|Is psychoanalysis in danger of being judged unfit to be practised?
Contribution to the conference of The College of Psychoanalysts-UK ‘Are you fit to practise? From ethical framework to model of good behaviour’- London, 6 June 2009
As parliamentarians have now discovered, established ideas about ways of achieving what appeared originally to be sound objectives, sometimes have to be blown out of the water and exposed for scrutiny, in order to arrive at a new way of doing things that better meets the interests of the professionals concerned and members of the public alike. Maybe psychoanalytic practitioners have now reached a similar position in their own profession.
The situation that concerns me here, arises out of a principle which originally applied only to complaints against medical practitioners but which has since become the established norm and basis for dealing with complaints against practitioners from many different professions in the UK. I am concerned about how this principle now threatens to extend to psychoanalytic practitioners. It all hangs on three simple words: fitness to practise, which are the words that formulate the principle in question. These words comprise, perhaps, a rather innocent-sounding phrase. They constitute, in fact, a term loaded with the dynamite of a revolution which lies at the very core of recent regulatory processes.
When the term fitness to practise first appeared, some years ago, its meaning was very literal. The question to be answered then, in relation to professional complaints, was whether the professional concerned was physically or mentally fit to practise and it was therefore limited to issues of physical and mental health. It still means that but now, additionally, it means far more than just that. The word fitness has now become synonymous with the word suitable. The question are you fit to practise? is no longer confined only to issues of physical and mental health but has now become, in effect, the question are you a suitable person to practise? This constitutes an enormous shift and a fundamental extension of the original question are you fit to practise? It transfers that concept from entirely objective issues to ones that are far more subjective in nature.
The danger for psychoanalytic practitioners, if complaints against them do become subject to this principle, would be that almost any complaint a patient might make against them could be formulated within the context of that single word fitness. The risk would then encompass all aspects of competence and would inevitably encourage patients to question the ability and reasonableness of practitioners, at every level of their endeavour and behaviour.
If regulation by the state comes into force for our profession, via the Health Professions Council, the overriding context and aim within which complaints will be dealt with, will be subsumed within this concept of are you fit to practise? There will arise an inevitable invitation to engage with all the myriad possible ramifications of the term fitness. It will not be a question of rien ne va plus; but rather one of a game of roulette that rarely stops rewarding any patient displeased with their analyst, for whom the chips will always be down.
In the light of these possible developments, we need to address urgently and seriously the vital question of how clinical psychoanalysis in particular might survive under such circumstances.
I am not for one moment suggesting that psychoanalytic practitioners should not be regulated. The public needs to be protected from unscrupulous practitioners. There is a need for effective codes of conduct and all practitioners should be subject to suitable sanctions when they are in breach of such codes. For many years, such regulation has been achieved very effectively by voluntary registration with bodies such as the United Kingdom Council for Psychotherapy. In my own professional organisation, The College of Psychoanalysts, we have our own code of professional conduct, with suitable sanctions that can be imposed on those who are found to be in breach of those standards.
The obvious shortcoming of such a system of voluntary regulation is the important issue of those practitioners who do not voluntarily register. However, that problem will not disappear with the advent of compulsory regulation. Some would inevitably avoid any need for registration; by not using professional titles regulated by HPC and so remain outside its jurisdiction.
It is within the context of all of the above issues that I raise the important question: Is psychoanalysis in danger of being judged unfit to be practised?
Some might reasonably ask why I am raising my question only in relation to psychoanalysis. Is it only psychoanalysis that is threatened by the concept of fitness to practise, rather than the wider disciplines of psychotherapy and counselling as a whole? For the reasons I will set out, my answer to this question is a resounding yes: that psychoanalysis is not only threatened by HPC and the concept of fitness to practise but is in danger of no longer being available as an effective form of psychological intervention; and this in a quite unique way that does not comparably challenge or threaten any other modality of psychotherapy or counselling.
At this point, some clarity in what I understand psychoanalysis to be, might seem worthwhile. However, I am going to avoid that issue. Psychoanalysis is a very wide discipline, based on many different theoretical positions and any attempt to even summarise these positions risks inadvertently leaving out some important area of psychoanalytic theory and practice. What I propose to do instead is to try to suggest five essential components of a psychoanalytic understanding of the human psyche, in a manner that might, I hope, be acceptable to almost all psychoanalytic theoreticians:
That a significant part of the human psyche lies concealed beyond consciousness and functions dynamically, in a manner that is not accessible to consciousness: what psychoanalysts commonly refer to as the unconscious or the internal world of each individual. This is the part of the mind that stems from our earliest existence and where the origins of all our emotions are rooted. There is frequently conflict between this unconscious area of the psyche and other parts of the mind that, through nurture, socialisation and developmental experiences, later evolve into those parts of the psyche where consciousness and, in the absence of severe psychopathology, a coherent sense of self reside; rooted in both subjectivity and reality. It is an area of the mind where we can more freely reflect and reason.
