CORRESPONDENCE RELATED TO THE REGULATION OF TALKING THERAPIES
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LETTER FROM DR. PAOLA MIELI TO HER COLLEAGUES IN THE USA (1)
Questions Raised by the Report of the Psychoanalytic Consortium on Analytical Training.
Letter to Our American Colleagues.
In 2001, four major American psychoanalytic associations, grouped together under the umbrella designation of The Psychoanalytic Consortium, formally drafted and ratified a document titled "Standards of Psychoanalytic Education." These four organizations are: the American Psychoanalytic Association, the American Academy of Psychoanalysis, the National Membership Committee on Psychoanalysis in Clinical Social Work, and Division 39 of the American Psychological Association. In her official presentation of the "Standards of Psychoanalytic Education," Dr. Laurel Bass Wagner explains that this document is the fruit of compromise among the different opinions of the organizations that ratified it -- a process that took roughly two years and, to some extent, left everyone involved dissatisfied (2). It nevertheless represents, in the words of Dr. Bass Wagner, "an enormous achievement." In support of this document, the Consortium has established an entity called the Accreditation Council for Psychoanalytic Education (ACPE), which is seeking official recognition as the national accrediting body for psychoanalytic training institutes. The express goal of this body is to gain authorization from the US Department of Education as the accreditation center for psychoanalytic institutes in the United States.
Given the nature of the document and its grave implications for how psychoanalysis is understood and taught, for its very present and future, it appears crucial for us to join in this debate. Let's do it by approaching the issue over a common point of reference: Freud's own teaching. In light of the importance of the matter at hand, it is to be hoped that psychoanalytic associations will acquaint themselves with the Consortium's proposal and voice their opinions regarding its aims and substance.
The impetus behind the "Report to the Psychoanalytic Consortium on Analytical Training" can be understood as an attempt to overcome the discrepancies among the training practices of the four major American psychoanalytic organizations, in order to achieve a high level of professionalism in the field and protect the public from malpractice. The document can also be seen as reflecting an effort on the part of psychoanalysts to assure their legitimate authority by establishing basic regulations for their profession, so as to avoid outside interference in their field from governement agencies, such as state or federal courts and legislatures. Finally, the document may be viewed as a strategic step towards the establishment of a coalition calling for recognition as the preeminent or sole authority over questions of accreditation in psychoanalysis, with power of selection and exclusion.
Psychoanalysts are rightfully concerned about the importance of transmitting psychoanalysis in the best possible way, guaranteeing the professional quality of psychoanalytic practice. They have an ethical duty in this regard: first, in relation to the individuals they prepare for the profession; second, in relation to their present and future patients; and third, in relation to the practice and dissemination of the analytic discourse itself. In this respect, psychoanalysts have every reason to claim their authority to establish the regulations of the very profession they practice, since no one outside the profession could fully grasp its complexity and particularity. Indeed, psychoanalysts have a duty to respond to the social reality in which they practice, and must themselves vouch for professional quality and ethical performance.
Over the years, psychoanalytic associations and institutions have fulfilled the task of providing analytic education, functioning from the first as an interface between individual training and social requirements. It is not clear why a single body responsible for the accreditation of training institutes according to the Consortium's specific standards would now promote better training and provide guarantees of performance. Some colleagues may claim that standards of training in different institutes are too unequal and that certain institutes do not even apply what many consider to be basic requirements. If this preoccupation is truly central to the Consortium's proposal, it would behoove us to examine the Consortium document more closely and reflect upon the standards it contains, as well as upon how those standards purport to improve the quality of analytic education.
Many comments could, of course, be made regarding the Consortium proposal. We will confine ourselves to just a few basic questions.
Any psychoanalyst belonging to the Freudian tradition cannot help but notice that the very requirement the creator of psychoanalysis considered to be the fundamental condition – the conditio sine qua non -- for any possible approach to the formation of the analyst, is put in a secondary place by the Consortium, which gives priority to such issues as the "selection of candidates" and their "eligibility" (3) and "suitability for psychoanalytic education and training" (4). Only after discussing why and how a candidate is selected for training does the Consortium document mention "Psychoanalysis of candidates," recommending a personal analysis "characterized by depth and intensity." This order of things may indicate some of the reasons why psychoanalysts are so often dissatisfied with the outcome of the analytic standards they themselves have advocated.
