THE AMERICAN

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PSYCHOANALYTIC

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BURNESS E. MOORE,M.D.

ASSOCIATION:

ITS JANUS POSTURE

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exhibited at the Jewish Museum in New York in the fall of 1974, there is a Janus-headed figure, one face of which shows Minerva, goddess of wisdom and the intellect, and the other Silenus, the drunken old companion of Dionysus and, hence, an archetype of evil. The two faces looked forward and backward, inside the temple and outward. The temple itself was closed during peace and open during war. It is idle to speculate what meanings Freud may have attached to this head and its possible influence on psychoanalytic theory, but it is obvious that the statue, an example of primary-process condensation in artistic form, has implications of conflict, of guardianship, of inner and outer directedness, and of time-attributes of the human psyche related to the functions of the ego. By my title I am suggesting that the American Psychoanalytic Association has, of necessity, a posture like that of Janus, looking within and surveying the past, but also facing outward and beyond its own confines to appraise external reality. These essentially ego functiqns are but part of the total psychic structure the Association represents for its members. Id impulses, both libidinal and aggressive, affect our ability to live up to a common ego ideal, and our superego functions, discharged in the setting of standards, may vacillate between being too N FREUD’S COLLECTION OF ANTIQUITIES,

Presidential Address to the Plenary Session of the American Psychoanalytic Association, December 14, 1974. Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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harsh and being corrupted by expediency. The organization, like the human beings it represents, seldom functions with maximum effectiveness, or fully achieves its ideals. In fact, operating as an analytic group as well as individually during much of our history, we have been more concerned with the past and the immediate present than with the future. If psychoanalytic organizations have been -like the eminently satisfying analytic patient -self-observing, introspective, and eager to explore their problems, they have at the same time been obsessively ruminative about the conflicts within the family-in relation to authority, standards, and training programs -in what seems a narcissistic way, without optimal regard for the realities of the world in which we live and their effect on our organizations, our professional lives, and psychoanalysis itself. Indecision and failure to change, even to act, have often marked our efforts. As in our analyses, we appear in organizational activities to tolerate the timelessness of the unconscious, and we set no deadlines. My personification of the organization is not original. In his 1952 Presidential address, Robert Knight described the Association as an overgrown adolescent going through the pangs of development, with troubles related to rapid growth, self-discipline, and to problems of learning and self-teaching. A decade later, Rangell (1962) said that the gawky adolescent had inched his way up to the twenty-first birthday and stood on the “brink of maturity.’’ At the present time, to continue the metaphor, some of our critics would contend that in the fifteen years that have passed since Rangell’s evaluation, the Association and the science it represents have gone into a rapid decline and premature senescence. I would myself place it somewhere beyond that age of thirty which is the boundary for the trust of youth. In developmental terms, however, this is the stage at which certain maturational goals have been achieved, career and object choices have been made, and a new family entity and home base have been established. The turbulence, impulsivity, and instability of adolescence have Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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passed; there has been sufficient time for self-observation and introspection; and repetitive neurotic problems can no longer be ignored. Analysis of the roots of disruptive inner conflicts is indicated if we are to be less hampered in meeting new problems and in planning for the future. Such an analysis was begun in Knight’s own historical survey of the early clashes within our organization and continued in Ives Hendrick‘s (1955) review of the development of professional standards; in the significant questions to which Bernard Bandler addressed himself in 1960; in Leo Rangell’s (1962) “Prospect and Retrospect,” which examined among other topics our scientific attitudes and issues, our relations with contiguous disciplines, and relations inter- and intra-analysis; in Max Gitelson’s (1964) plea for psychoanalysis to accept its identity as a separate scientific discipline; in Royden Astley’s (1974) look to the future; and in Samuel Ritvo’s (1971) view of the prospects and challenges of psychoanalysis as science and profession. The day-to-day process has been carried on in the routine work of institute Educational Committees, in the workshops and site visits of the Committee on Institutes, and in the deliberations of the various Committees of the Board and Council, The Rainbow Conference in 1955, followed by the Lewin and Ross Survey of Psychoanalytic Education in 1960, provided an over-all perspective, and currently we are at the culmination of another stocktaking, with panels at this December, 1974 meeting reporting on current theories of the psychoanalytic process, on a National Conference on Psychoanalytic Education and Research, and on a critical assessment of the future of psychoanalysis from outside the profession. It is an impressive effort, mounted over many years by many capable and dedicated analysts. In seeking to add to it, I shall be following the attempt to apply psychoanalytic knowledge to an understanding of our group problems initiated by Sylvan Keiser (1972) and Jacob Arlow (1970). Groups-for study and discussion as well as for scientific and professional purposes-have played a vital role in the Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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development of psychoanalysis (Moore, 1965), and it was perhaps inevitable that Freud’s (1921) initial insights into group psychology be followed up by studies of the psychoanalytic group itself. In this effort, however, a large measure of caution is indicated. We must be sensitive to the danger of lighting up old conflagrations, and an adequate methodology has yet to be developed. Familiar analytic concepts cannot be simplistically applied to a large group, and the assistance of other disciplines, such as sociology and systems analysis, would be helpful. The customary data with which we deal as analysts of individuals are lacking, and what we do have often cannot be divulged for reasons of confidentiality. As a starting point, however, we might consider certain commonly recognized phenomena of a symptomatic nature. These are indigenous to all organizations, particularly