for this treatment, and a trained analyst, and a frequency of three or more sessions per week. The commons assumption was that the frequency of treatment does not in itself define a psychoanalysis, but is part of the definition, just as free association, transference and neutrality are essential components. Frequency had become a de facto part of the definition of psychoanalysis and, as a rule of thumb, distinguished it from psychoanalytic psychotherapy, which was commonly understood to be once or twice a week treatment.
In succeeding decades numerous training institutes opened in New York and the New York metropolitan area. Some were devoted to training in psychoanalysis and followed the Eitingen model as modified by WAW and NPAP, i.e. required three times per week treatment. Some new psychoanalytic training institutes were founded by dissatisfied graduates of NPAP, and were influenced by the IPA model which required four times per week treatment. These included The New York Freudian Society and IPTAR which later affiliated with IPA following the law suit in 1986. Some institutes, such as the Institute for the Study of Psychotherapy (ISP), founded by Gertrude and Rubin Blank, trained only in psychoanalytic psychotherapy. Other institutes trained in both psychotherapy and psychoanalysis, such as The American Institute for Psychotherapy and Psychoanalysis, and The New York School for Psychoanalytic Psychotherapy and Psychoanalysis, which started as a psychotherapy school. Many training facilities were free standing, but others were developed by psychotherapy clinics, such as the Washington Square Center for Psychotherapy and Mental Health, the Postgraduate Center for Mental Health, and there were many others.
In most cases psychotherapy seemed to fit well as part of the family of psychoanalytic treatments, but not completely. Even within the APsaA there was dissent about the parameters of what should be considered psychoanalysis. By the early 1950’s APsaA was involved in a bitter conflict with Franz Alexander and his followers who wished to promote less intense treatment to be accepted as psychoanalysis. The first issue of the Journal of the American Psychoanalytic Association in 1953 was devoted almost entirely to this dispute. Although the use of “suggestion” was most often argued as a criticism against Alexander, the role of reduced frequency was also always an issue.
By the 1950ies the rapid growth of psychotherapy and psychoanalysis had made many psychologists nervous about the issue of lay analysis, i.e. who had the legal right to practice psychotherapy, The New York State Psychological Association launched a campaign to protect the interests of their members. They tried to pass a law to establish a “scope of practice” license for psychologists, which would include their right to practice psychotherapy and psychoanalysis Despite opposition, in 1956 they were able to pass a law providing for psychologists with PhD training to become certified psychologists in New York State. However, they were able to do this only by agreeing to allow a “grandfather” psychologist status to a class of practitioners who were already in practice and had some graduate training in psychology, and usually some institute training, most often at NPAP.
Soon after this victory, they pressured the State Department of Education to refuse to allow new training institutes to issues certificates in psychotherapy or psychoanalysis to anyone who was not a licensed or certified mental health professional, i.e. a psychiatrist, psychologist or social worker. This closed the door to training for non-tri-discipline candidates at new chartered institutes, leaving NPAP as the only training facility open to them.
Thus, there developed three levels of psychoanalysts: members of the elite APsaA, who were almost all psychiatrists. The next level were licensed or certified mental health practitioners, psychiatrists, psychologists, and social workers, most of whom had graduated from one of the non_APsaA training institutes. The third group became a new class of “lay analysts” as Freud considered them, i.e. a variety of diverse professionals, some with very good psychoanalytic institute training, and some with very little. This third group often found it difficult to be accepted for training in some of the non-medical institutes. They had no legal status and were worried about making a living as analysts since they were usually not recognized for insurance reimbursements and often felt alienated and discriminated against.
These developments were threatening to increased numbers of graduates of NPAP who were not mental health professionals. In 1972 a group of mostly NPAP practitioners organized the Center for Modern Psychoanalytic Studies. They took the leadership in organizing the National Association for the Advancement of Psychoanalysis (NAAP). This was a loose organization of therapists and analysts, and societies and training institutions, not only in New York, but across the country. They were committed to two goals: one, that psychoanalysis was not the property of the traditional licensed mental health professions, but should be open to true “lay analysts” as described by Freud. They were determined that non-tri-discipline practitioners should achieve a scope of practice license in psychoanalysis on a federal or state level. Their second goal was to establish that psychoanalytic training should no longer require frequency of treatment for the training analysis or the required supervised treatments, thus re-defining and eliminating the traditional distinction between psychotherapy and psychoanalysis. They organized into a coalition of many individual practitioners, mostly non-tri-discipline, with many diverse societies and self proclaimed analytic training groups, such as Adlerians, Jungians, Laconians, and others, thus presenting a widely divers panoply of theoretical orientations.
The non-tri-discipline practitioners were particularly alarmed when in 1975 the APsaA, always adamantly against non-medical analysis, proposed that it be recognized by the United States government as the accrediting agency for all psychoanalysis in America. This move was defeated, with the opposition of many groups. Subsequently, NAAP applied to be recognized as the only legitimate accrediting organization for psychoanalysis, first on a national level, and when that failed, in various states
In New York, the Council of Psychoanalytic Psychotherapists (CPP), a loose association of training institutes and practitioners, had promoted standards of training for psychoanalytic training institutes based on the three time a week minimum treatment of the the Eitingen model and different standards for psychotherapy training institutes requiring less frequency. On two occasions CPP actively opposed NAAP’s attempt to become the national accrediting organization based primarily on the lack of frequency requirements for psychoanalytic training.
