Thursday, January 3, 2013

Psychoanalytic Consortium Report: Licensure, Accreditation, Certification, and Beyond
Recently it came to my attention that my previous comments about accreditation formed the basis of a warning to members of the National Association for the Advancement of Psychoanalysis (NAAP) by its president, Doug Maxwell. He described me as making a “sweeping plea,” promoting the idea that “all tri-discipline institutes [should] . .  .  accredit with the Accreditation Council for Psychoanalytic Education.” He inferred that my comments reflected a larger attempt to “regulate psychoanalysis to the scope of other professions, and at worst to eliminate us as practitioners completely.”

 It is a sad fact that my “sweeping plea,” is seems, has only served to alarm the NAAP president, whereas many institutes around the country have failed to follow my marching orders. Here’s why. The Psychoanalytic Consortium is made up of four psychoanalytic membership organizations,[1] none of which have any direct power over institutes. While the American Psychoanalytic Association (APsaA) certainly has some leverage over its constituent bodies, it cannot dictate to these institutes, especially concerning issues of accreditation. The Accreditation Council for Psychoanalytic Education (ACPE) that emerged after years of discussion is also a completely independent organization and sets is own rules and policies. As a result, the opinion of one psychologist member of the Psychoanalytic Consortium carries very little weight indeed, however sweeping.

 It is incorrect to assume that I want to “regulate psychoanalysis . .  . and at worst to eliminate . . . completely” psychoanalysts who teach and practice from traditions and standards different from ACPE. I was trying to make the point that there might be more common ground between psychoanalytic traditions than appears evident and that the efforts of the Psychoanalytic Consortium have in fact worked toward creating this common ground. I will try again later in this article.

 It is true that ACPE seeks to attract as many psychoanalytic institutes as possible that agree to follow the standards document that forms the basis for its accreditation guidelines. More than that, ACPE hopes to have its authority to accredit recognized by the Department of Education (DoE). While this may alarm some, the fact remains that ACPE was developed in part in response to the efforts of the American Board for Accreditation in Psychoanalysis (ABAP) to accredit institutes; and ABAP has also had plans to seek recognition from the DoE.

So in this article I will review three areas of controversy, licensure, accreditation, and certification that have occupied Consortium discussions and decisions. At the same time, I want to be clear that these are my views only and do not represent the views of the Consortium or the Division of Psychoanalysis. Hopefully, I will get most of the facts right, feel free to correct me.

The Consortium has taken the position that psychoanalysis is an advanced specialty of the mental health disciplines and that accreditation, certification, and licensure should be guided by this basic proposition. The Consortium also has a policy statement that psychoanalysis is not an independent profession and should not be separately licensed, a position that has not stopped states from developing licensing laws to regulate psychoanalysis in Vermont, New York, and New Jersey.

 Ultimately, licensing is a political process rarely informed by the specific arguments concerning the status of psychoanalysis as a practice. Since licensing is solely the purview of state government, efforts to establish psychoanalysis as a separately licensed profession have been advocated or opposed by varying coalitions and forces, based upon the interests of those involved. Psychoanalytic organizations are relatively insignificant politically and have sought allies in these conflicts. An example may suffice. In Massachusetts members of APsaA, Division 39, etc., have turned to other mental health organizations (that is, the state psychological and psychiatric associations) to oppose a certification law that would establish psychoanalysis as an independent practice, while those associated with NAAP have allied with groups (marriage and family counselors, art and dance therapists, and so on) seeking to expand independent licensure, scope of practice, etc.

 I offer this necessarily superficial survey only to make a particular point. While the original purpose of licensure was to establish a discipline as capable of regulating itself, the economic point of licensure has overshadowed this aim. Holding a license is considered essential to financial reimbursement by insurance companies and other third-party groups. Physicians, psychologists, social workers, and nurse practitioners, each in their turn, have fought for and won the right to regulate their professions (almost always after bitter fighting with already-licensed professions) primarily for their financial survival.

The fact is that in many states a person can set up a practice as a psychotherapist or, in this case, a psychoanalyst, and not be licensed. Whether this is a good thing or not may depend upon how many incompetent licensed clinicians you have had dealings with over the years.

 Despite the position advanced by NAAP and others that psychoanalysis is a separate discipline, the actual laws require a licensed psychoanalyst also to be trained as a mental health professional. To cite the New York law as an example,”The program of study in a psychoanalytic institute shall include coursework substantially equivalent to coursework required for a master's degree in a health or mental health field of study.” This is a curious outcome, since many of those promoting licensure have strongly advocated psychoanalytic training for anyone, regardless of mental health background or degree.

