Chairman Paul J. Fink introduced the panel as analysts who were also chairmen of departments of psychiatry and who were therefore in an excellent position to deal with the mutual concerns of academia and psychoanalysis. Dr. Fink had asked the panelists to 'cover the problems of junior faculty, of analytic institutes and academic departments, of residency curriculum and that of analytic training, and of how senior analysts fit into departments of psychiatry.
As an introduction to addressing the problems of junior faculty, Morton F. Reiser, in an effort to avoid excessive entanglement in the maze of issues, proposed a credo: Psychoanalysis, as a theory, research method, and mode of treatment constitutes a major sector of the mental health field in general and psychiatry in particular. Its sector lies mainly in the psychological sphere and offers to psychiatry a theory basic to the understanding of psychopathology and psychotherapy. Learning to understand and conduct psychotherapy includes learning analytic principles- as the only thoroughgoing theoretical rationale for psychotherapy- and acquiring therapeutic skills through practicums and supervision. Teaching of both psychoanalytic and psychoanalytic psychotherapy would ideally involve analysts at varying levels of experience and career development; e.g.. senior analysts might best teach psychotherapy and candidates teach analytic theory, especially Held at the Annual Meeting of the American Psychoanalytic Association, Atlanta, May, 1978. Panelists: Paul J. Fink, IVilliam A. Frosch, Herbert Pardes. hlorton F. Reiser.
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during their immersion in the original literature. Candidates and residents could well teach the extrapolation of psychoanalytic principles to understanding doctor-patient relationships and medical care. This is important in the education of medical students and nonpsychiatric physicians and health care personnel. Analysts doing research might round out a well-balanced program with interdisciplinary collaboration. Reiser turned to the difficulties in implementing this credo, particularly the interruptions in the path for development of junior faculty. The charge of the medical school is to pass on existing knowledge, generate new knowledge, and render service. These missions are currently carried out in the midst of a crisis of professional identity in psychiatry, with confusion among the mental health professions about who and what a teacher is, and who he is training and for what role(s). There has also been a steady erosion of federal funds, which, paradoxically, most affects teaching just when more requires to be taught. Moreover, promotion of junior faculty is based on the quantity and quality of research papers and scholarly activity, with teaching and clinical duties considered of secondary importance if not actually “illicit.” In addition, promotion committees often consider psychiatric and psychoanalytic research and papers unscientific. While scholarly endeavor is required for promotion, the pressure of time and duty leads junior faculty to give first to patients, then to teaching and clinical administration; the fact that diminishing funds limit the number of tenure slots further squeezes junior persons immersed in these activities. When junior faculty drop out of academia for psychoanalytic training and then try to come back, they are similarly without the required credentials. In sum, climbing the academic ladder as junior faculty, good clinicians, teachers, and administrators, while simultaneously becoming analysts, makes it difficult to become senior faculty with tenure. For analytic candidates, all of these difficulties are compounded by financial pressures and pressures of time when analytic training and analysis are in full swing. The result is that a number of junior faculty leave full-time academic life for private practice and find it difficult or impossible to return. Such a situation, when analysts contribute only as part-time voluntary faculty, has a number of implications. Major role models no longer include psychoanalysts, the quality of teaching in long-term psychotherapy may well decline, and analysts no longer participate meaningfully in policy making within the department.
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Reiser concluded by saying that to carry out the credo he described, junior analytic faculty must be enabled to move into full-time senior faculty positions. Only in this way would there be a balanced ambience in departments of psychiatry, a balance of professional ego ideals with whom students could identify, and a comparable balance in the departmental decision-making process. Introducing the next speaker, Fink agreed with Reiser’s views and added two more problems of concern to junior faculty interested in analytic training: first, the pressure by colleagues who derogate an interest in what they consider passe‘, and second, the ceiling on full-time earnings for those who must support analysis, analytic training, and possibly a family. Herbert Pardes’ focus was the relation between academic departments and institutes. He proposed that the difficulty in achieving mutual understanding between these two types of institutions was a function of their different goals. A psychiatric department aimed at developing excellent educational programs, creative and productive research, and model clinical service programs; it also focused on the development of outstanding general physicians and professionals in mental health, enhancing critical thinking, and attending to the needs and values of the mental health and general communities. The goals of a psychoanalytic institute are to develop an outstanding educational program, promote psychoanalytic education and thinking in the mental health and the general community, and turn out outstanding practitioners of psychoanalysis. Institutes also take an advocacy position for psychoanalysis, and consistently emphasize efforts to assure high quality in students, analysts, and teachers. The similarities are manifold, with the greatest differences appearing to be a greater interest in research, in departments of psychiatry. and an overemphasis on reviewing the qualities of individuals who are in training, in the institutes. Research in analytic institutes has not assumed the importance it should have, said Pardes, and the emphasis on screening qualities of those who are allowed to enter training, to start classes, to take on cases, to practice independently, to graduate, and so forth can be nothing short of paralyzing. A further extension of the concern with preserving the “pure gold” is that honest questioners may be identified asantianalytic and there may be condemnation of those who interact with other disciplines or take on other responsibilities.