professional and psychoanalytic, from the local to the national and international levels, but what I have to say is related most specifically to the American, since the structure and functions of our national organization are in many respects almost unique. I refer, of course, to the fact that the American represents individual members, affiliate societies, and approved institutes -constituencies of quite different orders -and its functions include those of a professional organization holding scientific meetings and representing the interests of its members on a national basis, and an educational Board whose actions are equivalent to accreditation and certification. In its multiple representation of individuals and disparate groups and in its varied functions, our Association is more comparable to the American Association of Medical Colleges than to other professional organizations (see Coggeshall Report, 1965). This organizational complexity is one source of complications, but these existed long before the present form of the Association and will undoubtedly continue. The Presidential Addresses I have mentioned document the fact that, well before our generation, the Association had essentially the same preoccupations with which we are conDownloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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cerned at present, and many of the questions asked in those earlier times are still unanswered. By all accounts, 1932 was the significant year in determining the principles upon which psychoanalytic education and training were to be based in the institutes within our Association. At that time it was decided, and reaffirmed many times later, that medical and psychiatric preparation are prerequisites for psychoanalytic training, which should include personal analysis, supervised analysis , and seminars. Psychoanalysis was held to be a science, not a dogma, whose elements were discovered by Freud. It was to become a basic science of psychiatry, and training was to be a function of institutes, rather than of individuals. As Hendrick said in 1955, these principles and the decisions implementing them defined “the prime reason for our existence and the keystone of sound Association policy, the need for a national organization of accredited analysts concerned primarily with the scientific and other problems of psychoanalysis” (pp. 563564). As a first step toward providing such accreditation, or certification as it would now be called, the Association set up definitive membership requirements, a need strongly felt because of a rapid increase of “wild analysts.” In this brief historical note one can perceive the primary issues about which conflict has existed throughout the subsequent years: (1) Psychoanalysis as a science, not a dogma; (2) authority for establishing and maintaining standards; (3) the separate identity of psychoanalysis as opposed to a status as a subspecialty of psychiatry and medicine; (4) the desirability or undesirability of the training of lay analysts; (5) the means for certifying individual competence and accrediting training programs; (6) and finally, the organizational means for accomplishing the aims about which there is a consensus. Our history has been in part typical of the gradual evolvement of any new profession, but the continuing persistence of issueswhat Rangell has termed perseveration-presumably settled over 40 years ago, is symptomatic, I believe, of underlying conflicts inherent in psychoanalysis , only partially acknowlDownloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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edged and never resolved, but fought out interminably on an organizational level, where the real motivations constitute a hidden agenda. Theoretical differences occur in all fields of science, but schisms in psychoanalysis have been particularly damaging to our status. In our Association, they have been less divisive in recent years, Earlier, as in the case of Horney and Rado, well-defined differences did lead to conflicts over ,the curriculum content in institutes and cries of orthodoxy and liberalism. Damaging disruptions within institutes continue to occur between individuals and groups primarily over training issues and the selection of faculty. These .have been discussed in some detail by Arlow (1970) and Keiser (1972). I mention them in the present context because they are often viewed as local and private battles, reverberations of which reach the national officers, but without objective reports until a site visit occurs or an impasse is reached and the Board is called upon to resolve the situation. While local conditions require, and there is much advantage in, a certain degree of autonomy for institutes to develop their own structures, philosophies, and pedagogical orientations, the dilemmas I have mentioned require a central authority that is more distant from the scene and less involved in the conflict, though often such local dissensions spread and affect decisions even on the national level. This was especially true in the early years of the Association, when the authority of the Board was challenged, not only by the institutes themselves, but by the Executive Council as well. In general, institutes have favored national authority over training standards for all institutes except their own, and it was not until 1972 that the Association passed a Bylaw providing due process for the disaccreditation of an institute or the disaffiliation of a society. A consultative educational approach has been found to be more effective than authoritarian control in the maintenance of standards, and the excellent workshops and site visits of the Committee Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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on Institutes have served this purpose. Nevertheless, until recently the Board has lacked the clout to deal with a possibly recalcitrant institute and thereby discharge the accrediting function for training programs the Association has assumed. Moreover, although there are experientially determined bases for judging the adequacy of a training program, these criteria and those for certifying the competency of the individual remain to be precisely formulated if we are to establish accrediting and certifying bodies acceptable to the health disciplines and society at large. The possibility of establishing an independent certifying board for psychoanalysis has been considered no less than five times-in 1939, 1948, 1955, 1960, and at present. Well-advanced negotiations were defeated by a vote of the Association in 1960 because the certifying function would have been carried out as a subspecialty under the American Board of Psychiatry and Neurology. Its opponents argued that psychoanalysis would lose its identity as a separate profession, and there were fears that our own rigorous standards might not be preserved by a mixed Board whose membership might be subject to antithetical influences. Let me mention a few other examples of major concerns of the Association during the past fifteen years on which action was delayed or defeated because of strongly held