 So advocates of separate licensure for psychoanalysts end up in curious agreement with the Consortium position advocating that psychoanalysts must be mental health professionals as well. They disagree only about the level of training necessary to be considered an independent mental health professional.

I am puzzled what it can mean to be a licensed psychoanalyst. As a clinical psychologist, I have been trained to understand and work with people through assessment, diagnosis and treatment of emotional and psychological difficulties. Although there are important differences, clinical social workers and psychiatrists have roughly the same basic role and therefore an educational background steeped in an understanding of the broad range of human difficulties. As a psychoanalytic practitioner, the theory and practice of psychoanalysis informs my understanding and structures the way I work with others. One of the ways I work with others more or less conforms to a “standard” of psychoanalytic treatment, that is, seeing patients multiple times a week, using the couch, etc. I am licensed to deliver mental health services; but my training and orientation reflects my commitment to psychoanalytic thought.

 Under current laws in most states, a potential analysand can be relatively sure that someone offering psychoanalysis has completed three to five years of postgraduate education and been supervised and trained in a variety of mental health venues (that is, hospitals, outpatient clinics, etc.) and has then undergone further years of education, supervision and training to become a psychoanalyst.

This will no longer be the case in states that enact laws similar to New York’s. There, a licensed psychoanalyst need not have had the breadth, depth, or length of experiences that have typically been considered required. Under the New York law, someone who wants to be a licensed psychoanalyst must acquire both the equivalent of mental health training and psychoanalytic training within the same institution, over approximately the same period of time spent by a mental health professional in similar analytic training.

Does it matter? That is hard to say. Psychologists were told they did not have the medical background to justify independent practice. Social workers were told they did not have the social science and research background to justify private practice. And our psychoanalytic institutes, including the so-called “tri-discipline” institutes are eagerly willing to adapt their curriculum to accommodate non-mental health trained candidates. We have now created a new kind of mental health professional, called a psychoanalyst. As a result, the definition of who is and who is not a psychoanalyst has changed and whether it serves the larger purpose of advancing psychoanalytic theory, practice, and public acceptance remains to be seen.

We are entering a new phase of the Consortium’s relationship with ACPE. The Consortium does not plan to make further contributions to ACPE operations. We have reached the point that this organization will thrive (or not) depending upon the fees and contributions from the institutes they will serve. In the last year there has been progress on that front. Although ACPE has yet to acquire the all-important “federal link” that would allow it to initiate a request for recognition by the Department of Education (DoE), it has begun to accredit a sufficient number of institutes that would make ACPE a viable proposition.

For those who find such details absorbing, this is what the “federal link” is. To have a “federal link” means that someone in the government sees the value in having a new accrediting body. In practical terms, this means getting someone high up in government to agree that psychoanalytic training at an accredited institute is important for this government organization. If the head of the Veteran’s Administration wanted its mental health professionals trained as psychoanalysts in accredited institutes, for example, this would constitute the “federal link” that would allow ACPE to make a valid claim to the DoE that ACPE application should go forward. This would, of course, only be a start. Since, as noted above, ABAP has also explored becoming a recognized by the DoE, they would have to go through the same process.

 There are many remaining obstacles to the success of ACPE, including the perceived desirability of even having accreditation. Many institutes, certainly the APsaA institutes, are accredited in various ways. Some are accredited as educational degree granting organizations, for example, and must periodically undergo reaccrediting. ACPE Trustees have worked hard to streamline the process and coordinate site visits, for example, to coincide with other accrediting body visits.

 Another obstacle is getting information out to institutes regarding the value and process of accreditation. In the last few years, ACPE Trustees have worked hard to schedule workshops explaining the process. There was and is a great deal of misinformation about the ACPE guidelines and the flexibility inherent in these guidelines to address the needs of various training philosophies and traditions.

There remains, of course, the core issue of the frequency and length of the personal and training analyses. While the requirement of “at least three sessions weekly on separate days” was adopted primarily to insist upon the depth and intensity of training, it is certainly true that this is an aspirational statement about psychoanalytic practice that can easily feel like hegemony. My own very limited survey of some institutes that cannot meet this expectation, however, is that the three-times-per-week standard is considered valuable but impractical in today’s marketplace. I know at least one training program did change their policy to conform to the standard and the world did not collapse. While the standard of frequency of sessions has some empirical support and broad acceptance as an ideal, the fact remains that it is a much harder “sell” to analysands than in the past, and not solely because of financial considerations.