The priority given to the selection of candidates (with all the requirements attached to it) manifests the spirit of the US tradition in professional analytic training. Considered from its inception as one therapy among many in the field of mental health or "mental hygiene," as a branch of medicine, psychoanalysis continues to be approached as a profession requiring standards of training comparable to those of other professions. The analytic institute has come to represent an establishment devoted to the production and the reproduction of a certain business, just like other professional schools, for instance, those for law, dentistry, accounting and so on. Once a candidate is deemed "fit" for the profession, s/he is already on track, and the experience to come proves predictable for most aspiring psychoanalysts. The candidate will simply have to follow the particular institute's regulations and duly meet its requirements, which may call for variations in the length of training according to individual "character and disposition." Within this framework, high standards encourage conformity. Professional quality coincides with business interests.
It is striking that, in the history of North American Psychoanalytic Institutions, this order of things has never been seriously questioned. In fact, as Freud always insisted, psychoanalysis implies by its very nature a training that is not comparable to that of any other profession, since it implies the experience of the subjective division between unconscious and consciousness and, therefore, the confrontation with the unknown (including the unknown of one's own vocation, which may radically contradict one's career choices). It is not by chance that Freud considered personal analysis to be the condition for becoming an analyst: we cannot know what the outcome of a personal analysis will be. The desire of the analyst can only be the consequence of one's personal analysis, not its condition. Such a desire cannot be confused with the wish "to become" an analyst, which, as an ideational formation or ideal identification, is nothing more than a symptom among others to be analyzed.
To assess "eligibility" prior to analysis on the grounds of involvement and experience in the mental health professions, implies the confirmation of a choice already made , granting to it the status of a requirement, prior to giving a person the chance to analyze it and question it. As supervision attests, this results all too often in the institutional re-enforcement of symptoms, rather than their resolution.
It is of course to be wished that people who have chosen to work in the field of mental health -- social workers, psychologists, psychiatrists, nurses and so on -- will decide to undertake an analysis. This will certainly be helpful in the choice they have already made. Occasionally their analysis will make them into analysts. But to require involvement in a mental health profession as a main condition for a candidate to be eligible implies an error of timing, indicating an error of judgment, a problematic misunderstanding of the specificity and uniqueness of the analytic field. There is no way of shortcutting the process of analytic formation. The outcome of an individual's own personal analysis should be the grounds for his/her decision to become an analyst, for the discovery of that vocation; this will then imply the appropriate theoretical studies and clinical experiences, which the analytic institution should provide and supervise, independently of any previously made career choice.
Strikingly, the Consortium's idea of "suitability for psychoanalytic education and training", is, among other things, paradoxical, insofar as it expresses a mistrust in the process of psychoanalysis: if we believe in the effectiveness of analysis, why should a person not become "suitable" as a result of his/her own analytic experience? Is analysis not the prime instrument for effecting a subjective ethical change, a "subversion," which may lead to a new relation to life, to vocation, to creation? To assuming responsibility, as Freud teaches us, for the very causes of which we are the effect? Isn't this experience itself what grounds the coming-into-being of the analyst's position, of his/her capability to handle the transference, to direct a cure and to transmit the analytic discourse?
The notion of "suitability" proposed by the Consortium necessarily implies an idea of normativity and, with it, a preventive pedagogy: not only can someone deemed "unsuitable" be excluded, but it will also be possible, for instance, to "fix" certain symptoms or character traits and make a candidate fit the standards of the institute. This reflects the belief in a deterministic philosophy that presupposes a pre-established, wholly transparent knowledge -- precisely what the process of psychoanalysis refutes (5). This determinism implies operating according to a fixed model, a norm that excludes differences, chances, revelations, unknown and unexpected transformations.
It is apparent that the Consortium's notion of "psychoanalysis" has little to do with Freud's idea of psychoanalysis. To begin with, Freud is fundamentally opposed to determinism and deterministic pedagogy, since they contradict the very discovery of the unconscious, the discovery of the contingent and over-determined factors at work in the unfolding of psychic causality. These factors, which define the specificity of each individual history, can only be analyzed in the aftermath. The idea of a fixed model for understanding is in stark contrast with Freud's own notion of science, which is built upon theoretical models as temporary working models subject to being refuted.
