ETHICAL FLAWS IN TRAINING ANALYSIS
Zvi Lothane
Abstract: With the spread of Freud’s psychoanalytic movement, in numbers as well as ideas, there came a time when what used to be informal “training”, in the course of peripatetic or brief analyses with the master, was bureaucratized as a tripartite training system comprised of training analysis, didactic instruction, and analytic work under supervision. This was codified in the first official psychoanalytic institute established in Berlin that superseded the earlier tradition of Freud’s Vienna. This development created a perennial tension between the goals of training and of treatment, with blurring of boundaries and creation of insurmountable ethical conflicts. The crux of the conflict is that the vested interests of the training analyst hamper the spirit of a good-enough treatment analysis: freedom of choice, suitable analysand-analyst fit, and more. The present is an analysis of these ethical conflicts and a pleading for reform.
Key words: training analysis, treatment analysis, teacher-oriented training, student-oriented training, psychoanalytic politics.
Whereas psychotherapy has existed from times immemorial, and psychoanalysis as a method of treatment has been with us ever since its discovery, or invention by Freud in 1895, training analysis and analytic training were first introduced and codified in 1922, and not in Vienna but in Berlin, where the first analytic institute was founded by Max Eitingon. The problems concerning training analysis models I present here reflect the history and current status of training in the American Psychoanalytic Association and the International psychoanalytical Association; I believe, however, that the analysis of these problems equally applies to other training institutions, those of the American Psychological Association, or any other training body, however politically organized.
Eitingon was a member of the famed “Committee,” originally comprised of Ferenczi, Rank, Sachs, Abraham and Jones. It was either the Committee’s idea, or perhaps it was Freud’s right “to claim, tentatively, paternity for the idea [and] the first requirement, that ‘this committee had to bestrictly secret.… [as recalled by Jones]: ‘a united small body, designed like the Paladins of Charlemagne, to guard the kingdom and policy of their master’ ” (Gay, 1988, p. 230). Either way, the Committee initiated the institunalization and bureaucratization of training analysis within the psychoanalytic establishment, movement, and international and local associations. How was training done before? This is how Eitingon got his own training analysis with Freud in 1909:
“‘twice weekly, after dinner, he comes with me for a walk and has his analysis during it.’” (Balint (1965b, p. 275). Freud thoughts on training analysis in 1937 “Analysis terminable and interminable” are quoted by Balint as follows:
“For practical reasons this analysis can only be short and incomplete … It has accomplished its purpose if it imparts to the learner a sincere conviction of the existence of the unconscious, enables him through the emergence of repressed material in his own mind to perceive in himself processes which otherwise he would have regarded as incredible, and gives him a first sample of the technique which has proved the only correct method in conducting analyses. This in itself would not constitute adequate instruction, but we hope and believe that the stimuli received in the learner’s own analysis will not cease to act upon him when the analysis ends, that the processes of ego-transformation will go on of their own accord, and that he will bring his new insight to bear upon all his subsequent experience. This does indeed happen, and, in so far as it happens, it qualifies the learner who has been analysed to become an analyst.” (Balint, 1965, p. 276).
In the above passage Freud only discusses training, nottreatment. But in the same 1937 paper he says, again as quoted by Balint (1965a): “‘It cannot be disputed that analysts do not in their own personalities wholly come up to the standards of psychic normality which they set for their patients. Opponents of analysis are wont to point this out decisively and use it as an argument to prove the uselessness of the psychoanalytic method.’ ” (p. 256). Problems in the analyst’s personality acquired a new meaning when the good name of psychoanalysis seemed to be compromised by analysts that got in trouble with the law, as for example in the case of Theodor Reik who in the 1920’s was sued by a paranoid man, so that treatment was mandated also as a firewall against the inclusion of socially undesirable individuals. The net result of this trend was the steady increase in the duration of the training analysis: from days, to months, and years, and lately to interminable years. Balint proposed to call “a‘fully completed analysis’ … obviously more than is usually needed for therapeutic purposes … ‘supertherapy’” but shared Freud’s skepticism in 1937 that by means of analysis it is possible to attain to absolute psychical normality and to be sure that it will be maintained’” (p. 277). Super-therapy implied the presence of super-pathology that had to be zealously rooted out.