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The potential strengths of an integration between analytic institutes and academic departments of psychiatry might be achieved by some type of administrative interaction and linkage. Institute members identified with a department of psychiatry have a vested interest in it and influence its direction. T h e departments might influence the institute by questioning its conclusions, looking for ways to integrate theory and practice, evaluating analytic work, and exploring research. There must, of course, be checks on the potential abuse of individuals upon the relationship, but tight administrative links can enhance recruitment, program development, and communication. Institutes need students, and residents (the potential students) are heavily influenced by the department of psychiatry faculty. Analysts within a department, for example, also influence those physicians going into general health fields, who will consider analytic therapies appropriate for help with psychological problems to the extent that they themselves have had adequate training and exposure. Undergraduate curricula, therefore, should shift from a cafeteria-style emphasis on numerous specific facts to pass National Boards, to a synthesis, a general approach to behavior best taught by analytically trained personnel. To become thus involved is a challenging demand on institute faculty, but it is also the means to have a real impact on future professionals; if it is disregarded, institutes may well shrivel and be reduced to “evening discussions with friends.” While the messenger with bad news may sometimes have to take it on the chin, Pardes cautioned that he may also be the one who has worked to insure that the message is not‘ as bad as it might have been. The analyst brings to academia an understanding of behavior and a contribution necessary to any academic department of psychiatry interested in the true seeking of knowledge. Academia brings to the analyst the respect of being a member of the academic community of scholars, and the placement of students, its most prized products, in their hands. William A. Frosch dealt more specifically with the needs of medical school and residency curricula and their relationship to psychoanalysis. He quoted Henriette Klein and Emily Mumford as having chided the American Psychiatric Association for failure to provide a clear, active, and important presence in medical schools. Psychoanalysis, too, with its obsessive concern for purity, has cut itself off from medical schools, a source of renewal and strength. In so doing, it has failed to contribute to the medical school
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curriculum that which is the unique distinction of psychiatry and psychoanalysis, an awareness of the psychic experience- the individual’s experience over time of himself and the world. Now that concerns over funding and National Health Insurance press toward a rapprochement with medicine] the time is optimal to reclaim our place in medical education.. Such a plea is not new, Frosch said. and he noted that several COPER papers had urged analysis to re-examine its emphasis on case reports to the exclusion of research, with the resulting isolation from the rest of the scholarly world. Wallerstein, too, had stated “we live in isolation from the university . . . [and] have suffered grievously . . . to the detriment of the entire scientific/intellectual community.”’ L. Robbins, at the same meeting, had criticized the exclusive analytic ideal in institutes, that of becoming a training analyst, as implicitly disparaging the academic researcher or analyst. If analysis is to achieve a significant role in medical education, it must become visible in departments of psychiatry, and to medical and surgical faculties as a whole. Analytic expertise can be important in student selection] in adaptation to stressful training, in framing certain segments of the curriculum, and in stimulating toward later psychoanalytic careers. The public appears to be quite aware of the frequent lack of humane qualities among physicians. Analysts serving on medical school admissions committees could bring a broader view than the emphasis on physical and biological science that may contribute to this situation. Analysts could also help other members of the committee develop more skillful use of the interview in the assessment of ego assets and coping strengths and the recognition of conflict and defense. As with outcome studies of analysis, there are few studies of studentselection criteria that bear on outcome or success in terms other than the ability to pass examinations. On how to select for human attitudes, or the results of such selection, there is very little. The Menninger study of resident selection and outcome might serve as a model for such work. More often than not, our predictions at the time of eva1,uation of what maturation may be expected are overestimates. The stresses that produce suicides, addiction, and alcoholism begin during medical school, and assessment and prediction of at-risk individuals fall within the realm of psychiatry. Thus, Frosch felt that analysts are uniquely suited to contribute in 1 See Goodman, S. (1976), Psj.choannZ_ytic Educafion and Research. New York: International Univefsities Press.