opposing viewpoints. Participation by the Association in a court action for tax relief for candidates’ training analyses was vigorously opposed by some members, who felt that a favorable ruling would in effect make psychoanalysis a subspecialty of psychiatry. At the time the I.R.S. had ruled that training analyses were tax deductible only if it could be shown that they furthered the candidates’ skill as psychiatrists. The establishment of a Central Office of Education was defeated for reasons that were never fully clarified to the membership, partly for reasons of confidentiality. A Committee on Organization worked for several years to try to simplify our organizational structure, but an increase in the number of Councilorsat-Large was the only recommendation accepted. It required Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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some thirteen years to give membership recognition to distinguished nonmedical training and supervising analysts, who were important educators at various institutes. A Code of Ethics and means for implementing it have been pending, with only partial action, since 1947. A drop in membership applications of recent graduates led to the appointment of a Council committee to investigate the causes and make recommendations regarding membership policy, but its concerns were largely the prerogative of the Board, and a second, Joint Committee had to be appointed, which has only now completed its assignment. One of the results of that effort, a move toward inclusion of candidates and recent graduates in our membership structure and committee functions, encountered strong resistance from a minority who look upon it as a threat to the integrity of the transference and the analytic process, and to membership as a form of certification. At least one institute refused to provide the Association with the names of candidates and recent graduates who were eligible for Affiliate and Associate Membership. Less than half of those eligible accepted Associate Membership, and it seemed that some of those who did had overlooked the fact that this form of membership is limited. Some who assumed that it was permanent accepted because they wanted to be associated with the national organization, but for various reasons could not go through the procedure for active membership. Many hold-outs were interested enough to write in their objections, Allow me to quote the principal and recurrent themes: Associate Membership is an expedient, a compromise to substitute for a more realistic and fair policy in regard to the requirements for active membership. Limited to three years, it does not avoid an ultimate confrontation with the application process for active membership. The latter is an onerous, complicated, time-consuming, unwarranted review of credentials already conducted by the individual institutes. Having completed the requirements of an approved institute, why should the graduate have to go through another archaic Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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rite of passage? The present requirements represent an effort to maintain control over standards in an illogical way. The graduate, who is powerless, is made responsible for proving the adequacy of training in the institute. If the Association desires to exercise accrediting powers, it should compel the institutes to conform to its standards or abandon them. The rigidity of the Association in such requirements contrasts sharply with other professional societies, which invite the graduate to membership without reservations. For their dues, applicants for Associate Membership are often offered only “second-classcitizenship without a vote.” Refusal of the invitation is a protest against the relative exclusion of nonmedical colleagues. These objections overlook the fact that approved institutes, no matter how carefully they are monitored, will necessarily vary in the quality of training provided, and even the best may, for very human reasons, graduate candidates not fully qualified for a national certification that is meaningful. Moreover, while it is true that active membership is available to all graduates of approved training programs in some professional organizations when separate accrediting and certifying agencies exist in those fields, the graduate must undergo another screening for certification. The rate of rejection of these certifying Boards is uniformly higher than that of our Membership Committee. In the meantime, candidates had formed their own national organization and were pressing for recognition, representation on all committees, Board and Council, and full voting rights, with active membership in the national Association automatic upon graduation from an institute. Representation on relevant committees is now an accomplished fact. Automatic eligibility for full membership upon graduation, which is advocated by some societies as well, would make the Association solely a scientific and professional organization before independent accrediting and certifying bodies have been established. Continuing conferences with the organizaDownloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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tion of Candidates (or Clinical Associates as they are called in some institutes) have helped to reconcile differences. The two organizations now have an established means of official communication and appear to be working together harmoniously. These difficulties with both graduates and candidates do underscore, however, the misunderstanding of objectives that may arise as a result of the complexity of our organizational structure and the multiplicity of its functions. At the same time, they reflect personal philosophies-e.g., disagreement with membership as a quasi certification on a national levelaqd a lack of knowledge of the history of the Association and its struggles to find a solution to these issues. It is also apparent that in the past both the institutes and the Association itself have neglected to inform candidates adequately about the objectives of the national organization and the desirability of membership in it. The need for a brochure for this purpose was recognized as early as 1959, but it was not given a very high priority and is only now nearing completion. In fact, for many years in the past communication seems to have been a problem at all levels. Action on important matters has often been delayed because local institutes and societies failed to give prompt consideration to the issues referred to them by the Association and to communicate their reactions. But the fault lay on both sides. Members have sometimes not been adequately informed by the Association or their societies of the significance of issues in advance of discussions at meetings of the Board and Council. The business meetings of members, which acquired a tradition of long, detailed reports of the activities of the Board, Council, and the various Committees, became so boring that the attendance of members at the meetings eventually made a farce of the quorum. This array of symptoms- ambivalence, splitting, identity