The ideas of Balint are still under the influence of the Eitingon model. A very different model was proposed in 1952 by Sigfried Bernfeld, PhD (1962), an erudite and wise man analyzed by Freud, who devoted lots of energy the study of children and adolescents, a historian of psychoanalysis who taught in many institutes: the idea of a “free institute” defined as follows:
While psychoanalysis has revolutionalized education and the student-teacher relationship, the institutes are carrying on with a teaching system that is prepsychoanalytic, fully teacher-centered, and dominated by questions of administration and policy. The idea of a student-centered system is quite alien to our institutes; and, what is even worse, matters of local policies and administration are mainly decided by a national committee, according to the interest of the national professional association, whereas according to psychoanalytic theory and practice it is obvious that nothing should count so heavily as the concrete local human relationships (p. 457).
… unfortunately in our system the training analyst is also charged with the duty of deciding when the candidate is ready to attend seminars, when he may be admitted to controls, when the training analysis is to be considered finished. In general, it is largely at his discretion whether the candidate becomes a psychoanalyst or not. The training analyst is not, as freudian method demands, a mere transference figure. He is instead a part of the patient's reality, a powerful and even decisive factor in it. … Our system does not even permit the analyst to modify the regulations under which he works. He must take a judge's attitude in every case. By policy and circumstance the institutionalized training analysis thus bears the features of a non-freudian technique. … The personal analysis is no barrier against heterodoxy. The inventors of our training system, who had set such anxious hopes in its preventive force, have been definitely proven wrong. It seems quite sufficient for our point if we list only some of the former trainees of the Berlin Institute: Alexander, Rado, Horney, Fromm, Reich, Fromm-Reichmann (pp 475-476).
The goals of training analysis are currently defined as follows in the bylaws of the American Psychoanalytic Association (APsaA):
Education in psychoanalysis begins with a highly personal experience of psychoanalytic treatment for the candidate (student). Such an experience aims to enable the candidate to appreciate the extent to which psychoanalysis offers an opportunity for self-understanding and hope for lasting change. In a successful personal analysis the candidate experiences how self-knowledge and emotional growth contribute to richer interpersonal relationships and a more effective use of talents and abilities. The personal analysis also aims to help the candidate recognize the importance of self-understanding in psychoanalytic clinical work. …
An essential aspect of psychoanalytic education is the personal, or training psychoanalysis. …The candidate must be in analysis with a Training Analyst for a substantial period of time that overlaps the supervised casework. In the Institutes of the American Psychoanalytic Association, the personal analysis of candidates are conducted in person at a frequency of five times a week or four at a minimum through termination
…
A searching personal experience into the depths of human suffering and conflict, an experience through which one is profoundly affected, as both patient and analyst, seems an essential base from which to derive a conviction about the effectiveness of psychoanalysis. Such a conviction can sustain one’s life work as an analyst. A successful personal analysis during candidacy requires confidentiality and privacy. Therefore, progress in analysis is not usually directly considered in the evaluation of candidate progression. The faculty of the Institute, through observation of the candidate’s work in seminars, supervised analyses, and case presentations will be able to judge the extent to which the goals of the personal analysis are being achieved.
This curriculum is based on the tripartite Eitingon model of training: training analysis, didactic courses, and cases analyzed under supervision. The ideals espoused in the above recommendations are sound enough, but the role of the training analyst (TA) and the process of evaluation reveal a serious ethical flaw: treatment and training are administered by an institutionally appointed TA. While the document declares the importance of the principle that “a successful personal analysis during candidacy requires confidentiality and privacy,” and reporting by the TA to the Educational Committee is officially banned, it should be fair to question, in view of the tradition of strict secrecy still in the training procedure whether non-reporting is totally leak-proof. The wording of the bylaws lack definiteness and transparency: “progress in analysis is not usually directly considered in the evaluation of candidate progression,” it is stated. If not usually, what are the unusual circumstances that mandate considering the progress? Do unusual circumstance mandate reporting, as, for example, the Tarasoff ruling about a patient’s verbalized intent to commit a crime?
