Legal, Ethical, and Professional Issues in Psychoanalysis and Psychotherapy
ON THE CONSORTIUM'S PROPOSED NATIONAL STANDARDS
FOR PSYCHOANALYTIC EDUCATION
Cynthia McLoughlin, Ph.D.
The Spring 1999 issue of the Psychologist Psychoanalyst (the Newsletter of the Division of Psychoanalysis  of the American Psychological Association) contains the text of a "Provisional Draft of Standards for Psychoanalytic Education." In a headnote, Spyros Orfanos, the president of Division 39, emphasizes that the Division has not yet agreed to support these standards, and asks for feedback from the membership that will help the Board determine what outcome would be in the best interests of the Division's membership. In response to Dr. Orfanos' request, this article provides background information that is intended to help members place the proposed standards in their historical context.
A BRIEF HISTORY OF PROFESSIONAL EDUCATION
In the major professions, there have been certain common stages in the development of education. In the
first stage, people educate themselves through private study and apprenticeship. In every century before
this one, a professional person typically educated himself. He (almost invariably it was a he in those days)
studied on his own, hired on as an apprentice to an established member of the profession to gain the benefit
of his elder's experience and, when he felt he was ready, hung out his own shingle.
In the second stage, schools are established. Now, instead of learning the profession as apprentice to one "master," scholars are taught in groups by a number of teachers. Schools typically decide on a planned course of study that, if successfully followed, will lead to the scholar being granted a diploma or some other symbol of certification. The earning of this symbol of certification indicates that the individual has met some criteria decided upon by established practitioners. This is usually seen as increasing the confidence the public can have in retaining the services of a graduate of the school.
In the third phase, the profession comes under governmental regulation. This is accomplished in two separate but related ways. First, the government regulates the professions through the accreditation of schools or programs that purport to prepare scholars for the practice of the profession. Accreditation establishes minimal standards for training programs. Standards are established and programs are invited to apply to the accrediting body (typically a private professional organization, such as the AMA or APA, that receives its accrediting authority from the government) for certification that they have met these standards. This process is meant to protect both the student purchasing the professional education and the public by guaranteeing that the degree-granting institution meets basic criteria.
Up to now, psychoanalytic organizations have been free to accredit affiliated institutes--or not--according to their own standards. The American Psychoanalytic Association, for example, has kept a relatively tight gripon its institutes, removing its imprimatur from those that did not toe the line on a number of issues. Incontrast Division 39, forbidden by the American Psychological Association from performing accrediting functions, has exercised no direct control over institutes affiliated with its local chapters.
The second element of government regulation of professions is the licensing of individual practitioners. Licensing requirements may be different from and independent of the standards of the accrediting body. For one thing, licensing has customarily been a state government function, and accreditation has been a federal function. For another, to the extent that the two can be separated (which is not very great), licensing addresses itself to protecting the public rather than advancing the profession. For example, in Michigan, a person need not have graduated from an accredited doctoral program in clinical psychology to be fully licensed. Standards for the accreditation of programs are set by national leaders of a given profession and are geared toward educating practitioners in particular directions valued by those leaders at a given time.
Licensure, on the other hand, is an attempt to address the government's interest in protecting the public from practitioners who fall below a certain minimal standard of competence.
Licensing requirements apply to an individual not just at the time of entry into practice, but throughout his or her career. Rules for licensure may require a professional to meet criteria not directly related to (or in addition to) graduate education. For example, in Michigan, psychologists must complete 4,000 supervised post-doctoral hours and pass the National Exam in order to be fully licensed. A license may be revoked as a result of actions (such as felony conviction) that the state has decided make an individual unfit to practice. Through its licensing function, the state may attempt to require practitioners to keep up with new knowledge in their field. Thus some state laws require licensees to produce proof of "continuing education."
Psychoanalysis is traversing the same steps as the other professions in the development of professional education. But, in part because psychoanalysis is a new profession, coming on the scene when the older professions (such as law and medicine) were well into the second and even third stages, the steps in the development of psychoanalytic education have been telescoped. Thus while we are still straddling the first and second stages (apprenticeship and private study versus formal education) we are simultaneously running into the third (government regulation).