Let us now turn to the Consortium's definition of psychoanalysis:
"Psychoanalysis is a specific form of individual psychotherapy that aims to bring unconscious mental elements and processes into awareness in order to expand an individual's self-understanding, enhance adaptation in multiple spheres of functioning, alleviate symptoms of mental disorders, and facilitate character change and emotional growth". (p. 8)
We immediately see that psychoanalysis is included within a mental health ideology inspired by a medical discourse driven by the idea of adaptation, symptom relief, and assimilation. It refers to a conception of psychic reality defined according to the categories of "good" or "bad" functioning. In a case of "inappropriate functioning" of the mental organism, therapy aims at re-establishing a mental balance analogous to the physical balance regained after illness. Considering a symptom to be the sign of a mental "disorder" implies the belief in a "natural" or "neurophysiological order." This reflects a return to -- or the persistence of -- a 19th-century medical conception that preceded the Freudian discovery of the subjective division. But Freud has shown us that the unconscious is structured and that a symptom, far from being the sign of a disorder, should be understood as the result of a specific order of things, as a compromise formation conveying a subjective truth.
According to its founder, psychoanalysis is to be distinguished from what is generally referred to as therapy. Thanks to the understanding and handling of the transference, psychoanalysis aims not at "suppressing the symptoms," as Freud puts it, but rather to overcome the subject's resistances, which are grounded on a specific libidinal economy (1926: p.225). As every psychoanalyst knows, the disappearance of a symptom or a behavioral "assimilation" does not in itself represent the completion of a cure; occasionally, it may happen that such occurrences actually represent resistance to the cure.
To the concept of "therapy", psychoanalysis opposes the concept of cure, that is, the confrontation with the subject's division and the truth of one's unconscious desire. Such a cure involves the modification of a subject's libidinal economy, which entails the resolution -- not the suppression or alleviation -- of specific symptoms or inhibitions. Analysis is a process of discovery and novelty; the logical time that organizes a subject's structure and history gives to it a particular rhythm; it is a process that can only unfold within the articulation of the transference and its resolution. Every case is a unique case, an "exception," that cannot be reduced to the generality of a diagnostic category. It is not by chance that Freud recommended that analysts approach each and every new patient's analysis as if it were the first they ever handled. To the categories of "general" and "particular" inherent in the notion of norm, psychoanalysis opposes the notions of structure and singularity.
Regarding the notions of "awareness" and "understanding" stressed by the Consortium, let us remember that the process of analysis is specifically characterized by the unfolding of events within the transference generating subjective transformations independently from the subject's awareness; so much so that an analysand is most often incapable of understanding the nature of such transformations. If "understanding" occurs at all, it may only be in the aftermath of the experience. Contrary to intellectual awareness, which is grounded on faith in a rational ego and the belief in a full translatability of unconscious processes into consciousness, psychoanalysis defines itself as the experience of the subjective division. The subjective division cannot be reconciled or undone; it implies awareness and unawareness, revelations and misrecognitions -- the confrontation, as Freud puts it, with the irreducible nature of a subject's castration. This process is underlined much more by emotions, affects and surprises than by intellectual realizations. And the transformation of the subjective position brought about by the end of an analysis leads more to a savoir faire, a "know how" to handle life, desire and limitations, to a new creativity, than to any intellectual understanding.
In opposition to any idea of conformity, psychoanalysis is fundamentally an experience with and towards otherness, a practice of de-identification that enhances the relation to difference. It is the subject's practice of "exile," a leaving behind of mystifying individual and group identifications and of the guarantees provided by the already known. It is a journey towards what is unknown and foreign within the subject, as manifested, for example, in the formations of the unconscious. This practice of exile leads towards the progressive "deconstruction of a person's idolatry (ego narcissism and super-egoic requirements)," towards the "encounter, in the rigour of one's speech, with one's singularity, style and difference" (Fuks, 2002, p.20).
For this to occur, it is necessary that transference, the main tool of and obstacle to the cure, as Freud defines it, must unfold to its end. And this means accepting that the analyst has relinquished the position of the "subject supposed to know". The Consortium's proposed requirements seem, instead, to encourage a candidate's identification with his/her analyst and teachers. This emulation, by fostering devotion to the same ideals, reinforces group identifications and symptoms, while excluding difference, autonomy of style and the possibility of new creations - including research and advances in the field of psychoanalysis. No wonder, then, if the results of such emulation are repetitive and poor psychoanalytic productions, as the landscape of institutional psychoanalytic literature largely shows.
There is no way to shortcut the process of analysis. The making of an analyst --a formation, more than mere education and training-- involves a process much more rigorous, unique and complex than the one outlined by the Consortium's proposal. The required minimum of 3 analytic sessions per week is in no way a guarantee of "depth and intensity," as the Consortium naively puts it (6). More than anything else, such a requirement once again points to a serious misconception about the very nature of psychic time and psychic causality. No required frequency can accelerate a subjective pace or provoke "depth;" much less can it substitute for the appropriate analyst's listening. Only this listening and the unfolding of the cure can establish the appropriate analytic frequency for each individual case, establishing the specific direction of a cure for the formation of an analyst.
