Saturday, June 23, 2012
Psychoanalytic Consortium Meeting
The Psychoanalytic Consortium consists of the four major psychoanalytic organizations in this country. It was formed after the settlement of the lawsuit brought by a group of psychologists (GAPPP) affiliated with Division 39 against the American Psychoanalytic Association to open training resources to psychologists. Its purpose was to develop improved communication and collaboration among these organizations. The Consortium developed guidelines for public officials and the public clearly describing the nature and purpose of psychoanalytic training (more on that later).
Its primary accomplishment over the last twenty years has been the development of guidelines for psychoanalytic education that led to the formation of the Accreditation Council for Psychoanalytic Education (ACPEInc.org), an independent accreditation body for psychoanalysis. While ACPE continues its efforts to both accredit institutes and win recognition from the Department of Education (DoE) as an accrediting body, these tasks increasingly will be supported by the funds generated by ACPE rather than by the Psychoanalytic Consortium.
Why Accreditation? For some of our members, the issue of accreditation has been received with indifference and even opposition. For those members who are not institute-trained the concerns about accreditation seem distant, even arcane. For some institute leaders, accreditation has seemed like an additional “hurdle” for both the institute and candidates. Obviously the Division’s financial support for ACPE has limited our ability to fund other worthy projects.
We have pursued this aim to establish ACPE for several reasons. The first has been to provide a “level playing field,” that is, a definition of psychoanalytic training that is flexible enough to accommodate different traditions, theories, and approaches while providing a transparent process that would enable institutes to be on an equal footing with other institutes. By seeking recognition of ACPE by the DoE, we will also have a nationally recognized standard for psychoanalytic training that both the public and legislators can rely upon in addressing issues such as education loans and state licensure.
Why should we care? One reason to care is largely defensive. Without a nationally recognized standard for psychoanalytic training, individuals and organizations will increasingly attempt to impose their own standards as definitive. More and more state legislatures are being asked to define psychoanalysis as a separate practice subject to separate licensure. The “standard of care” for psychoanalytic practice could be increasingly defined as a sub-doctoral and non-mental health profession requiring medical oversight. In addition, if once-a-week psychoanalyses are defined as “standard,” seeing analysands more than once a week might be considered non-standard.
Another reason to care is for our profession. Even for those who will not attend an institute, the development of clear and transparent standards for psychoanalytic training will mean that psychoanalytic education will be seen as a “normal” advanced specialization of the mental health disciplines, providing a clear rationale for psychoanalysis as only one of many mental health specialties rather than seen as a separate discipline unrelated to mental health. While psychoanalysis has been and continues to be informed by the liberal and scientific arts in the widest sense, as a treatment its basis is in relief of suffering and the nurturance of emotional and interpersonal growth and change.
Whither the Consortium? The establishment of ACPE as a separate organization has clearly been a successful effort on the part of our organizations and from what I have learned of the “early days” in the Consortium, one that would not have necessarily been predicted at the beginning. I believe that our Division 39 leaders, among them Jonathan Slavin, Laurie Wagner, and Lew Aron played pivotal roles in moving the Consortium toward this resolution. In this column I will review some additional projects and potential projects we have been discussing.
Before doing so, however, I want to make a personal observation about my experience on the Consortium. I came with a whole set of ideas and fantasies of the role of the American Psychoanalytic Association within psychoanalysis. While I was aware that the “old days” when members (almost) came to blows were long past, I was certainly wary enough that even the friendliest of gestures might mask ongoing efforts to advance an agenda and monopolize issues for APsaA’s benefit. And regardless, APsaA is the elephant in the room. Although is has as many members as Division 39, it has a budget that allows it to offer $100,000 yearly in research grants, that allows it to hire a publicist, and so on, resources we cannot hope to approximate. They cannot help stepping on a few toes!
My actual experience with APsaA president, Warren Procci, and president elect Bob Pyles did not match my initial wariness. Not only did Warren and Bob take an active interest in developing greater collaboration with our organizations, Warren invited me to speak to their BoD on two occasions in order to present some of the ideas originally developed out of our Division 39 meetings. It occurred to me later that the Division had never extended a similar invitation to an APsaA president. I think it is time for our organizations, or at least the Division 39 leadership, to recognize that a sea change is occurring within psychoanalysis and within APsaA in particular.