Although it appeared that most professionals in the mental health area recognized the distinction between psychotherapy and psychoanalysis on the basis of frequency, there were others, besides NAAP, who increasingly asserted that frequency was not an element in defining psychoanalysis. The most important such group was in Division 39, the Division of Psychoanalysis of the American Psychological Association, organized in 1979. One part of the membership formed Section One, Psychologist Psychoanalyst Practitioners, which required institute training based in three times per week training analysis and supervised analysis. Another group of members organized Section Five, Psychologist-Psychoanalysts’ Forum, which later changed its name, despite much opposition, to Psychologists Psychoanalyst Clinicians, where membership claimed recognition as clinicians but did not require a training including frequency of personal psychoanalysis or supervised psychoanalysis.
The settlement of the law suit in 1986 opened up IPA to non-medial analysis, so that four non-medical training institutes which required four times a week analysis were accepted into IPA. However, this achievement still left many analysts behind. NAAP received no recognition and WAW and NPAP were left out, primarily on the basis of the four times per week requirement of IPA.
By the 1990’s some analyst realized that if psychoanalysis was to be saved as a living profession in America some program of accrediting psychoanalytic training institutes based, on common sense compromises would have to be made. The fact that many reputable training institutes had functioned for decades on the basis of three times a week analysis led to the formation of the Accreditation Council for Psychoanalytic Education (ACPE) in 2000-06. The ACPE established criteria for accreditation of psychoanalytic training programs which included an academic and clinical curriculum of at least five years and a training analysis and supervised analyses of at least three times per week. ACPE was organized by a committee including representatives of the American Psychoanalytic Association, the Academy of Psychoanalysis and Dynamic Psychiatry, the Division of Psychoanalysis of the American Psychological Association and the National Membership Committee on Psychoanalytic Clinical Social Work. After years of preparation, ACPE started to evaluate psychoanalytic training programs for accreditation in 2007.
As everyone knows, NAAP spent over thirty years promoting its agenda with persistence, dedication, and a great deal of money devoted to lobbying federal agencies, and later, state legislatures. They were successful in passing a law establishing a Licensed Psychoanalyst status in New York and in some other states. Evidently, in New York State, a deal was made by the New York State psychologists with NAAP to allow the passage of the NAAP Licensed Psychoanalyst bill to pass if NAAP agreed not lobby against psychology’s scope of practice license bill, which was subsequently passed. This was a secret decision by the leadership of the New York State Psychological Association to abandon psychoanalysis to NAAP that was hardly democratically decided.
The issue of the relevance of frequency to psychoanalysis is ultimately a scientific issue. Eventually, we should have scientific measurements that will demonstrate whether five, or four, or three times per week treatment will yield significantly different results than once or twice a week treatment, other things being equal. But, pending that long-term goal, those of us who feel we have experienced the unique process of psychoanalysis several sessions a week, and have had life changing experiences in our own analyses, and good results in practicing it, and are convinced that psychoanalysis is not once or twice a week therapy is a unique process that, when it works, should be recognized as such.
But, let me be clear that I do not wish to denigrate psychotherapy. Psychoanalytic psychotherapy also requires good training to develop effective practitioners. Psychotherapy is as valuable clinically as psychoanalysis, as Kernberg has pointed out, and is the treatment of choice for many patients. It can be of enormous help for many people and is often the preparation for psychoanalysis. Good training in psychoanalytic psychotherapy has often been neglected and requires standards for training comparable to those for psychoanalysis.
The new NAAP sponsored New York State License in Psychoanalysis achieves the goal of opening up psychoanalytic training to non-tri-discipline practitioners broadly and giving them a legal basis for practice. The law also provided for a generous “grandfather” category of Licensed Psychoanalysts who had been in training at NAAP institutes. However, it is based on a flawed view that psychoanalytic training can be conducted on a once or twice a week basis, ignoring the importance of frequency in developing a psychoanalytic process. This law attempts to change the traditional definition of psychoanalysis and undermines decades of improving standards of training in psychoanalysis.
Frequency does not guarantee a psychoanalysis, but it many be an essential condition for the establishment of a psychoanalytic process. I hope my high lighting of some of the historical events relevant to these issues will be of help in supporting Rick Perlman’s thesis that psychoanalytic training requires certain minimal standards, and that among these standards is the element of frequency in treatment.
Edwin Fancher (Full Disclosure: I am a “grandfathered” psychologist in New York State; a founding director of the Washington Square Institute for Psychotherapy and Mental Health; founding president of the New York School for Psychoanalytic Psychotherapy and Psychoanalysis, which recently became the second institute in the nation to be accredited by ACPE; a training and supervising analyst of the New York Freudian Society; a member of IPA, APsaA and CIPS. I am also a former president of the Council of Psychoanalytic Psychotherapists.)