Institutions have existed and do exist in the world that have approached analytic education differently than the Consortium's proposal. Such institutions successfully distinguish psychoanalysis from other professions. They respect the need for the best education while recognizing the uniqueness of analytic formation, making out of it a work in progress, a constant challenge. It would be fruitful for the Consortium to realize that, in the vast universe of psychoanalysis, the standards for training it proposes appear, first and foremost, to be notanalytical.
It is important, therefore, to reflect upon how the idea of a monopoly on the regulation of analytic standards of training could be beneficial and ask if it would not, in fact, lower the quality of training rather than the contrary. At any rate, doesn't this idea of a monopoly jeopardize the principles of psychoanalysis (and, for that matter, of democracy), grounded as they are on singularity, differences, pluralism? Should we foresee the establishment of an antitrust regulation to protect quality and variety in the field of psychoanalysis?
I will conclude these remarks by recalling Freud's recommendation: analytic education cannot be limited to the medical domain but must include several humanistic disciplines. As Freud writes to Ferenczi (7), the emphasis on medical training can only be viewed as a mask concealing the most dangerous resistance to psychoanalysis. In addition to regular courses, seminars, workshops and working groups in psychoanalysis, an institute should offer -- or request and supervise attendance in -- courses not only in psychopathology, differential diagnosis, neurology, pharmacology, but also in linguistics, anthropology, philosophy, literature, art, epistemology, history of religion, law. And it should make sure that participants take an active role and engage in forms of intellectual production, rather than merely play the passive part of students learning their teachers' words by rote. This broad field of differentiated disciplines will prepare the ground appropriately for the analyst's listening to the subject's discourse in all its cultural diversity and become the base for a psychoanalyst's continuing education. The coming into being of an analyst as the result of an analysis can then be seen as only a first major step into a universe of learning that will accompany him/her throughout life.
In the field of psychoanalysis, theory can only be the outcome of a practice. In turn, theory will inform certain technical approaches that practice may then redefine, producing new theoretical advances, and so on. This loop of experience, of which theory is a consequence, compels the analyst to permanent production, to permanent creation - if s/he really wants to occupy the place s/he claims.
Not an easy choice for a "career".
Dr. Paola Mieli
109 Third Avenue
New York, NY. 10003
(1) This letter has been published in: "Les nouveaux enjeux de la psychanalyse: subversion and conflictualité", Analuein, Journal de la F.E.D.E.P.S.Y., Strasbourg, 2004 ; "Come lavorare insieme in psicanalisi", Spazio Aperto, Nodi Freudiani, Rome,2004; Lacan e a formaçäo do psicanalista, Contracapa/Corpo Freudiano do Rio de Janeiro, Rio de Janeiro, 2004 .
(2) Laurel Bass Wagner, "Progress Report on the Psychoanalytic Consortium," Psychologist Psychoanalyst, Newsletter of Division 39, Vol. XXI, Fall 2001, Wahsington, D.C., p. 7 .
(3) According to the Consortium, eligibility for admission to an institute is first determined in terms of a candidate's graduate degrees and his/her involvement in the domain of mental health: "1. Graduate education. To be eligible to undertake psychoanalytic education, a candidate will possess one of these degrees: Ph.D, Psy.D, D.S.W., M.S.W., M.D., Ed.D. D.O., R.N. (plus a master' s degree with Clinical Specialist certification or Ph.D.) or a comparable mental health degree and education/training leading to licensure or certification for independent practice of a core mental health profession at the highest clinical level. [...]
2. The applicant will have the ability to diagnose mental disorders. [...]
3. The applicant will have had psychotherapy practice experience. S/he will have had close supervision of individual cases.[...]" ("Standards of Psychoanalytic Education, Accreditation Council for Psychoanalytic Education, The Psychoanalytic Consortium," Psychologist Psychoanalyst, Newsletter of Division 39 , Vol. XXI, Fall 2001, Washington, D.C., p. 8).