Be that as it may, there are two more principles that count a great deal in any personal analysis: loyalty and power. The latter two requirements are met in a private analytic arrangement between an analysand and analyst where the fees paid by the analysand ensure that in virtue of the analytic contract he retains the power to hold the analyst to account for his ability to serve him well, that, in short, he retains the power of hire and fire. In an institutional analysis, as captive audience, the analysand forfeits this right because the candidate has to prove himself to his TA as a person fit to graduate and to be anointed as an analyst. The TA’s loyalty is split between the institute and the candidate: as the old adage goes, a man cannot serve two masters.
Consider the following situation. The candidate has been in a private analysis before starting training with a reputable member of the APsaA who is not a TA. The candidate had exercised his freedom to choose from among a number of people he considered the one person with whom he felt a bond of affinity, mutual liking, understanding, trust, and confidence. He has enjoyed the benefits of working with this capable analyst in the community who, however, is not an institute appointed training analyst, and in the course of the treatment with him has overcome many personal difficulties; he felt secure in having the worst possible symptoms without being criticized, expressed his most hostile emotions without fear of retaliation. Now he is told to leave his former analyst, break a rare emotional bond and working relationship, and lie on the couch of a stranger whose allegiance to the institution has the potential of infringing on his loyalty to the candidate. An exceptional training analyst might perhaps be able to meet both ends, but how many such people are out there? But can one expect such a feat from an average training analyst, one less powerful, one who seeks to curry approval from his superiors in the institution, who is scared of the candidates pathology or has his own unanalyzed repugnance, or as we say, counter-transference, to the candidate’s utterances? And how ready and able is a candidate, aware of the politics of the institute and so anxious about being passed for graduation, really open his heart to his training analyst? We have often heard about people having two analyses: one for the institute and another one for themselves, once they passed the perils and pitfalls of training in an approved institute, which proves my point that with respect to the basic requirements of a sound analytic contract the training analysis system is seriously flawed. All this points inescapably to the conclusion: a personal analysis of a candidate should not be the business of any institute. If the admission committee has done its job properly and selected for training men and women that have shown personal maturity, or sound judgment, or adequate clinical experience as therapists, then they should also be deemed responsible enough to contract a good enough analyst for a personal analysis. They should be given the basic freedom to choose someone with whom they feel a basic bond of acceptance, liking, and trust. TA’s might be chosen by some, but then TA’s would have to compete with all the others in the market to be selected.
The issue is further highlighted by the statement that “the faculty of the Institute, through observation of the candidate’s work in seminars, supervised analyses, and case presentations will be able to judge the extent to which the goals of the personal analysis are being achieved” – fair enough, but if the faculty have this good ability to evaluate the above goals, why then would not they be able to judge if such goals have or have not been achieved in an analysis with a professional who is not who is not a training analyst?
Two other matters encumber the ethics of the TA system.
The first has to do with training analysis as a vested interest of the training analyst system (TA system). Traditionally, becoming a TA has always been considered a coveted status bound with the triple benefit of power, pecunia, i.e., money, and prestige. Having overcome the hoops of training and the bigger yet hurdles of becoming a TA, who would want to give it up for some ideal of a more sound ethical system?
The second has to do with potential conflicts of interest and rivalries within the institutes between goals of training vs. goals of supervising. It has been traditionally held that because the training analysis is so personal, a training analyst cannot be a person’s supervising analyst and vice versa. This principle seems to have been rather imposed by the TA’s than requested by the candidates, more protective of the TA’s desire to remain anonymous, even as how this can be truly guaranteed within a given institute or society is anybody’s guess. The logic for this restriction would become less stringent if the training analysis were really focused on training and not on treatment. If the candidate were left to his own devices to about finding his own private analyst for his personal problems, I could see the logic of having a few months’ worth of a training analysis with an approved TA to show the candidate, as Freud wished, what a truly correct technique is like, assuming there is agreement about such correctness, but only for purposes of demonstration. An analyst performing such a demonstration analysis would then be free to supervise the same candidate’s analytic work.