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medical school faculties so as to foster maturation of medical students, resolve the normal developmental crises of medical training, anticipate maladaptive patterns and intervene preventively, and to treat acute breakdown. Freud, in “On the Teaching of Psycho-Analysis in Universities” (1919), recognized two roles psychoanalysis plays in the medical school curriculum: to make plain the significance of mental factors in different vital functions and illnesses, and to prepare for the study of psychiatry. The way in which such teaching is conducted is crucial to its success or failure. Medical students are addicted to facts, relevancy, interweaving with other sciences, and avoidance of pat phrases and formulations. A negative image of psychiatry is often reinforced by a poor quality of psychiatric teaching, because good people, especially psychoanalytic candidates and graduates, drift away just as they gain the experience and expertise that would make them still more valuable. Frosch illustrated the power of excellent teaching with a vignette in which a student opted for analysis as a career after hearing a senior analyst describe a case in such a way that the student felt “from his knowledge of analysis, he [would] know about the way I thought and felt, too.” Frosch closed by stressing the need for senior full-time role models, and noting that only from the context of function within medical school can new opportunities be seized to attract candidates to enter analytic training earlier-perhaps through new developments and specialized tracks -and to influence student selection and over-all curricula. Before giving his own presentation, Fink commented that the medical student had difficulty in understanding the symbolic process because his education discouraged thinking and was obsessed with numbers. He then addressed the issue of the senior analyst in academia. Following World War Two, Allan Gregg predicted that psychoanalysis would find difficulty in surviving its new prosperity; the prediction may well have come to pass. The senior analyst of today in academic departments does not have the esteem he enjoyed in the postwar years. He is primarily a private practitioner who donates time to his institute; he may hold an academic appointment in return for minimal supervision: his visibility is limited and his clout minimal. Residents have an opportunity to compare him and his abstruse language and analytic uncertainty with others who display no uncertainty and who convey concepts crisply without cant; in these comparisons he may
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also be found wanting in his knowledge of other theories and therapies in psychiatry. From his vantage point as analyst-department chairman, the senior analyst has a number of important contributions to make: he can serve as a role model for medical students and residents, aid in the recruitment of candidates into psychoanalysis, and discharge well the public relations needs of the profession. Analysts must realize that while nearly all psychiatrists learned analytic theory in the past, this is unlikely to continue in the next two decades unless a positive effort is made. The failure to see where psychoanalysis fits into the over-all care of the mentally ill. the fatigue at fighting negative press, and their own doubts may at this point cause analysts to serve as negative role models. Psychoanalysis must respond accurately, cogently and without cultism to questions and derogations in its public relations role. The academic analyst must be a capable teacher, must extend his ideology to interpersonal relationships he fosters with trainees, be a credible member of the medical faculty, and be comfortable in converting analytic language to understandable concepts. Analytic principles which should be taught would include the unconscious (most unbelievable to medical students), the structural theory, child development, as well as pathology and the meaning of transference and countertransference. Psychiatry is under attack because there are not specific bodies of knowledge or sets of skills that identify it, as a separate specialty of medicine. There are those who believe that the nonpsychiatric physician or the nonmedical mental health professionals can deliver mental health care equivalent to what psychiatry offers. Defining the worried well and who will care for them are further points of contention. Teaching the analytic approach in the face of such difficulties, we must avoid cookbook medicine. The individualized approach and in-depth investigation of dynamic factors must be re-emphasized, along with the distinct concern of analysis to combine the search for conflict and defense with the capacity to be humanistic and to listen. The analytic teacher must also know and be able to articulate when to turn understanding into definitive action and when directive therapy is appropriate. Only by clarity in these areas can analysis avoid the encroachment of those who espouse conscious psychologies and who are not equipped to fully orchestrate the total care of the patient. The further failure of analysis to develop bona fide research extends to the medical schools, too, where there is rarely a cadre of research analysts. Indeed, analytic education militates