I want to emphasize that these changes may spell a new kind of challenge for Division 39. If APsaA becomes a more open organization, it may attract many psychologists and others who would not formerly have associated with APsaA because of its exclusionary practices. In addition, within not very many years, the leadership within institutes and APsaA will be mainly psychologists and social workers (the incoming president-elect is Mark Smaller, a clinical social worker). These changes will make APsaA more “competitive” in attracting members and pose an increasing challenge to the ever challenging question of Division 39: Are we mainly psychologists or mainly psychoanalytic psychotherapists?
Adding one more “pitch” for ACPE: After initial uncertainty whether APsaA institutes would embrace the ACPE process and apply for accreditation, we are now at the point that many more APsaA institutes have applied to ACPE than non-APsaA institutes. If that continues, ACPE will be dominated by APsaA institutes. We have been conducting outreach efforts to “our” institute leaders for several years and hope that they will see the value of contributing to establishing ACPE as representative of the vast majority of psychoanalytic institutes.
Certification: Certification as a psychoanalyst is available to only two professional groups, that is, only clinical social work and psychology have established independent organizations that review and certify members as psychoanalysts. For psychology, of course, it is the ABPP in Psychoanalysis that was established largely through the efforts of Division 39 members. In addition, the American Psychoanalytic Association (APsaA) has a certification process for graduates of its institutes (regardless of profession). Although independent of the individual institutes, certification is very much an ‘in house” process largely connected to APsaA training needs, that is, need to approve supervising and training analysts. Finally, the American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP) does not have an equivalent certification process available for psychiatrists (the AAPDP is affiliated with the American Psychiatric Association [ApsyA] and the odds of establishing an equivalent certification process within ApsyA is virtually nil).
This lengthy explanation is by way of pointing out that there is no one recognized certification body for psychoanalysis, no equivalent of ACPE for individual analysts. While their respective independent bodies certify clinical social workers and psychologists, psychiatrists (or other medical professionals) not trained in an APsaA institute have no access to certification. While graduates of APsaA institutes may be certified, the process is not truly independent.
The Consortium has been struggling with this issue for a few years, attempting to determine if there would be some way of developing a certifying body that would be independent of both institutes and professions. We have explored the possibility of a “super board” that would essentially review and approve certification by other independent organizations. APsaA is likely to move to establish truly independent certification procedures in the next few years. If that happens, at least three of our organizations would be able to recognize as equivalent the certification offered by another group. This would still leave out AAPDP members.
While the goal of a central certification process is appealing, the practicalities remain to be worked out. It is clear that the goal of ACPE is to ensure that eventually all faculty would be certified psychoanalysts and all graduates of ACPE institutes would have certification as a goal for completing training. In fact, however, our current ABPP standards, for example, are quite strict, stricter than most institutes in requiring the applicant to have completed a full analysis before being considered for certification. For APsaA members, their certification process has assured them a way of presenting credentials to supervise and perform training analyses, but would a “super-certificate” make the non-APsaA-trained analyst eligible to do the same at APsaA institutes?
These and other issues remain to be worked out; but they signal the convergence among our organizations for the need for independent agencies to both accredit and certify psychoanalytic institutes and graduates as a way to assure the public of the adequacy of training in this specialty. Within Division 39, of course, we have a long way to go to convince even many of our senior members and leaders to apply for the ABPP and this in turn limits the viability of this certificate to communicate anything of value to the public.
DSM-5: As you know there has been considerable controversy over the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). While it has not been published and much remains to be decided, many individuals and groups both within and without the mental health field have called for a more transparent process in revising the PDM and an end to the increasing “biologization” of emotional distress and suffering. There were two issues under discussion at the Consortium and the main issue was how and whether APsaA would issue their own response to the new document. The issue originally before the APsaA BoD in January was whether to become a signatory to the letter circulated by Division 32 (Humanistic Psychology) of APA. They have instead decided to draft their own letter to DSM and will share that with the other members.