The long high frequency analysis is based on the following philosophy:
A personal analysis during the course of candidacy aims to help the candidate achieve a high degree of character stability, openness, flexibility, and maturity. It is essential that the candidate develop the capacities for self-observation, self-reflection, and ultimately, ongoing self-analysis which are necessary for the capacity to maintain a basic psychoanalytic stance, including a creative openness to what the analyst learns and experiences. These achievements are essential if the future analyst is to be sufficiently free of those psychological vulnerabilities and character traits that may interfere with psychoanalytic work in any of its aspects. The personal analysis should result in direct appreciation of the nature and power of conscious and unconscious processes, including conflicts, affects, defenses, and their interrelationship. It should also result in conviction as to the therapeutic value of the analysis of transference and the value of gaining understanding of the role of childhood experiences, memories, and fantasies.
Analytic educators appreciate that a higher frequency of sessions in an analysis facilitates the reopening of early conflict, the analysis of defenses as they occur within the process, optimal intensity, and continuity of the process. Furthermore, many aspects of the analytic process require an environment that is largely a function of regularity and frequency. Examples include joining insight and affect, the necessary tolerance of unsettling states so that new synthesis and integration can occur, and the delicate receptivity to unconscious determinants both on the part of the patient and the analyst. The analyst’s own experience in psychoanalysis and his first experiences functioning as an analyst have an important role in the formation of an analyst's career. For this reason, it is necessary to provide those conditions that optimize the potential for the fullest psychoanalytic experience (APsaA, 2006).
This philosophy is evaluated as follows in the bylaws of the International Psychoanalytical Association (IPA):
Theanalysisaims at dealing with defence structures, overcoming resistances, exposing and analyzing neurotic transferences, infantile material, gaining conviction about primitive mental states, de-idealizing the analyst and the profession. This requires asintensive an immersionas possible inanalysis, preferably 4-5 times a week. Similarly, a candidate's experience in conducting analysis should also be as intensive as possible, i.e., 4-5 times a week. The capacity for continued self-analysis is an ideal, intended goal. A candidate needs to develop sustained courage for this.Immersionrequirements: numerical requirements exist, but it is doubtful how useful they are for evaluating individual growth. Requirements should be more individualized. The best tool for evaluating readiness to graduate is the collective opinion of supervisors (IPA, Appendix).
The above passages contain a not so veiled criticism of the rigidity of the American system. Issues of authority and power in the American are described as follows in the IPA bylaws:
Authority is vested in the Education Committee, with varying degrees but with an increase of candidates' representation. The Training Analyst status and power is a wide spread issue and concern. It has become more democratic, people may propose themselves, but it still creates a two-tier system, introducing strain. Many maintain that the TA should not be a status or life-time appointment but a function. There is conflict around the dispersion of power: greater democracy is evident, but there are many questions about its effects (e.g., "pluralism and democracy have become buzz words for anything goes"; "difference between secrecy and confidentiality – democracy has certain limits in a psychoanalytic society (IPA, Appendix).
It is not the first time that the IPA and the APsaA, proud of its special status as a “regional” and not merely a “component society,” have been at loggerheads with respect to training rules. Founded by A. A. Brill in 1911, fought Freud tooth and nail since in 1926 he expressed his views in favor of lay analysis and keeping the APsaA strictly medical and by means of an exclusionary policy against the admission of non-medical members for training and membership (Mosher & Richards, 2005). Mosher (2006) aptly characterized the APsaA system as a “monopoly” which has now come to an end in New York State with writing into law the regulation of the profession by the State Education Department in Albany and issuing of licenses to practice psychoanalysis. Mosher also pointed out thetrainingmonopoly set up by APsaA Board of Professional Standards in 1955 in its code of “unauthorized training”: “that it is unethical for any member of the American Psychoanalytic Association to train or supervise any individual for the practice of therapeutic psychoanalysis, except under the direct auspices of a recognized training institution of the Association” (p. 63), including the TA system. It was sheer politics: a self-serving code when the APsaA was the only game in town; it was honored more in the breach than in the observance: for example, the venerable Henry Alden Bunker secretly trained a number of non-medical analysts in New York City, but I do not know of any expulsions from the Association for that reason.