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against the fostering of such a group. Thus, nonanalytic psychiatric researchers almost inevitably fail to include concepts such as Waelder's principle of multiple function, for they are left to pursue legitimate samples and double-blind designs that will stand the scrutiny of statisticians. Barriers to a full-time academic career for the senior analyst stem from both the analytic institutes and the university. The institute's training fosters one's clinical skills and desires to become a training analyst who will spend at least 50 percent of his time in actual psychoanalytic practice. Due to institute ethnocentrism, trainees are often criticized if they show an interest in anything nonanalytic. Community mental health, pharmacology, directive therapies, and the like are all suspect, and Piaget and child development are tolerated only if clearly related to analysis. Confidentiality, visibility, and notoriety are other inhibiting factors, for students may end up as patients of the senior analyst. Barriers from the university consist of low full-time salaries, difficulties in advancing in rank because the least credit is given to clinical practice, and diminished autonomy in conducting analytic practice because of university priorities. Fink concluded by saying that analysis and academia needed each other. Analysis needs psychiatry because its future, and especially payment for long-term psychotherapy, require an unambivalent view of analysis as a medical treatment. The future of psychoanalysislicsin reducing its elitism and ethnocentrism and in clarifying psychoanalysis to the community through the good offices of the university. A concerted effort must be made on both sides to reduce the barriers to having a dual role for the senior analyst. In the open discussion, Kenneth Altshuler commented that, for junior faculty to stay in universities and undertake the additional burdens of analytic training, a certain amount of masochism must be present. Traditionally, the masochism related to pursuing an academic career is analyzed out rather than the masochism related to pursuing analytic training. Junior faculty need assistance so that they can maintain both career choices: they could, for example, be excused from supervisory fees or by the departments with regard to tuition or such fees. Altshuler thought that the excessive zeal with which we protect our analytic purity would suggest that'we have an exaggerated fragility in the sense of self. Perhaps we are safer than we have realized in allowing scrutiny, openness, questioning, and disagreement. Finally, he cited a recent
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report that general physicians found psychoanalytic theory to be the least valuable part of their psychiatric training, and interview technique and management to be the most important, yet most neglected, part. The fact that these graduate physicians did not perceive the close relationship between interviewing and analytic theory is a clear indication that we were not getting our message across well, even when more analysts were teaching. Fink noted that consideration of an analytic career is also limited by the fact that some 50 percent of students have had loans and scholarship help, with time limits on when they must start paying it back. From the audience, Herbert Weintane (W. Virginia) recalled Kubie's plea that to avoid the inadvertent rape of the young when inexperienced psychiatrists become professors with little clinical knowledge, senior analysts with greater experience and income be part of the senior faculty. Pardes responded by wondering whether senior analysts would be willing to take on academic schedules and demands: Fink added that even were they willing, they usually couldn't be hired into these positions because they "hadn't done enough. " Anthony Kowalski (Oklahoma City) recalled Sharpe's admonition that analysts must free themselves of the sadism of looking. He advised that the analyst must go out and be willing to be scrutinized, and he must surely scrutinize himself to recognize if he retreats to a pseudo-analytic, opaque position or defensively puts aside his values. William Shanahan (Denver) described having allowed students or residents to get therapy and pay him back as their income increased. He had done this for some 25 years, and while it complicated therapy, it did not prevent it. He believed it was better t o , provide the treatment than wait. He and Jose Barchilon have discussed this in connection with institutes, possibly arranging for later reimbursement, or with the training analyst putting aside sums for a training fund. Reiser concurred, but noted that residents start with such debts that further borrowing capacity may be limited. He recalled that some people had thought subsidization by NIMH would complicate analysis, but it had not. Frosch felt that the issue of cost produced an increasingly selective group going into medical school, as tuitions rose precipitously, and even more selection about who entered psychiatry and analytic training. He added that the panel had dealt only with analysts and departments of psychiatry, but he reminded the group that there should be
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linkages with analysis in other university departments, such as psychology and sociology, as well. Abraham Freedman (Philadelphia), commenting on Pardes’ discussion of institutes’ continual scrutiny of candidates, noted that despite eight to ten years of analytic training and scrutiny, some problems still existed in terms of those who graduated. He reiterated that analysts should serve on admissions committees in medical schools and suggested they might also participate in student health programs; a good psychiatric experience by medical students with medical therapists will engender respect for analysis in physicians later. Pardes noted that blind predictions by psychiatrists of medical students at risk for emotional troubles had proved true, a clear demonstration that we have something to offer. He encouraged the health service as a critical contact point and pointed out that when his school had asked students about willingness to pay higher insurance premiums to cover therapy, they agreed. Whether other students, without