This brings me to the last of the “big three” and the last to be taken up by the Consortium. In the last few years, we have been discussing the advisability and feasibility of developing a mechanism that would provide a common standard to certify that someone has completed psychoanalytic training. As I wrote about in an earlier column, there are three competing organizations that certify someone as a psychoanalyst.

 The American Board of Professional Psychology (ABPP) recognizes a specialty of Psychoanalysis in Psychology. While primarily designed to certify graduates of psychoanalytic training organizations, the ABPP also offers a pathway for psychologists who have completed the equivalent of a training institute. Once certified, the ABPP is expected to continue education but there are no further specific requirements of oversight (other than yearly dues!). The American Board of Examiners in Clinical Social Work (ABE) has a certifying process roughly similar to the ABPP, but does have ongoing expectations concerning both education and experience in conducting psychoanalytic practice. Importantly, these specialty designations are profession specific and only psychologists are eligible for an ABPP and only social workers may obtain certification through ABE. Both certifications confer status of “diplomate” in psychoanalysis.

 In contrast, APsaA has a very different process whereby graduates of American institutes are recognized as competent and capable of become supervising and training analysts. The process is separately run through the Board of Professional Standards (BOPS), but is essentially a process of peer recognition and anyone reaching training analyst status acquires clear power and authority within a given institute. In other words, the BOPS process is aimed at identifying superior psychoanalysts, however defined, whereas the other certifying agencies are content to identify the psychoanalyst as competent. Finally, APsaA “certification” is offered only to graduates of American institutes, but is offered regardless of discipline.[2]

 So the Consortium’s task has been to identify how and whether there could be a process that would 1) allow for the development of an independent certifying body that would be open to any psychoanalytically competent individual regardless of profession or institute training; and 2) provide for essential equivalence of certification status with the currently established, profession-based agencies. It is the position of the Psychoanalytic Consortium that both conditions above would have to be met. This could be met, for example by developing a “super board” with representatives from the three certifying boards that would act primarily as a clearinghouse recognizing all certifications as equivalent.

 This position of the Consortium is important since there appears to be continuing debate and controversy within APsaA over the status of BOPS and the possible establishment of an independent certifying body. There are some within APsaA who want to essentially transform BOPS into an independent agency while retaining its mission of identifying training and supervising analysts. This would presumably mean that the vast majority of institute graduates could only apply for specialty certification, that is, diplomate status, within their profession of psychology or clinical social work[3].

Development of an independent body that would essentially reproduce the BOPS process is seen as a nonstarter for the Consortium. Although some of those associated with this plan have indicated this independent body would certify any graduate of any institution, this ambition seems improbable given the very different purpose of BOPS in identifying training analysts. Ho that would work is a mystery. At the same time the only psychologists and social workers would have access to a specialty designation that fits ACPE criteria and is similar to other specialty designations. Finally, this would introduce two levels of specialty designation, with one perceived as the more “real” and valuable, essentially re-instantiating turf conflicts that have been minimized over the last twenty or so years..

Why Licensure, Accreditation, and Certification?
In the interests of full disclosure I will point out that I never attended a psychoanalytic institute, my personal therapy was with someone who was not a certified psychoanalyst, and my education in psychoanalytic ideas, begun in graduate school, has continued through supervision, consultation, and conferences/seminars. To the extent I am a psychoanalyst, I am a most unregulated psychoanalyst. My education does not conform to the standards advocated either by ABAP or ACPE. Both organizations seek to regulate who is and who is not a psychoanalyst and under their regulations I am not.

As someone who has participated in the Consortium meetings over the last three years, I marvel at the effort, dedication, and perseverance of so many of our colleagues struggling to influence licensing laws, develop accreditation standards and support recognition of the value of certification. Their ongoing efforts to regulate our professions, to regularize our standards, and to promote professional recognition of competence inspire my admiration. At the same time, I wonder about the value of increasing regulation, increasing “hurdles” in the way of professional development. We have seen the rampant “bean-counting” mentality inflicted upon our graduate schools and internships sites, all in the name of demonstrating that the stamped-out products of our teaching are competent and efficient, able to draw upon the latest scientific studies to fashion time-saving approaches to treatment of human ills.

 Of course the argument cogently made is that unless we regulate ourselves, someone else will regulate us. To the regulated, however, it rarely feels that we are being regulated by “us.” Few of us see our State Boards of Healing Arts as on our side when it comes to regulating our profession. Most of us groan at the prospect of site visits and the hours of preparation put into writing policies and procedures that demonstrate our multicultural, science-driven, approach to vital issues such as the correct placement of fire extinguishers. And the prospect of having one more group of Solons grill us on our understanding of psychoanalytic process and technique is mainly just annoying.