problems, poor object relations, impaired functioning, acting out, and failures in communication, as well as the capacity for Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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struggle and adaptation -has , as you have heard , more than once led speakers to refer to the organization metaphorically as a living organism, even in human terms. Organizational problems necessarily have their origins, at least in part, in the psychology of the individuals who constitute its members. Keiser (1972) stated this eloquently in regard to institutes, enumerating the historical and personal “elements which might become a recognizable force in releasing an institute’s potential for disruptive action” (p. 521). Also speaking of these problems, Arlow (1970) applied Freud‘s (1921) “Group Psychology and the Analysis of the Ego” to their understanding. He elucidated the cohesiveness of a group in terms of a common need and shared unconscious fantasies contributing to mutual identification and libidinal ties toward a common external object who fulfills the function of a collective ego ideal. Conflicts are expressed in unconscious fantasies which take the derivative form of myths, infiltrating ideology and giving rise to ritual in the form of institutionalized practices. But “Overidealization,” he said, “is the opposite side of the coin of hostility.” Applied to psychoanalysis, the transference implications may be missed, and the possibility exists for the persistence of ambivalent transference residues. “By way of reaction formation, the underlying doubt . . . gives way to dogmatism.” “Sooner or later the unanalyzed hostility, cemented by group alliances with like-minded individuals is projected” onto the bad object, a‘so-called enemy of real analysis, who is really a repudiated aspect of the self. In the name of defending Freud and psychoanalysis, “the unresolved transference bond to the father-analyst is pursued with a vigor and intensity that reveals its unconscious origin. ” My summary does not do justice to Arlow’s thesis, but I must be brief if I am to carry forward the analysis in reference to the problems of the national organization. We come together from diverse origins -personal, geographical , and analytical-having emigrated, as RenC Dubos (1974) said, to a new land of the mind. For the most part, Arlow points out, we Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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have to put behind us any sense of identification with family, religion, or national group, and psychoanalysis serves as the family romance of psychoanalysts; but I would a d d that residues of earlier identifications remain. At each successive stage -of medical education, psychiatric residency, and analytic training-new and different ego ideals have been fused within the self, to form a new identity cathected with aggressive- as well as libidinal-drive energies. Solnit (1972) assumes, along with others, that “aggression becomes bound or fused when there is a satisfactory relationship to the love object, Le., libidinal ties promote the availability of aggressive-drive energies so they can be modified and subject to the dominant role of the ego” (p. 437). When Margaret Mead presented her address on “Unbound Aggression” at the Denver meeting in May, 1974 and referred to this binding quality inherent in nurture, I reflected that more than any other profession, psychoanalysts nurture their young, but over a protracted period of analysis so conducive to regression that it may be considered a third and artificial stage of separationindividuation. Despite its advantages, the tripartite nature of training fosters split transferences and easy displacements of libidinal and aggressive cathexes. Out of the multiple identifications resulting, a new, final, and highly individualized identity must be formed and zealously protected against the regressive pulls toward fusion with the primary transference object, This can be accomplished most readily if there is a collective identity, a relatively stable structure, but subject nevertheless to stresses from within and without that threaten the sense of analytic identity won at such effort. Arlow referred to the consequences within the local institute. But outside the relative safety of the local institute, exposure to new personalities and new ideas threatens the stability of this latest identity formation. Though Freud and the science of psychoanalysis constitute our common ego ideal, its most significant representative objects have been the parental figures responsible €or training in the local institutes. Having Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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shifted his identity so many times, the analyst is likely to cling to the philosophies and practices of his local group and resist any divergent views he encounters on the national scene. The psychic maneuvers developed on the local terrain are transferred to the national arena, adding another complexity to otn-organization -nebulous and unnamed groups made up of a tenuous network of alliances, based on shared identifications and common myths, but even more unsubstantial and subject to doubt because they are based on transient and shallow contact. The latest collective identity is reinforced by a regressive cathexis of earlier positions, which take on some of the quality of those narcissistic substructures that Kohut (1971) and Kernberg (1966) have described, with all the overestimation of personal and group attributes we have come to recognize. An archaic superego zeal that brooks no compromise is needed to protect against the aggressive inner forces that might threaten fragile object ties and integrity of the self. Why, otherwise, should we fear dilution and the disappearance of a science that has proved its validity and heuristic usefulness over more than half a century? Yet we are afraid to modify even slightly any principle we regard as basic. These usually relate to our earlier, narcissistically cathected identities, and medicine and psychiatry are prominent among them. Such sequential development in identity formation occurs among the individuals of any group; what differs is the nature of the resulting conflicts based on the history of the individuals and the groups. But the national forum has a leavening influence as well. Within the national committees, Board, and Council, the group process operates again, but with lessened intensity of libidinal and aggressive investment because of briefer and intermittent contact. Consensus, in the form of an overwhelming majority if not unanimity, is usually possible with regard to ordinary business. It is primarily when matters are of such moment that they have to be referred to our constituent institutes, societies, and individual members that trouble Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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arises again. On such occasions, the tension recurs between factions within the individual institutes and spreads to implicate other institutes, or the Association, as the culprits whose