(4) On this point: "Suitability refers to the personal characteristics of the applicant that are deemed necessary for psychoanalytic education. The applicant will show evidence of integrity of character, maturity of personality, reasonable indication of capacity and motivation for self-reflection, psychological mindedness, clinical aptitude, and appropriate intellectual ability. [...] An ethics violation disclaimer will be part of the admission procedure. If an applicant has been found by a recognized professional or governmental body to have comitted an ethical violation the institute shall be responsible for reviewing the finding and documenting its conclusions and actions. If there is an ethics or malpractice case pending against an applicant the institute may defer its decision on the application until the case is resolved (ibid., p.9).
(5) It is interesting to note that, after defining the selection of candidates for analytic training in terms of "eligibilty and suitability," the Consortium feels obligated to specify that: "Applicants will not be excluded on the basis of race, color, ethnicity, religion, age, gender, sexual preference of physical disability. An anti-discrimination clause will be prominently displayed in official publications of the institute (8)."
(6) "Psychoanalytic work is characterized by depth and intensity which are achieved in the context of frequent treatment sessions over a long term. [...] The psychoanalysis of a candidate is expected to be conducted in person at a frequency of three to five sessions per week, for a minimum of forty weeks during a year and for a minimum of three hundred (300) hours. This criterion may be modified to accommodate candidates who are physically handicapped or who live and work at a considerable distance from an appropriate analyst. Such execptions shall be reviewed by the institute and its descision shall be documented (pp. 1; 3)."
(7) Letter, April 27, 1929.
S. Freud, The Question of Lay Analysis, Standard Edition, Vol. XX, pp. 183-258.
B. B. Fuks, "Judéité , errance et nomadisme: sur le devenir juif de Freud", Essaim, Revue de psychanalyse, n.9, Paris 2002, pp.15-25.
A LETTER FROM PROFESSOR ANDREW SAMUELS TO THE CONVENER OF PROFESSIONAL FORUM
Professor Andrew Samuels
148 Mercers Road,
London N19 4PX
Tel: 020 7272 1292
Fax: 020 7272 2122
18th. June 2004
Our profession has certainly suffered from divisiveness in recent years and, in the spirit of Ann Scott's words (BJP Vol20 No 3), I would like to draw the attention of practitioners, in Professional Forum, to the following:
1. The foundation of BCP itself, which had been long prepared in secret and was triggered by the refusal of an AGM at UKCP to accept what was termed (by the BCP-to-be) as the 'Security Council' model for the organisation of the profession of psychotherapy. In this model, all serious power and responsibility were to reside in a small number of long-established training bodies, all of which were psychoanalytic. The intent was to dominate the whole field of psychotherapy; not only psychoanalysis.
2. BCP's adoption of its 'Single Membership Policy' (no organisation could remain in BCP if it was also in UKCP). This policy caused splits in nearly all of its constituent societies, was of dubious legality, and causes friction to this day that could well damage attempts to achieve proper regulation of the profession: whether statutory; or via the Health Professions Council; or by enhanced voluntary models.
3. The announcement made by BPA-S (as it was then) to its members, making it seem very dangerous for them professionally if they continued to participate in the training of organisations that were not aligned with the policies of BCP. The threat was that they might lose their memberships of BPA-S and IPA.
4. The attempts by ACP to halt new developments in child psychotherapy, including making malicious complaints against the newer organisations in the field; instructing its members and trainees not to work for such organisations (and not to continue with their ongoing work). This culminated in ACP's withdrawal from UKCP, rather than accept the decision of the Registration Board to grant the use of the label 'Integrative Child Psychotherapist'.
5. The attempts (written and verbal) made by the Royal College of Psychiatrists (via its Psychotherapy Section in which psychoanalytically-oriented psychiatrists predominate) and the Tavistock Clinic to bring pressure on UKCP not to permit its Registration Board to allow the use of the label 'UKCP Registered Psychoanalyst'. The threat was, and continues to be, that these organisations might leave UKCP, were the contentious label to be granted.
I believe that what the profession as a whole needs to debate, and in respectful and creative terms, is the present distortion of our field by the power and influence of BPAS. The current dispute over The College exemplifies the historical problem.
CORRESPONDENCE IN THE BRITISH JOURNAL OF PSYCHOTHERAPY
Two letters to the Editor were recently published in the British Journal of Psychotherapy. One was from the President of The College, drawing readers' attention to the aims and objectives of The College. The other was from Carola Thorpe, a practitioner who is opposed to The College and who, in her letter, attacked the basis on which it has been formed. Both letters were introduced by the Editor who invited practitioners to air the discussion about The College in a way that allows individual practitioners "to come to a considered, well-informed view about whether The College is divisive, or is making a sincere attempt to achieve pluralism in a divided profession" BJP 20:3, pp 409-416