 It is true, however, that we are “regulated” all the time by those whom we trust and rely upon. I applied to graduate school because my school principal at Irving Schwartz Psychiatric Institute told me I couldn’t do the work I loved without moving on from teaching. I became a clinical psychologist because the teacher who became my dissertation chair told me I was a “schmuck” if I didn’t apply for an open position in that program. I went to my internship because a friend told me all the supervisors there were great (failing to inquire further to learn that they were “great” lovers of opera and lousy supervisors!). I got involved with Division 39 because Gemma Ainslie wrote to say someone from our local chapter needed to attend Section IV meetings. I sat for the ABPP because Johanna Tabin and Dolores Morris threatened to never leave me alone until I did so. At each juncture of my life, someone encouraged, prodded, or cajoled me to stretch my view of who I was and what I could do.

I bring this up not because my experiences are unique, but because they are so utterly ordinary. We are constantly challenged by others to do our best. Maybe at its best all our regulations and demands are institutionalized ways to force us to connect with others, to remind us that we only grow and change in connection with others. To request licensure, accreditation and certification, not to speak of the yearly grind of continuing education and conferences, affords us at the very least opportunity to demonstrate to ourselves that the work we do is important and vital and can stand up to, and perhaps benefit from, the scrutiny of others.

In fact my actual experiences with institutional hurdles have been positive, except for my own grumblings, resistance, and paranoia. I found completing a dissertation to be an insuperable task until I submitted to my dissertation chair’s invitation to finally join his research group and accept the help, support, and ideas of my fellow students. My ABPP exam was actually a pleasant and collegial experience. My time as newsletter editor was not without its moments of being called on the carpet, but it was a soft carpet and no bones were broken in the process. Perhaps I have been lucky, but institutional regulations do not always result in power plays and conflicts.

I think that at least at times our institutional restraints and resulting conflicts provide opportunities to bridge divides of training, philosophy and perceived power differences. I think the Psychoanalytic Consortium itself is a model of how four professional groups warily came together and not without some drama proved able to see past our institutional and historical divides to work together. At our last meeting, another psychoanalytic group requested to join the Consortium, suggesting further lowering of old animosities.

 As noted at the beginning of the article, I had several colleagues from the “other camp” (NAAP, ABAP, etc.) contact me about the earlier article on accreditation. I felt we had a good dialog about the issues we both face, whether or not we can ultimately come to an agreement. I think it helps when we can speak honestly and recognize, for example, that financial considerations underlie the concerns of both sides in the licensure conflicts. Unlike the “bean counters” of the DoE, we do not need to cling to an illusion that any particular standard of psychoanalytic training or dimension of psychoanalytic care is clearly superior. We can recognize that we are doing the best we can and that differences of opinion, however firmly held, are ultimately just that.

So I plead guilty to making a “sweeping plea” that our psychoanalytic organizations and institutions develop ways of valuing our diversity, recognizing our similarities, respecting our differences. This necessarily includes developing a measure of humility and irony about our cherished ideas about what constitutes “real” psychoanalysis, psychoanalytic training, and psychoanalytic practice. It also means letting go of something we often prize even more: our grievances. Not all differences can be resolved; but many can be ameliorated by acceptance of our common interests. Given the struggles we really face to inform and educate the public about the value and importance of our work, our interests certainly must outweigh our conflicts.


[1] American Psychoanalytic Association (APsaA), American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP), American Association for Psychoanalysis for Clinical Social Work (AAPCSW), and the Division of Psychoanalysis (39) of the American Psychological Association.
[2] There is an important variable in addressing the issue of certification. For the vast majority of applicants, the acquisition of diplomate status carries very little concrete reward, let alone remuneration. Academics and employees of large organizations (such as the Veterans Administration) do experience some benefit with increased pay and status. ACPE guidelines state that instructors and supervisors should be certified psychoanalysts. But for most the benefits are primarily rooted in a sense of accomplishment and a contribution to the profession. In contrast, graduates of APsaA institutes who undergo the certifying process through BOPS do obtain the specific benefits of becoming training and supervising analysts; and there is an inherent incentive for those who wish to do this. While there is a value to the profession in having psychoanalysis recognized as a specialty by an independent board (e.g., ABPP or ABE), candidates for diplomate status do not appear to have an immediate incentive to apply.
[3] The American Psychiatric Association has a moratorium on establishing any new specialty board.

1 comment:

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