proposals are experienced as alarming threats to psychoanalysis. These are, I believe, at least some of the intrapsychic and group sources for our difficulty in resolving long-standing issues or embarking on new directions, It is not my intent, however, to convey the impression that all of our organizational problems are inherent in the nature and results of psychoanalytic training itself. Various contributory historical factors are well known and need not be specified. A talent for organization is not given a high rating within our system of values, and our leaders are often selected for other reasons. While an administrator must be respected, creative individuals and astute clinicians do not always possess the talents or the interest needed. Other means than election to office need to be found to honor distinguished scientific contributors. Busy as practitioners, teachers, and in other capacities in their institutes and psychiatric communities, many analysts often can give only limited time to national activities. The rigidity often ascribed to the Association is attributable in part to the democratic process itself. We have only to look to the shortcomings of any legislative group for similar problems. A major effort at reorganization is likely to be defeated and will retard progress because it unifies otherwise divergent groups who disapprove of one or another aspect of the proposals. Worthwhile change is a very slow process; support for it must be built up gradually, and it must be implemented in a step-by-step way. In the highly individualistic psychoanalytic community, respected colleagues equally well informed about problems may differ widely on what to do about them. Our complex issues require patience and careful exploration of divergent viewpoints for solutions that are acceptable. Returning to the analogy with the psychoanalytic process, in organizational matters a long period of working Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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through is necessary. Acknowledging this fact, as well as the real dangers that exist in change, we must also recognize that failure to act, to adapt to new circumstances, may constitute a negative act potentially even more dangerous than what has been proposed. It is time, now, that I turn to the other face of Janus, the one looking outward. In his 1972 address, Robert Wallerstein (1973) dealt with external reality and its current evanescent quality -no longer the “average expectable environment” which we have so long assumed to exist. He mentioned some of the broad social and cultural changes-alterations in life styles, sexual mores, and family patterns-that have come to be accepted without necessary implications of psychopathology during the past decade, Equally revolutionary changes have occurred in medicine, in psychiatry, and in our economy. Medical schools have radically revised their curricula, shortening the course in many instances to three years, and offering a core of basic subject material, followed by separate tracks leading to early specialization. In most fields except for psychiatry, which has already tried and rejected the experiment, internships will cease to exist after 1975, the training heretofore provided to be incorporated into a total graduate program. The Coggeshall Report (1965), commissioned by the Association of American Medical Colleges, has recommended that all health care training programs be organized under the aegis of universities to achieve better integration and interdisciplinary cooperation. The pre-eminent position of psychoanalysis in American psychiatry no longer prevails. It was at its peak at the time of Rangell’s address in 1962. Other modalities of therapy have been developed and are the vogue, even though their scientific validity and therapeutic effectiveness are, for the disorders analysts treat, no better established than that of psychoanalysis. Psychoanalytic principles have been absorbed into psychiatry, often without attribution, sometimes modified and distorted, but perhaps not unjustifiably, since they are being Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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applied to populations with which we do not deal. The content of the psychiatric residencies has been greatly expanded, and a variety of track programs have been developed in the larger centers. Individual psychotherapy is one of these, and psychoanalytic instruction may be included, given by respected analysts. Supplemented by a personal analysis, such exposure to psychoanalysis is regarded as sufficient by many residents who would at an earlier time have sought analytic training. They are deterred by their already long training and by the personal sacrifices entailed- absence from a growing family and a cost that is overwhelming-factors that reinforce whatever inner resistances exist. Attention in medicine and psychiatry, prodded by changing social attitudes and governmental direction, is now being focused more than ever on systems for the delivery of health care services to all segments of the population. Consumer protection is the watchword, and accountability is a responsibility the profession must embrace or have the controls wrested from it. Means for evaluating competency must be devised, and there is a trend, already well advanced in many states, to link licensure to certification, and even recertification, on the basis of continuing education. Professional Standards Review Organizations have been assigned the task by Congress of setting standards for diagnosis and adequacy of treatment. Questionable situations will be subject to review by Peer Review Committees. Apparently for political reasons at first, but now because of inflation as well, government funding for medical and psychiatric education and programs has been drastically cut. Psychoanalytic training never received more than modest support at any time, and that little is being reduced to nothing. Health care has become so expensive that a National Health Insurance Program is considered inevitable, and a massive effort has been necessary to insure the inclusion of intensive psychotherapy and psychoanalysis, with the outcome still in doubt. Certain insurance companies, administering Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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programs for the government, have already moved to cut down on benefits for psychiatric and psychoanalytic treatment. Such.cuts will follow in the private insurance sector as well, and many insurance companies are demanding more and more information in the processing of claims covered under current policies. Third party payments and peer-review mechanisms present problems of confidentiality that are of particular concern to analysts. To complicate matters still further, there is no doubt that we are in a recession; the serious reverses suffered by even the wealthy may cause them to look upon analysis as a dispensable luxury. But even before these economic changes, in fact since 1965, our Association Survey (Moore, 1972) showed there had been a gradual decline in the number of patients seeking