For me, however, the more interesting discussion, some of which preceded the meeting, was a review of the original purpose of the DSM. Although it has traditionally been described as a document for psychiatrists to use to insist they were treating “real” illnesses and should be reimbursed for this by insurance companies, this is not the whole or even main story. At least by the time of the DSM-III the primary purpose, at least as described by Robert Spitzer and others involved in that revision, was to develop a research-friendly tool that would allow clinicians to come to some reasonable agreement that depression in Walla Walla was the same thing as depression in Boca Raton. Despairing of finding an approach found in ordinary medicine (where, for example, high blood pressure is meaningless without an understanding of the causes for the rise in pressure), psychiatry would “settle” to at least be able to reliably know that the symptoms observed could be consensually validated.
The point of all this exposition, at least for me, was the realization that the DSM in whatever incarnation it chooses to present itself is a document that is useful for what it purports to do, which is to define symptoms (and maybe even syndromes). What it was not supposed to do, what it shouldn’t do, is serve as a guide to treatment. That said, it is clear that not only do clinicians treat the DSM as a treatment manual, the American Psychiatric Association markets the DSM in precisely this way, hence DSM-IV-TR. As a result this organization makes a fortune in royalties from this misuse of the DSM. It seems to me it is long past due for our clinical organizations to call out the American Psychiatric and the DSM for its distortion of clinical practice. Far more than simply advance the “bioligization” of mental health, the DSM continues to rest on the shakiest of foundations and does not meet the criteria of advancing a biological understanding of mental illness. It does, of course, serve the pharmaceutical companies in their quest for more disorders to allow more drug marketing. But that is not the same as medical science. We do not need to “improve” the DSM; we need to replace it entire. Fortunately we have an alternative and that brings us to the next item we discussed.
Psychodynamic Diagnostic Manual (PDM): The PDM was the brainchild of Stanley Greenspan and was developed with the support of the Consortium members as well as the International Psychoanalytic Association. It is an impressive document that was well received when first published in 2006, providing an alternative to the DSM symptom focused approach to treatment and offering a way to conceptualize treatment in a clinically rich and empirically sound framework. Unfortunately two things happened. First the PDM was self-published in order to keep the costs down and this limited institutional support for sales. Secondly and more important, Dr. Greenspan died and with him much of the moving force behind it.
Recently there has been an attempt to “revive” and revise the PDM, that is, to literally revise it to update and streamline its contents and to educate both clinicians and researchers about its merits. Concerning the latter, Bob Gordon and Ken Levy have been active in promoting the PDM as a useful way to look at treatment and treatment results. In brief, the point is that the PDM approach (that personality patterns and psychological/emotional etc. resources must be considered as being at least as important as symptoms) might be a useful way to parse out the differential effects of particular approaches in treatment. In other words, depression in a schizoid character requires a different form of treatment than depression in a paranoid character. In addition, process and outcome measures may need to be different with different kinds of patient characteristics.
In addition, a psychologist in Italy, Vittorio Lingiardi, has begun to form an international group of researchers and clinicians to revise the PDM, updating the research that has emerged in the last 7-8 years, adding important sections inadvertently omitted (such as treatment of the elderly) and developing a more consistent marketing approach to emphasize the PDM’s utility as both a treatment guide and research tool far superior to the DSM. While the original authors were all psychoanalytic theorists and researchers, the core assumptions of this document apply to any approach that relies upon psychological interventions. The PDM, like almost all good clinicians, assumes that the bulk of the treatment will be in understanding the personality dynamics that make the symptoms understandable and that treatment must also be guided by a full understanding the person’s strengths and weakness. To give a trivial example, a behavior therapist who assigns “homework” to a client is more likely in the next session to explore why the client did not complete the assignment rather than simply re-assign the task. To do so means to take into account the client’s reaction to being assigned a task rather than simply focus on the task.
There are lots of immediate goals for a new PDM. The first would be to find a commercial publisher to support advertising. The second would be to develop training modules for professionals to help them understand and then communicate with each other using the structural approach advocated. The third would be to encourage researchers to try out the approaches suggested as a way to better refine research protocols by taking into account the whole person rather than circumscribed symptoms. Ideas beyond that include developing a PDM for physicians, a “dumbed-down” guide with requisite checklists that would help family practice docs understand there are a world of treatment options others than pills. Getting more expansive, the PDM might be turned into a “parent guide” allowing parents to access information by completing online information about their child’s emotional difficulties with the result that a printout of recommendations would include the pros and cons of various treatment possibilities and helping them to access such services (and begin to demand such services from insurance carriers).