the good relationship established by teachers in the department would do so is, of course, uncertain. He described the practice of Drs. Brandt and Eleanor Steele in Denver, who often act as hosts to the incoming faculty to the medical school, as having great public relations ramifications for psychoanalysis within the community. Robert Michels (New York) complimented psychoanalysis for being able to assemble a panel of full-time analysts in academia. He proposed that a major problem for psychoanalysis is that there are no criteria for excellence. Analysts who do research and write have acceptable credentials, but the superior senior analystteacher who hasn’t published and isn’t known outside the analytic establishment is not considered acceptable by search committees, and other institutions also have difficulty evaluating him. This further separates analysis from other areas of scholarship, since in the absence of concrete evidence of scholarship, such as published articles, the analyst must, in his evaluation of an individual. lean heavily on members of the same discipline, whereas in other departments evaluations and selection may be done by peers in other areas of medicine. Pardes reiterated the importance of developing criteria to measure excellence and suggested that the energy spent in “making sure one tainted soul doesn’t get in” would better be diverted to such efforts. Norman Decker (Houston) suggested that possibly the de-
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creased prevalence of analysts in medical schools is correlated with the increasing insistence on full-time positions for academic faculty. He questioned the need for full-time academic purity and proposed part-time positions as a solution to some of these problems. Reiser responded that these decisions are made mainly by schools, not individual departments. When there are individual exceptions made to a full-time rule, it usually creates a morale problem for the full-timers. Pardes said that although there may be decreasing numbers of analysts in academia overall, Seven appointments of analysts as chairmen have recently been made. Arnold Cooper (New York) discussed the fact that analytic organizations were suspicious of psychoanalysts who become chairmen and often placed unrealistic practice or other demands on them, in effect asking them to demonstrate that they are still analysts. What is needed is some effort to clarify what the identity of an analyst is, whether there are multiple identities possible for an analyst, and realistic criteria for how the identity as an analyst is maintained. Amplifying Cooper’s point, Altshuler said since analysts more than any other group believe in the integrity of history, history should be replied upon in establishing the analyst’s identity. Years of one’s own training, teaching others, and practicing analysis are good predictors that the individual’s identity and talents will not be altered by acceptance of a chair. Fink believed that the analyst in academia must consistently and unashamedly identify himself as an analyst and tolerate the disapproval of institutes despite his performing tasks for them in academia. Ghislaine Godenne (Baltimore) proposed that medical students might be more receptive to a psychoanalytically trained student health service if the name “counseling” rather than “psychiatric counseling” were used. She also said it was time for institutes to rid themselves of the myth that people who remain in academia have dependency problems. Robert Stoller (California) suggested that one of the things that separates academic from nonacademic analysts is that academicians state their ideas as hypotheses to be tested. He proposed as such a hypothesis: “If institutes don’t change the style in which they train. we may not have another generation of analysts who could sponsor seminars at our association meetings such as the present one.” Pardes agreed and noted that even with a panel such as the present one, those who come are already the most sympa-
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thetic, and those who should most hear the message are not present. Fink urged there should be no dichotomy between research and psychoanalysis. Tinbergen, he said, had acknowledged that psychoanalysis was the onIy science which approached an understanding of autism in a manner with which he as an ethologist could agree. Such proponents are available from other areas of science to meet and work with psychoanalysis, and should be encouraged to join us in looking at the future of psychoanalysis. He proposed that the two institutions, academia and psychoanalysis, be happily married. 5323 Harry Hines Blud. Dallas, Texas 75235
As an introduction to addressing the problems of junior faculty, Morton F. Reiser, in an effort to avoid excessive entanglement in the maze of issues, proposed a credo: Psychoanalysis, as a theory, research method, and mode of treatment constitutes a major sector of the mental health field in general and psychiatry in particular. Its sector lies mainly in the psychological sphere and offers to psychiatry a theory basic to the understanding of psychopathology and psychotherapy. Learning to understand and conduct psychotherapy includes learning analytic principles- as the only thoroughgoing theoretical rationale for psychotherapy- and acquiring therapeutic skills through practicums and supervision. Teaching of both psychoanalytic and psychoanalytic psychotherapy would ideally involve analysts at varying levels of experience and career development; e.g.. senior analysts might best teach psychotherapy and candidates teach analytic theory, especially Held at the Annual Meeting of the American Psychoanalytic Association, Atlanta, May, 1978. Panelists: Paul J. Fink, IVilliam A. Frosch, Herbert Pardes. hlorton F. Reiser.