analysis from our members. The reasons are undoubtedly complex, and a Committee has been appointed to investigate the causes, but I would like to mention one possible contributory factor easily overlooked because of our self-preoccupation. There appears to be a burgeoning of so-called psychoanalytic institutes in some parts of the country. In New York City, for example, in addition to the three institutes approved by the Association, there are 23 other groups offering “psychoanalytic training.” Could it be that patients seeking analysis are as numerous as before, but have no clear indication as to what analysis is or who its qualified practitioners are? Here we come full circle back to the basis for the development of standards for membership in 1932- the proliferation of “wild analysts.” These trends have serious implications for our Association and for psychoanalysis. Traditionally, psychoanalytic training has been financed by candidates and by the faculty of institutes and members of societies, with little support from outside funds. New licensure provisions that would preclude “moonlighting” activities for residents may delay the beginning of personal analysis, and graduate analysts could conceivably be in a less favorable position to support training Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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activities from their own resources. But the changing circumstances also provide opportunities. The trend toward integration of health care training programs under university auspices promises to contribute to the development of new professions cutting across disciplines. One such program for the training of mental health professionals has already been launched by Mt. Zion Hospital and the University of California, Berkeley, along lines similar to those advocated by Kubie (1954, 1957). The track system of medicine and psychiatry might make possible the beginning of psychoanalytic training at various stages in the graduate course. Innovative use of these possibilities will require, however, a greater degree of flexibility on our part than has heretofore been evident. Note the lead time of nearly twenty years before Kubie's ideas were followed by action. This brings me to some of the paradoxes that have resulted from our ambivalence in the past, which changing realities should motivate us to correct. First about the issue of the training of lay analysts. Repeatedly, the Association has taken the stand that a medical and psychiatric background constitutes the best preparation for therapeutic analysis. At the same time, the contribution which lay analysts may make to the science of psychoanalysis has been abundantly demonstrated and has been recognized in Board provisions for a waiver of the medical requirement for selected researchers in other disciplines. But the qualifications for such a waiver in the past have been so stringent that the possibility attracted only a handful of individuals, for whom we provided no membership base for many years. Although this situation has been considerably ameliorated, many still regard our provisions as insufficient. A piece of reality has been overlooked. We have no exclusive prerogative to Freud's heritage. Lay analysis is here to stay. It is only a question of whether our Association will play a significant role in guiding and promoting its development along lines that we believe advantageous to psychoanalysis. Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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As a result of a National Conference on Levels and Patterns of Training in Professional Psychology in Vail, Colorado, in 1973, the American Psychological Association recommended the development of a variety of nontraditional educational programs to prepare individuals in the human services area. Even before that time, more than 150 “Academic-Applied” programs in psychology existed in colleges around the country, graduating thousands to work in correction and drug abuse centers, in schools, and in a variety of other mental health settings. The American Psychological Association went a step further by endorsing the development of separate professional schools of psychology, offering a doctorate degree, and several large schools have been established-four in California, one in New Jersey, and one in Illinois. This is only part of a general movement on the part of psychologists and social workers toward a more therapeutic role, which is gaining increased acceptance even on a private care basis. Postdoctoral programs are available to psychologists in many psychiatric departments and hospitals and are equivalent to a partial residency in psychiatry. Governmental health care programs, and even private insurance carriers, now reimburse psychologists for private therapy. It is inevitable that many of these professionals in related fields will be attracted to psychoanalysis and seek training. Can we ignore this trend? In the late forties, the issue of unauthorized training was a violently charged one. It was focused in particular on the issue of training for child analysis, and an attempt to bring nonmedical child analysts into a special section of the Association was defeated. As a result, the child analysts formed their own Association, which fortunately has remained close to our own and now holds joint meetings with us. If we are to remain exclusively a medical Association of analysts, the best interests of psychoanalysis might be served by giving our support to a carefully selected group for the establishment of a model institute with adequate training standards for nonmedical trainees. Some of the 600 or more Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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members of a Division of Psychotherapy in the American Psychological Association represent themselves as psychoanalysts. A much smaller and more select group within the same Association, including gr.aduates of some of our own institutes, have organized psychologists interested in psychoanalysis, but have so far resisted division status and an attempt to secure a diplomate in psychoanalysis. A movement is underway, however, by another group of psychologists and social workers who do not have the support of the American Psychological Association, to gather institutes and analysts unrecognized by the Association into a National Accrediting and Certifying organization. In New York State it would be virtually impossible to define psychoanalysis in licensure laws in a way acceptable to us because of the greater number and industry in this direction of people whom we would regard as unqualified in the field. The other side of the paradox is that, while clinging to our identity as physicians and psychiatrists as well as analysts, we have done comparatively little to establish firm organizational bonds with medicine and psychiatry. The drift apart has not been wholly our fault, but we have contributed to it. Until four or five years ago, there had been essentially no contact on common concerns between the officers of the American Psychoanalytic and the American Psychiatric for a decade. We are even more remote from medical organizations. The value of psychoanalysis as a research instrument and its potential contributions to science rather than its value as a therapy have been emphasized repeatedly. Only recently, however, has the Association appointed a standing Committee on Scientific Activities which is to make its first report at this meeting. Meanwhile, it has been noted time and again that our candidates are selected on the basis of intent to become therapists, and are offered little or no orientation, except in a few institutes, in research methodology or even scholarly research. Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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While our training emphasis has been on therapy, and therapy has afforded us our means of livelihood, we have done comparatively little to demonstrate the therapeutic effectiveness of psychoanalysis, a fact that has not escaped the attention of our critics and the agencies that grant funds. I am a*are of the tremendous complexity of attempts to evaluate the outcome of therapy in the mental health field (see Wallerstein, 1963, 1971; Schlesinger, 1974), but our efforts need to be expanded. For some recent reports on major studies, see Kernberg et al. (1972) and Schlessinger and Robbins (1974). Because of the new challenges we face and the opportunities as well as the liabilities they present, I have highlighted some of the inconsistencies between our objectives and our performance as an organization and the paradoxes that have resulted. In the main, our major unresolved problems reflect ambivalence in regard to conflicting ego ideals- those of the pioneer American psychoanalysts who established our principles of training in 1932 and those. of the large body of distinguished European analysts who migrated to this country and, for the most part, adhered to Freud’s ideas about lay analysis. As late as 1967, at least a fourth of our members were foreign born, and their viewpoints have had a profound influence in shaking if not modifying the earlier stand on this issue taken by the Americans. This would be an unbalanced presentation, however, if I were to neglect the positive accomplishments of the Association during the past decade. It is inconsistent with ego psychology to ignore strengths and focus only on weaknesses. Having looked into the accrediting and certifying procedures of other groups, I can assure you that our own standards are far superior. The jurisdiction of the Board on Professional Standards as a national authority over training policies and practices in the institutes is now generally accepted and has been included in our Bylaws. But though it is autonomous, the Board has wisely adopted a policy of consulting the Council and the institutes on important issues. Workshops of the ComDownloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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mittee on Institutes bring together representatives of institutes for discussion of common problems. There is an increasing trend for joint committees of Board and Council to consider overlapping matters simultaneously rather than sequentially, avoiding jurisdictional disputes and unnecessary delays in action. Factions within institutes continue to exist, but some are firmly resolved to mediate their differences. In other cases, a split may be inevitable, but advantageous rather than harmful. Reports at the Business Meetings of Members have been made more selective, devoted to the more important items, and now attract a broader spectrum of members and result in a more lively interchange. To the various communication media I described in a letter to the members, the Committee on Affiliate Societies has added another, vitally important one. At each meeting the Officers of the Association report directly on current events to a meeting of Presidents and Presidents-Elect of the various societies, so that they are not dependent on second-hand reports from Councilors but may ask questions and offer their own views. The result has been a better integration of effort and an enhanced sense of unity. Professional as well as educational concerns have been included among our objectives. The Association has negotiated a professional liability insurance policy for its members at rates so much lower than those generally available that the savings compensate for membership dues. To represent our professional interests in connection with new developments on the national scene, a number of new committees have been appointed: to study and influence National Health Insurance and negotiate with agencies responsible for third party payments; to establish contacts with Professional Standards Review Organizations and set up Peer Review mechanisms; and to effect liaison with other professional organizations in order to broaden our basis for influencing action consistent with our common interests. Problems of psychoanalytic practice are the purview of a committee appointed last year. Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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A broadly based Committee on Confidentiality has been appointed to study and make recommendations on a variety of threats to confidentiality hitherto unrecognized and is already taking action on a-national level in cooperation with other professional organizations. This is a far cry from the time when we attempted to protect confidentiality by posting Pinkerton agents at our doors and excluding the press. With the latter, we have set up effective communications lines and established a continuing dialogue. If the results are not always to our liking, we must accept the fact that psychoanalytic understanding is difficult to convey, and it is at least useful to see ourselves as others see us. Broadening our horizons has produced new problems of leadership a n d organization. T h e work load has greatly increased, making it difficult for the Executive Committee to supervise the activities of the Committees and find time for them to report to Board and Council. The time away from practice or other duties required for activity in the national organization now approximates two weeks a year, a greater sacrifice than some members feel they can make, and it has become increasingly difficult to find experienced leaders able to accept nomination for national office. The proliferation of small societies has given them a greater representation on the Council than seems desirable, and proportional representation and other structural changes in the organization are now under consideration. Our scientific meetings have become more open and stimulating. Under a succession of imaginative and innovative Chairmen, the Program Committee has instituted a series of changes, including the setting up of small discussion groups, which have increased membership participation dramatically to over half of our members at each semiannual meeting. Our interests have broadened and become more inclusive, so that workshops, seminars, and interdisciplinary colloquia now attract a large following from other disciplines. So organized, our scientific meetings will now serve admirably the needs of Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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the Committee on Continuing Education, which is devising the means for giving credit for attendance now required in some states. These developments are important not only for older members, but for our candidates and recent graduates, whose new status as Affiliate and Associate Members will foster their identity as analysts and broaden their psychoanalytic perspective through contact with eminent analytic educators from other parts of the country. Thanks to the old and the new Editors, and the efforts of their Editorial Boards, our Journal has become a highly respected scientific publication, with an abundance of papers of excellent quality. There are no easy solutions to our internal conflicts or to the changing external realities I have mentioned. We have, however, t?ken a significant step forward. Fourteen years after the Lewin and Ross Survey, we are again looking to the future. The COPER deliberations explored certain possible objectives, but further deliberation is needed, decisions will have to be made, and action taken. In carrying out these necessary steps, certain questions, facts, and attitudes might be kept in mind. In the face of changing realities, can we be content with our present situation and simply adhere to the status quo? If not, we must recognize that changes in psychoanalytic training policies and programs require years for implementation and evaluation. We must therefore look far ahead and begin to plan for the next generation instead of dealing with past and present problems on an ad hoc basis. Projection of current trends suggests that the increasing complexity of medicine will burden students with subjects largely irrelevant to psychoanalysis and require neglect of more pertinent knowledge. This may make it increasingly more difficult to select the type of candidate we want exclusively from medical and psychiatric ranks. In my opinion, we should be willing to encourage and support adequate programs offering a balanced curriculum derived from the humanities, biological, Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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and social sciences, with provision for sufficient clinical experience, preparatory to a doctorate in psychotherapy. Some of the graduates of such programs should be acceptable for psychoanalytic training. But there can be no certainty about the future and no unanimity about the best course of action to meet it. In the absence of implacable stands, however, we should be able to resolve differences without compromising principles. Tolerance and respect for other viewpoints, patience, and time will be the main requisites, but we do need to move forward. Greater flexibility in our approaches to both organization and training will be necessary to accomplish some of our longfrustrated goals. If we can establish more satisfactory agencies and procedures for accreditation and certification, perhaps we will be able to accept the need for greater diversity in training programs and in settings for them, as well as the desirability of candidates and faculty from a wider variety of backgrounds. The changes of recent years indicate, I believe, that our previous one-faceted concern has been replaced by an attitude more truly like that of Janus. Problems and controversy in psychoanalytic organizations, indeed in all groups, are likely to be as constant as was war in the Roman Empire, and, like the temple of Janus at such times, our Association should keep communication lines open and have commerce with divergent camps. With the development of the capacity to look outward as well as inward and to adapt to changing realities, any analysis is far advanced. It may still be interminable, but the results will be satisfying. REFERENCES

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Bandler, B. (1960), The American Psychoanalytic Association 1960. ThisJournal, 8:389-407. Coggeshall, L. T. ed. (1965), Planning f o r Medical Aogress Through Education (Report submitted to the Executive Council of the Assn. of Amer. Med. Colleges). Evanston: Assn. of Amer. Med. Colleges. Dubos, R. (1974), On choosing to be human. Address presented to the plenary session, Amer. Psychoanal. Assn., Dec. 13, 1974. Freud, S. (1921). Group psychology and the analysis of the ego. Standard Edition: 18:67-143. London: Hogarth Press, 1955. Gitelson, M. (1964), On the identity crisis in American psychoanalysis. In: Psychoanalysis, Science and Profession. New York: International Universities Press, 1973, pp. 383-416. Hendrick, I. (1955), Professional standards of the American Psychoanalytic Association. ThisJournal, 3:561-600. Keiser, S. (1972), Report to the Board on Professional Standards. This Journal, 20:518-539. Kernbera. 0. F. (1966) Structural derivatives of object relationships. Znternat. J. PsyFho-Anal.; 47:236-253. , Burstein, E., Coyne, L . , Appelbaum, A., Horwitz, L. & Voth, H. (1972), Psychotherapy and Psychoanalysis. Final Report of the Menninger Foundation Psychotherapy Research Project. Bull. Menninger Clinic, 3638275. Knight, R. (1952), The present status of organized psychoanalysis in the U.S. ThisJournal, 1:197-221. Kohut, H. (1971), T h e Analysis o f t h e Self. New York: International Universities Press. Kubie, L. S. (1954). The pros and cons of a new profession: A Doctorate in Medical Psychology. Texas Reports on Biol. B Med., 12:125-170. (1957). The need for a new subdiscipline in the medical profession. Arch. Neur. B Psychiat., 78:283-293. Lewin, B. D. & Ross, H. (1960), Psychoanalytic Education in the United States. New York: Norton. Mead, M. (1974), The increase in unbound aggression. Address presented to plenary session, American Psychoanal. Assn., May 4, 1974. Moore, B. (1965), Continuing a psychoanalytic tradition. In: Kris Study Group Monograph I , ed. E. D. Joseph. New York: International Universities Press, pp. 11-29. (1972), A biographical-professional survey of members of the American Psychoanalytic Association. Report received by Executive Council, American Psychoanal. Assn. Rangell, L. (1962), Prospect and retrospect. ThisJournal, 10:227-258. Ritvo, S. (1971), Psychoanalysis as science and profession: Prospects and chalenges. ThisJournal, 19:5-21. Schlesinger, H. J. (1974), Problems of doing research on the therapeutic process in psychoanalysis. This Journal, 22:3-14. Schlessinger, N. & Robbins, F. (1974), Assessment and follow-up in psychoanalysis. This Journal, '22:542-567. Solnit, A. (1972), Aggression: A view of theory building in psychoanalysis. This Journal, 20:435-451. Downloaded from apa.sagepub.com at FLORIDA ATLANTIC UNIV on July 16, 2015

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Wallerstein, R. (1963). The problem of the assessment of change in psychotherapy. Internal. J. Psycho-Anal., 4431-41. ,-. (1971). Issues in research in the psychoanalytic process. Internat.J. PsychoAnal., 5211-51. ___ (1975), Psychoanalyticperspectives on the problem of reality. ThisJournal, 21:5-33. Submitted January 21, 1976 I50 East 73 Street New York, New York 10021

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