That, very early in our mental development, representations of our primary relationships are internalised within the unconscious mind which, though influenced by the reality of such relationships, do not necessarily reflect their historical actuality. These internalised representations strongly influence all subsequent relationships throughout life. It is the nature of these internalisations which, along with conflicting emotions, determines the dynamics of the unconscious.
That much of the conflict between the dynamic demands of the unconscious mind and higher levels of consciousness is repressed and so prevented from becoming available within conscious awareness.
That the dynamics of this conflict, particularly in relation to the internalised representations of early relationships, is played out within the analytic encounter between patient and analyst. We call this the transference.
That patients invariably resist, whether to a greater or lesser extent, insight into the nature of this unconscious conflict and how it is represented within the transference.
I am sure that there are aspects of these five principles that some psychoanalytic practitioners would seek to challenge. That encapsulates the very nature of psychoanalysis. I ask only that we adopt my brief summary as a means of understanding what lies at the heart of the problems that psychoanalytic practitioners would encounter, within the fitness to practise rubric operated by HPC. It all boils down to the nature and ramifications of the transference.
All psychoanalytic practitioners take into account the transference, though in a number of different ways. At this point, maybe I should make it clear that, when I use the term psychoanalytic practitioner, I am doing so as a means of encompassing all those whose clinical work is based solely on psychoanalytic theory, in the widest possible sense of that term i.e. from all schools of psychoanalysis and whatever psychoanalytic professional title they use, ranging from psychoanalyst to psychoanalytic psychotherapist. There are, of course, other such professional titles. What I am suggesting is that they all acknowledge the above parameters of psychoanalytic clinical theory.
There are, however, profound differences within psychoanalytic clinical practice in relation to how the transference is used. Some practitioners interpret the transference at every opportunity: whatever the patient says is interpreted directly by the analyst as an indication of how the patient feels about the analyst, regardless of whom the patient actually claims to be talking about. Others rarely or never make transference interpretations but listen carefully instead to what their patient is trying to say, in order to understand the nature of the transference and in the hope that, eventually, their patients will realise for themselves, whether directly or indirectly, what is unfolding within that transference relationship. Some practitioners will make transference interpretations to their patients from the very beginning of an analysis. Others assume that their patients will feel persecuted by them if they interpret the transference too early in the analysis and will wait, sometimes many months or even years, until they are able to conclude that their patients are ready to receive their interpretations of the transference and are able to make use of them.
But the patient is not the only one to encounter the transference. Analysts also have transference feelings about their patients. Some practitioners pay attention to such feelings and often pay particular heed to them when they conclude that these are not stricly manifestations of their own feelings but that they arise out of unconscious or non-verbal communications by patients of their projections onto the analyst. We usually refer to such situations as the countertransference. However, few analysts will openly talk of their own feelings within the analysis. Many other practitioners, while aware of their feelings towards their patients, regard these as an intrusion and strive to ensure that they do not influence in any way the analytic encounter with their patients.
We need to be clear, however, that the transference is not a unique phenomenon of analytic treatment. Transference phenomena are universal and operate within almost every social situation. Clearly, therefore, the transference is, to some extent, at work within every psychotherapeutic and counselling relationship of whatever modality. Most practitioners from these other modalities have little or no knowledge of the transference and how it operates and, for the most part, are not trained to recognise its significance, let alone facilitate, interpret or otherwise work with it. Paradoxically, it is easier for these other practitioners to avoid the pitfalls that are likely to be encountered within an analysis, because of the likelihood that they will steer their clients, whether directly or otherwise, towards a much more conscious and reality-focused orientation in the therapy. In so doing, they, in effect, discourage any profound flowering of the transference relationship with them. In psychoanalysis, on the other hand, the transference is always anticipated and facilitated by the analyst, if not overtly orchestrated by them. For this reason, practitioners from other modalities are much less likely than psychoanalytic practitioners to face complaints that have their roots in florid transference phenomena, although this is by no means entirely out of the question.
This also ties in very well with research which has reliably established that all modalities of psychotherapy are capable of being effective: of producing some helpful change in the patient or client. What such research also showed, however, is that the factor which most influences such change is not the modality of the therapy but the quality of the relationship between the patient or client and their therapist, regardless of modality.