The first psychoanalysts were Freud's colleagues and personal "apprentices." The first institutes were formed in the 1920s, but institutes have never been the only recognized way to obtain an education in psychoanalysis--especially for psychologists. Up until the settlement of the GAPPP lawsuit, in 1989, psychologists and other non-M.D. applicants were severely discriminated against by most institutes and allowed to enroll only after they had signed the infamous "waiver," promising that they would never actually practice what they learned. By necessity, if not by inclination, many clinicians studied on their own and with teachers and supervisors of their own choosing and practiced what they learned without any formal certification. Section I of Division 39 (Psychologist Psychoanalyst Practitioners) has established standards for admission to its ranks, but considers the applications of self-educated persons on the same basis as those of persons who are institute-educated. The recent establishment of the diplomates in psychoanalysis by the ABPP was an attempt by psychologists to certify psychoanalysts without any requirement that they obtain
During the 1980s, there were rumblings within the federal Department of Education about the need to
establish accreditation standards for psychoanalytic institutes. Much to the surprise and consternation of
other psychoanalytic organizations, a group called the National Association for the Advancement of
Psychoanalysis (NAAP) made a bid to have its standards accepted by the Department of Education as the
standards for institute education. The NAAP is a group of psychoanalytic practitioners whose affiliated
institutes do not require candidates to have a graduate degree in a health-care profession before
undertaking psychoanalytic training. It has, for some years, promoted the idea that psychoanalysis should
be considered a separate profession, independent of psychology, psychiatry, or social work.
Toward the end of establishing psychoanalysis as a separate discipline, the NAAP has worked not only to establish accreditation standards for psychoanalytic institutes, but to establish state licensure for individual psychoanalysts. At this point, Vermont is the only state that licenses psychoanalysts, but similar laws are under consideration in New York and New Jersey. Under such laws, an individual must be specifically licensed by the state to practice psychoanalysis (current law in most states licenses psychologists, physicians, and social workers, but does not concern itself with who calls him- or herself a psychoanalyst).
In the early 1990s the Division of Psychoanalysis (Division 39) of the American Psychological Association (APA) joined with the American Psychoanalytic Association, the American Academy of Psychoanalysis, and the National Membership Committee on Psychoanalysis in Clinical Social Work in what has come to be called "the Consortium." The Consortium was formed in opposition to the NAAP's efforts and in response to the Department of Education's interest in establishing accreditation standards for institutes that would meet with the approval of the major psychoanalytic organizations.
The organizations that make up the Consortium oppose the accreditation standards proposed by the NAAP because they believe that divorcing psychoanalysis from the health-care professions will lower standards (essentially turning psychoanalytic institutes into master's programs rather than post-doctoral ones) and damage the reputation of psychoanalysis in the public mind.
The Consortium was formed with the idea that, if the major psychoanalytic organizations did not join together to come up with such standards, standards decided upon by the NAAP (or one organizational member of the Consortium, acting alone) would be accepted by the federal regulators and all institutes would be subject to standards in the establishment of which they had had no say.
Representatives of the four organizations that formed the Consortium began to meet to develop their own set of accreditation standards for psychoanalytic education. Under the proposed standards, educational programs would be accredited on the basis of standards decided upon by the Consortium, but each institute would also be required to meet the standards of its host professional organization.
The standards outlined in the Consortium's proposal are comprehensive: the selection of candidates (e.g., institutes must hold at least two interviews, and in at least one of those interviews, the applicant must present clinical material; candidates must hold a "mental health degree leading to certification or licensing in a mental health profession" and should have "a basic awareness of organic mental pathology and pharmacological regimens" as well as diagnosis and psychodynamics), practice of psychoanalysis, psychoanalysis of candidates, educational philosophy (an "open critical approach" and an atmosphere of respect are mandated), curriculum, supervision, evaluation of candidates, record-keeping, ethics, faculty development, and site visits, among other things, are addressed.
THE CONSORTIUM PROPOSAL AND THE ISSUE OF THE DIVISION'S IDENTITY
Some commenters on this proposal have framed the question in terms of an overarching tension in the
identity of the Division: Do we see ourselves primarily as psychologists or primarily as psychoanalysts? If we
see ourselves primarily as psychologists, this reasoning goes, we will probably reject the Consortium's
standards in favor of a separate accreditation process run by the APA, pursue closer alliances with
non-analytic psychologists and the Practice Directorate, and continue to treat non-psychologists as
second-class members of the Division. If, on the other hand, we see ourselves primarily as psychoanalysts,
we will probably adopt the proposed standards, seek alliances with other analytic organizations rather than
within the APA, and welcome non-psychologist psychoanalysts as full voting members of the Division. While
this dichotomy is not all encompassing, many observers agree that it is an apt characterization of major
points of view in the debates currently occupying the Division.