Let us now turn to the other training models in the IPA bylaws. The bylaws offer a comparison of three models, Eitingon, the French, and the Uruaguayan, in the five following parameters: “Intellectual Rationale; Philosophy of Psychoanalytic Education (immersion, qualifying, graduating); Psychoanalytic Process Underlying Educational Processes; Breadth vs. Depth of Exposure; Issues of Power, Authority & Authorization.” All three models are based on the tripartite curriculum, analysis, didactic courses and seminars, and supervision. The Eitingon model, the one adopted by the American Psychoanalytical Association is the most stringent with analysis is “an integral component of training,” as described above. In the French model, “analysis, while a required component of the training process, is strictly outside the boundaries of the training. There is no ‘training analysis and no ‘training analyst. Analysis can be with any IPA member.” The Uruguayan is conceived in a similar spirit: “There is no individual training analyst status. There is a transparency and equality of different functions and groups involved in training. Psychoanalysis is a conjectural, not an exact science. What is transmitted is a capacity to listen, an efficacy of the unconscious, vicissitudes of self, and an endless passion for psychoanalysis.” it is lagging behind the more open and flexible training systems in France and Uruguay.
The French model stipulates further:
Frequency is not determined extrinsically but intrinsically (usually 3-4 times a week) between the analyst and the candidate, and depends on clinical indications.
The admission interview assesses thequalityof analytical process undergone. Requirements emphasize unconscious contents and dynamics, e.g., flexibility of mental functioning, Oedipus, passivity & bisexuality, Apres-Coup, infantile neurosis, introjection of analytic function, negative capacity, etc. Defence analysis is considered "too psychotherapeutic". Supervision is regarded as the process that makes the candidate an analyst. Emphasis is on deepanalyticlistening – to patient material, and that of the candidate. The supervisor plays an essential and equal part in evaluation and validation – s/he presents the case to the evaluating group. OnlyFull Membersof Societies can do supervision (IPA, Appendix).
Furthermore: “The Training Committee is in the Psychoanalytic Society, to which it is democratically answerable. There is no independent Institute.” And this: “There is a general emphasis on Freud. Beyond this, freedom of courses and seminars is offered and freedom to select from them. Not a university type of teaching, but transmission by the teacher of his/her model and the expectation that the candidate will develop his/her own.”
The Uruguayans state that
“The model derives from a concern over and reaction to the previous concentration of power; an attempt to make training more free and equitable. There is not individual training analyst status. There is a transparency and equality of different functions and groups involved in training. Psychoanalysis is a conjectural, not an exact science. What is transmitted is a capacity to listen, an efficacy of the unconscious, vicissitudes of self, and an endless passion for psychoanalysis.” (IPA, Appendix).
The arrangements between candidate and analyst are defined as follows:
Frequency is at a minimum of 3 times a week, with periods of greater intensity and regression of up to 5 times a week. This is recommended practice, decided entirely between the analyst and the candidate. No authorization is required from the analyst, there is no required number of hours. The analyst informs the Institute of the start of the analysis and then only if the analysis is terminated unilaterally during training (IPA, Appendix).
The Uruguayan philosophy of training, recommending the longest analyses, is described as follows:
The analysis requires possibilities, time and space for regression. The educational process – seminars, courses and supervision – is modeled on the free academic or university approach: periodic written work is required and evaluated; candidates enjoy a wide choice of seminars and leaders. The final graduation paper is equivalent of a Masters thesis. The emphasis is on developing a capacity for psychoanalytic listening. There is a wide spectrum of theoretical offering, to combat its becoming narrow and dogmatic. It is intended that there is no opposition between depth and width of perspectives. This theoretical pluralism is not opposed to depth but to encyclopaedic knowledge that tries to synthesize all existing theories (i.e., it opposes leveling of theoretical differences). Candidates are free to choose, teachers, and to select seminars and courses. The basis of the educational system is an attempt to guard against a concentration of power and to safeguard its dispersion. The structure is mindful of transference complications, idealizations, and narcissistic passions. Nurturing should come from differences and avoid imitation and mimesis (IPA, Appendix).