Nevertheless, we should not lose sight of one very significant difference within the psychoanalytic encounter, compared with all other forms of psychological therapy, which is that the patient’s symptoms are not addressed directly. There is no objective of producing relief from those symptoms in a conventional manner, such as that followed by the medical model. Unlike other forms of therapy, psychoanalytic practitioners are not concerned directly with their patients’ symptoms although, of course, they do not simply ignore them. Far from it. Symptoms are almost always a rich source of insight. These are often valuable hidden indicators, symbols or even obfuscuators of some underlying disturbance whose nature can only be discovered through an understanding of the transference relationship that develops between patient and analyst. The danger of encouraging a patient to give up their symptom, without first allowing them to uncover any underlying disturbance, is that the presenting symptom is likely to be replaced by a new and often far more debilitating or harmful one; which more effectively conceals the true nature of the underlying disturbance that the original symptom was designed to conceal. When patients are ready to do so, they will usually abandon their symptoms quite spontaneously and unprompted by their analyst.
Returning to the issue of the transference, the most important aspect of an analysis is the unfolding of the patient’s transference relationship with the analyst. This is crucial and central to everything. It is as if we, as analysts, provide a small oasis in the middle of an otherwise vast, hostile and arid desert, in which we are approached by our prospective patient, who bears a delicate and mysterious seed from some far-off land which they wish to plant in the cooling shade provided by the analst within the surrounding barren desert. Neither of us has any idea what plant that seed might eventually produce. It is so tempting for the analyst to foster and try to nurture that seed; but for us to do so, rather than the patient, would only produce, at best, a grotesque and distorted plant or maybe nothing but bitter, poisonous, choking weeds; or even nothing at all. Instead, analysts find themselves largely useless, from any practical point of view, in the endeavour of the other to plant and cultivate their seed in that harsh wilderness that so often encroaches on and constitues the analytic scene. We must content ourselves, instead, with merely being at our patient’s side throughout and, at most, offering them the occasional watering can. Only by encouraging the patient with our consistent and non-intrusive presence can we, together with our patient, discover what, if anything, develops from their endeavours.
An analyst makes no promises and gives no undertakings or explanations about what will take place with their patient. It is merely an encounter between two people, where the patient knows almost nothing about their analyst, while the patient is the only one who knows anything at all about themselves. Only these conditions will foster the flowering of a transference that can have any capacity to be beneficial or therapeutic.
The transference is gradually projected by the patient onto the largely blank screen provided by the presence of the analyst. It is a relationship in which the patient will slowly attribute all manner of dispositions onto the analyst and in which, at times, they may identify with the analyst. This results in the creation of a situation in which the analyst comes to represent, for the patient, aspects of their early primary relationships; usually mother, father or siblings. This does not mean that the analyst attempts actively to enact those relationships or to replace or repair them. In reality, the analyst usually tries to adopt a non-intrusive and largely neutral position. It is the patient’s privilege alone to fantasise and create the transference relationship; whether for good or bad and whether for malign and defensive intransigence or, more hopefully, as a means of bringing about beneficial change. An outcome that is even worse than at the beginning of the analysis remains a possibility and it is not always feasible to predict the likelihood that this might happen.
During this process, many primitive and powerful emotions are experienced by the patient towards the analyst: feelings of love, hate, rage, loathing, revenge, sorrow, guilt, regret and many others. The consequences of these feelings are usually experienced by both patient and analyst. Powerful sexual feelings also arise. Everyone is familiar with the stereotype of the patient who falls in love with their analyst. This may indeed happen and, when it does, it can sometimes be a very painful experience for the patient and, occasionally, for the analyst also. It is certainly not a situation that can simply be ignored, glossed over or, even worse, dismissed as an episode of incomprehensible madness. It is a situation that must unfailingly be handled with considerable tact, empathy and understanding.
Under these circumstances, at different times and to varying degrees, patients experience their analyst in much the same way as, during their childhood, they experienced their principal caregivers. At times they may experience the positive aspects of those early relationships but, at other times, they will inevitably experience their analyst as reflecting the, entirely subjectively perceived, negative and unpleasant aspects of those early relationships; no matter how the analyst might behave towards the patient in reality or, for that matter, regardless of how the relevant figure from the past might, in reality, have hehaved towards the child in their care. There is very little concerning the transference that is necessarily about any actual, objectively observed history of early relationships: almost all of it is about early subjectively perceived experiences of such relationships and a considerable discrepancy between these two points of reference is often a distinct possibity, though not necessarily one with which analyst and patient need specifically to concern themselves.