PROS AND CONS
Those who urge the adoption of accreditation standards emphasize that psychoanalysis is such an important
and complex endeavor that it is important to set high standards of training to ensure that persons with
insufficient education and experience do not harm either their patients or the reputation of psychoanalysis as
a profession. Nathan Stockhamer, Ph.D., one of Division 39s representatives to the Consortium, said: "I think
the proposal is an important development in the maturation of training in psychoanalysis which, in my view,
is a specialization within each of the major health-care professions rather than a separate profession. The
proposed standards are important as a guarantee to the public that a person who has graduated from an
accredited institute has undergone rigorous training in psychoanalysis and as a guarantee to the prospective
candidate that an accredited institute will provide him or her with such training."
Some supporters of the proposed standards argue that the movement toward accreditation of institutes is inexorable and that, if the Division does not agree to some version of standards, the other members of the Consortium will go ahead without us, and psychologists will be subject to standards set by other groups.
Many observers see the Consortium's efforts as significant because of the collaboration they represent among the major psychoanalytic groups - groups that have traditionally been at odds over many important issues. Tensions among the groups are still evident, however, in the debate over such passages as: "It is recommended that candidates undertake the supervised analysis of at least three adult cases, with a required minimum of two adult cases, at an expected frequency of four or five times a week, with a minimum frequency of three times per week." The wording was a compromise between the representatives of the American Psychoanalytic (which requires candidates to conduct analyses a minimum of four times a week) and of Division 39 (which represents a significant number of members whose institutes require a minimum of three times a week). Some members of the Division resent the implication that analyses conducted at three times per week are substandard, and believe that such wording sets up a "two-tiered" system, in which the American's standards are presented as superior.
Those who oppose the adoption of this proposal do so for a variety of reasons. Some are affiliated with institutes whose existing training standards do not comport with the proposed standards. As a result, their training programs would not be accreditable. Institutes recognize that, once any set of standards is adopted, all institutes will have to work to get and keep accreditation because candidates, status, and income will all go along with accreditation and the lack thereof with the failure to win accreditation.
It will not surprise anyone familiar with Divisional politics to learn that wrangling over numbers--sessions-per-week of analysis, clinical work, and supervision--has been a major factor slowing down the adoption of any particular set of standards. No institute wants the stigma of not being up to snuff according to whatever standards are decided upon. To make sure that this doesn't happen, they must protect their interests as accreditation standards are written. The issue is of such critical importance to the survival of institutes that lawsuits have been threatened over numerical questions.
Another set of opponents of the proposal take issue with the fact that the proposed standards do not acknowledge any route to psychoanalytic education other than that gained through institute training. In a recent letter to the Division president, Etta G. Saxe, Ph.D., president-elect of Section IV, wrote: "The Section I [membership requirements make] it clear that the tradition of accepting and supporting self-directed, other-than-institute training is being maintained and seen as a valid equivalent for admission to Section I. In doing this, Section I not only acknowledges the reality outside of New York and a few other major cities of the limited so-called formal training opportunities, but more importantly supports a traditional (although not American) psychoanalytic perspective and value, i.e., the value of diversity of all kinds.... Even if few use the equivalency possibility, its presence is a message to all and a statement about the nature of psychoanalysis
and the psychoanalytic enterprise."
Yet another set of opponents of the proposal argue that psychoanalysis "ought to learn from history rather than repeating it" (or that psychoanalysis does not inevitably have to follow the stages other professions have followed in the development of professional education). They argue that national standards do more harm than good because they ignore important and valuable differences in educational philosophy and theoretical orientation, making educational programs more uniform, but not necessarily any better.
Yet others simply say that adoption of these standards would be premature. Marvin Hyman, Ph.D., a past president of Division 39, is among this group. Reached for comment on the proposal, he said: "The development of standards is such an extraordinarily important activity that it requires extended study, care, and discussion, and should not be undertaken precipitously. To date, the Consortium--however laudable its efforts--has not had sufficient time to consider all the implications and significances of these standards."
This article is reprinted with permission from the newsletter of the Michigan Society for Psychoanalytic Psychology, where it was first published in June 2000. The author may be contacted at CMcLoughlin@AcademyProjects.org
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