The above comparison shows a greater flexibility and freedom in the French and Uruguayan models as against the rigidity of the American system. One matter stands out: the politics of four vs. three times a week analysis, a debate more rabbinical than realistic.
One of the most vocal proponents of reform has been the distinguished German psychoanalyst Helmut Thomä, of the Thomä & KächeleTextbook of Psychoanalysisfame, who has been championing a model of training opposed to the German system of training which, like its American counterpart, has adhered to the Eitingon model (Thomä, 1993, 1999, 2004; Thomä, e-mail of April 18, 2007). I am in complete agreement with his and Kächele’s recommendations:
the right of psychoanalytic institutes to influence directly or indirectly the training analysis should be restricted. … To restrict the power of Institutes with regard to the length of the 'didactic' or 'training' analysis is not a bureaucratic measure but a sound way of doing three things: (a) to rescue personal rights (b) to preserve the otherwise permanently threatened therapeutic function of the personal analysis and (c) to create a professional curriculum where the work and knowledge of candidates is judged independently of diagnostic evaluations and unspecified expectations about what changes are to be brought about by further "purifaction" (that is, by extending the analysis beyond the required quantitatively defined term of analytic "self-experience"). …In our opinion candidates should be evaluated exclusively on the strength of their performance as clinicans instead of being diagnosed as patients. In principle, candidates who think that they can work without any self-experience should be allowed to prove their psychoanalytic attitude, thinking and skills in intensive supervision and clinical courses. …We agree with Kernberg that it is unethical for training analysts to report in any way about their candidates. But in our opinionit is even more unethicalto administer and to request from a candidate to undergo a "supertherapy" (Balint) as a pre-requisite for his or her profession. The dilemma of the training analysis derives from a confusion between therapeutic goals and professional qualifications (Thomä, 2007, excerpted from Kächele & Thomä, 2000; emphasis added).
While expressing some reservations about the French model, Thomä did not much criticize the German system, which has its own problems. To be sure, an institute should not operate like a ‘super’ psychiatric clinic, its function is to teach. Two more ethical matters, briefly noted. One is money. Freud wrote volumes about sex and next to nothing about money and the same is true of the literature. On the one hand Freud dreamt of free clinic treatment for the masses but made his own money on wealthy patients. Money plays a sizable role in psychoanalytic training, a financial indenture while for many the first analytic patients are clinic patients at low fees, creating a dual system of values for the candidate. Just as in psychiatry, there is one psychoanalysis for the poor and another one for the rich. Similarly, the rigid regimentation endured by the candidate would be balked at by one’s private patients: real life is made of conflicts of interest and practical compromises. At the end of the day, just as law is dispensed by judges and not by law books, so psychoanalyses are not run by blue prints but are co-created by the people who practice them. But teaching principles and ethical principles do make a difference. Unfortunately, politics have overpowered and overshadowed principles.
The writing is on the wall. The time for reform is overdue. A training institution should not act as a protective and self-serving Big Brother but inculcate in its students the ideals of love, intellectual freedom, and personal responsibility.
References
American Psychoanalytic Association. Bylaws. Last version emended through 2006.
Balint, M. (1965a). Chapter XIX, On the psycho-analytic training system. In:Primary love and psychoanalytic technique.New York: Liveright.
Balint, M. (1965b). Chapter XX, Analytic training and training analysis. In:Primary love and psychoanalytic technique.New York: Liveright.
Bernfeld, S. (1962).On Psychoanalytic Training. With an introduction by Rudolph Eckstein, PhD. Psychoanalytic Quarterly, 31,453-482
Gay, P. (1988).Freud a life for our time.New York: Norton.
International Psychoanalytical Association (2007). Requirements for Qualification and Admission to Membership. Appendix: Description of the Three Models.
Kächele, H., & Thomä, H. (2000). Letter to the Editor. On the devaluation of the Eitingon-Freud model of psychoanalytic education.International Journal of Psychoanalysis,81, 97-120.
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Thomä, H. (1999). Memorandum about a reform of the psychoanalytic education.
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Thomä, H. (2004). Psychoanalysts without a specific professional identity: a utopian dream.International Forum of Psychoanalysis, 13,213-226.