It is precisely within the context I have outlined above that the dangers will lie, in relation to possible complaints against practitioners under the fitness to practise rubric. It is, of course, vital that no analyst should gratify their patient, in terms of any reality, in relation to such trasference feelings. To do so would almost always be harmful to the patient. Thus, in many analyses, the patient will be confronted by powerful, apparently inexplicable feelings about their analyst who will also, very possibly, be experienced at times as unrewarding and often as cold, uncaring and remote, no matter how empathetic the analyst might be in reality. Under these circumstances, the possibility of almost limitless opportunities to make official complaints about the analyst are likely, sooner or later, to be seen as pursuits that are difficult to resist. Under the current conditions that prevail within the profession, the difficult situations that arise in relation to the transference can usually be contained and worked through between analyst and patient together, within the privacy of the analysis itself. However, under the proposed HPC regime, the opportunity to act out the dynamics of the transference, beyond the analysis and within the alternative forum provided by the complaints procedures, would be very likely to prove too much of a temptation for many patients. As soon as a complaint is made, the analysis would have to come, almost always irreversably, to an abrupt and often damaging end and the issues would then be acted out in that other forum, where there would be no prospect of working through them with any degree of understanding and containment.
I am certainly not claiming that psychoanalytic practitioners should, for their own benefit alone, be in a different or more privileged position, compared with other therapists, in relation to regulatory issues. What I am claiming is that the fitness to practise regime, as it has now evolved, should not apply to psychoanalytic practitioners without important safeguards, purely in order to preserve and protect the discipline of psychoanalysis itself: as an effective mode of psychological intervention that should continue to exist for the benefit of all. Such safeguarding is what would be in the public interest: not the effective killing-off of the discipline in order to comply with principles that have not been properly thought through, in relation to the needs of members of the public who seek to pursue the psychoanalytic encounter.
Arguably, there is nothing faced by members of the public, as consumers of psychoanalysis, that threatens them more than this concept of fitness to practise: not only in terms of their perception of the professional authenticity and integrity of those they consult but also in the freedom of those members of the public themselves to engage in the very pursuit of psychoanalysis.
How, under such a regime, could we ever contemplate challenging a patient about what might be going on within their unconscious or internal world, where there is repression or resistance? How could we ever contemplate raising significant sexual issues, without encountering the possibility of being profoundly misunderstood: as possibly inviting the very thing that is being talked about, particularly when this arises within an erotic or eroticised transference? How could we contemplate using anything but the most anodyne and remote clinical language in referring to sexual matters? For that matter, how could we ever be confident that making a transference interpretation would not be misunderstood and used against us? How could we challenge issues surrounding acting-out and malign regression and how could we possibly hope to persuade patients to own for themselves their introjections, their indentifications, their projections and their projective identifications?
In fact, how could we help our patients in what is really the sole objective of an analysis: to enable them to gain insight into and to understand their unconscious internal worlds; and to do so without running the serious risk that they might, if they were so minded, pursue a complaint against us under the concept of fitness to practise? Such action would rarely be capricious, even if this might appear so to uninformed others, but would almost always be rooted primarily within transference issues unique to the patient. Who, beyond the intimate encounter between analyst and patient, could possibly understand such issues, let alone assess them for the purpose of adjudicating within the context of a professional complaint?
But by far the worst aspect of the problem we and our patients would be facing is that any complaint would be heard, not by fellow practitioners but by a disciplinary panel comprising, almost entirely, persons without any training in any form of psychological therapy, let alone in psychoanalysis. How could any such non-trained person possibly understand and adjudicate on such issues?
What I have been saying provides only a taste of some of the difficulties we could expect to face, should complaints against us within our professional capacity, ever be dealt with under the principle of fitness to practise. It may become our misfortune to have this imposed on us via compulsory regulation by an agency of the state. There is, however, still time for careful reflection and deliberation, preferably with those from HPC who would be responsible for dealing with such matters, about whether, as a profession, we should willingly invite that beast into the lives of our patients. Could that be tantamount to abandoning one of the richest treasures ever offered to society? I would like to suggest that it might be just that.
It is my strongly held view that the concept of fitness to practise would become a millstone, not only around the necks of psychoanalytic practitioners but of our patients also; and of the discipline of psychoanalysis itself which would, in effect, be judged unfit to be practised in this country. If that were to happen, psychoanalysis would no longer be available to those very persons that the concept of fitness to practise is designed to protect. Could such an outcome ever be in the public interest?
Let us hope that there will yet be opportunities for exploration and discussion of these important issues, between all parties concerned, including those at HPC. If not or if those discussions should fail, we must then follow the example of the recent adamantine revolt against and within the UK Parliament. We must seek out a Joshua who will lead us and not hesitate to blow the trumpet that will bring crashing down the walls of the regulatory Jericho: lest it should otherwise, albeit unwittingly, fatally threaten and destroy that unique and golden discipline of which we, as practitioners, are merely its faithful guardians and acolytes; namely psychoanalysis itself.
Click here to go back to previous page