Public Education: We have been discussing our educational efforts for some time within the Consortium but we realize we are leaving some essential “players” out of the discussion. As a Consortium, of course, we have no direct authority over our boards and public education efforts have been developed in various ways and with various foci among our organizations. To that end, we plan to have a working meeting at our next session bringing together the key public information committee chairs from our organizations, and others as needed, to spend a day looking at our specific efforts but also developing a common message, a “brand” that we could begin to consistently use to define and describe psychoanalysis. My vote goes to “Psychoanalysis is not only a form of treatment but primarily a way of thinking about self, family and society” although it would need to be distilled further.
We also came out with a specific request for our publication editors to ask authors to consider writing short summaries of their research and/or clinical papers that would be accessible (and interesting) to a general reader and post these articles in a central venue that would clearly represent the viability of psychoanalytic treatment and the relevance of psychoanalytic ideas to a general public who only hears that psychoanalysis is passé at best. I will note that Division 39 has already begun to experiment with this idea by posting a series of articles under our rubric on Psychology Today blog, psychologytoday.com/blog/meaningful-you. Kristi Pikiewicz, the newly appointed editor of our online newsletter, InSight, has taken on this task. Within the last two months over 10,000 “hits” have been made to the site.
To get more expansive, we have begun to explore the possibility of increased collaboration at our scientific meetings and conferences. We might, for example, showcase specific outreach approaches at our different meetings and use these sessions to brainstorm other ways we can collaborate in our public service mission. We might hold a two-day Psychoanalytic Consortium Conference inviting all members to take part in a meeting highlighting the many roads to psychoanalytic education. These are some exciting developments and demonstrate a renewed sense of collaboration among our psychoanalytic organizations.
Psychoanalysis and Licensure: Licensure as a mental health clinician is an issue decided on a state-by-state basis and recent efforts to have psychoanalysis defined as an independent, master’s level, mental health treatment have been going on for some years. The latest effort is in Massachusetts and the problems with this particular effort are too difficult to clearly articulate in a short paragraph. The gist is that the bill before the legislature, originally meant to restrict individuals who had lost their license due to ethics violations, has ballooned into a “back door” licensing act that will have virtually no guarantees to protect the public or to require specific standards for those who seek license as psychoanalysts.
Combating this law has not been easy. Those supporting it have every reason to continue to push in order to gain licensure; those opposed can easily be painted as wanting to restrict commercial activity for their own gain, that is, as members of a self-serving “guild.” In addition, state legislatures are notoriously provincial and tend to be unmoved by the concerns of national “players” including our national organizations. At this point, we continue to support communication among our various members in Massachusetts and Division 39 will also work to enlist APA support in opposing this diminution of the value of our license. As noted earlier, the Consortium has previously developed a clear statement on psychoanalytic training that we will distribute to legislators.
Conclusion: If you have made it thus far, thanks. I hope you will have a better idea why we have a Psychoanalytic Consortium and why we have come to the conclusion that we need to work together in many ways to advance psychoanalytic training, education and outreach to the public and other professionals.
 American Academy of Psychoanalysis and Dynamic Psychiatry, American Association for Psychoanalysis in Clinical Social Work, American Psychoanalytic Association, and Division of Psychoanalysis of American Psychological Association
 I want to emphasize that this is not a criticism of APsaA process. It was developed to meet the training needs of the organization. It was notintended as a public assurance that the person accredited had met standard, transparent criteria to be considered a psychoanalyst.
 It would take another article to fully explain and defend the need to have both accreditation and certification of psychoanalytic training. Clearly institutionalizing psychoanalysis has implications for our professions, not all of them positive. Should psychoanalysis become like all other “ordinary” professions, defining who is and who is not a psychoanalyst? Many object strenuously to ACPE’s defining psychoanalysis as a subspecialty of a mental health discipline requiring specific procedures, including having lengthy, multiple weekly session training analyses, viewing this as rigid, limiting innovation, and contrary to the spirit of psychoanalytic inquiry. Many of those so objecting are strenuously pursuing states-sanctioned licensure of psychoanalysts and developing accreditation procedures that define psychoanalysis as a once a week treatment.
 Thanks for Jaine Darwin for coming up with this was of differentiating what we do from how we think. We are able to think (and act) psychoanalytically with out patients even if we are seeing them four times a week, once a week, or having a brief consultation in a nursing home.