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during their immersion in the original literature. Candidates and residents could well teach the extrapolation of psychoanalytic principles to understanding doctor-patient relationships and medical care. This is important in the education of medical students and nonpsychiatric physicians and health care personnel. Analysts doing research might round out a well-balanced program with interdisciplinary collaboration. Reiser turned to the difficulties in implementing this credo, particularly the interruptions in the path for development of junior faculty. The charge of the medical school is to pass on existing knowledge, generate new knowledge, and render service. These missions are currently carried out in the midst of a crisis of professional identity in psychiatry, with confusion among the mental health professions about who and what a teacher is, and who he is training and for what role(s). There has also been a steady erosion of federal funds, which, paradoxically, most affects teaching just when more requires to be taught. Moreover, promotion of junior faculty is based on the quantity and quality of research papers and scholarly activity, with teaching and clinical duties considered of secondary importance if not actually “illicit.” In addition, promotion committees often consider psychiatric and psychoanalytic research and papers unscientific. While scholarly endeavor is required for promotion, the pressure of time and duty leads junior faculty to give first to patients, then to teaching and clinical administration; the fact that diminishing funds limit the number of tenure slots further squeezes junior persons immersed in these activities. When junior faculty drop out of academia for psychoanalytic training and then try to come back, they are similarly without the required credentials. In sum, climbing the academic ladder as junior faculty, good clinicians, teachers, and administrators, while simultaneously becoming analysts, makes it difficult to become senior faculty with tenure. For analytic candidates, all of these difficulties are compounded by financial pressures and pressures of time when analytic training and analysis are in full swing. The result is that a number of junior faculty leave full-time academic life for private practice and find it difficult or impossible to return. Such a situation, when analysts contribute only as part-time voluntary faculty, has a number of implications. Major role models no longer include psychoanalysts, the quality of teaching in long-term psychotherapy may well decline, and analysts no longer participate meaningfully in policy making within the department.
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Reiser concluded by saying that to carry out the credo he described, junior analytic faculty must be enabled to move into full-time senior faculty positions. Only in this way would there be a balanced ambience in departments of psychiatry, a balance of professional ego ideals with whom students could identify, and a comparable balance in the departmental decision-making process. Introducing the next speaker, Fink agreed with Reiser’s views and added two more problems of concern to junior faculty interested in analytic training: first, the pressure by colleagues who derogate an interest in what they consider passe‘, and second, the ceiling on full-time earnings for those who must support analysis, analytic training, and possibly a family. Herbert Pardes’ focus was the relation between academic departments and institutes. He proposed that the difficulty in achieving mutual understanding between these two types of institutions was a function of their different goals. A psychiatric department aimed at developing excellent educational programs, creative and productive research, and model clinical service programs; it also focused on the development of outstanding general physicians and professionals in mental health, enhancing critical thinking, and attending to the needs and values of the mental health and general communities. The goals of a psychoanalytic institute are to develop an outstanding educational program, promote psychoanalytic education and thinking in the mental health and the general community, and turn out outstanding practitioners of psychoanalysis. Institutes also take an advocacy position for psychoanalysis, and consistently emphasize efforts to assure high quality in students, analysts, and teachers. The similarities are manifold, with the greatest differences appearing to be a greater interest in research, in departments of psychiatry. and an overemphasis on reviewing the qualities of individuals who are in training, in the institutes. Research in analytic institutes has not assumed the importance it should have, said Pardes, and the emphasis on screening qualities of those who are allowed to enter training, to start classes, to take on cases, to practice independently, to graduate, and so forth can be nothing short of paralyzing. A further extension of the concern with preserving the “pure gold” is that honest questioners may be identified asantianalytic and there may be condemnation of those who interact with other disciplines or take on other responsibilities.
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The potential strengths of an integration between analytic institutes and academic departments of psychiatry might be achieved by some type of administrative interaction and linkage. Institute members identified with a department of psychiatry have a vested interest in it and influence its direction. T h e departments might influence the institute by questioning its conclusions, looking for ways to integrate theory and practice, evaluating analytic work, and exploring research. There must, of course, be checks on the potential abuse of individuals upon the relationship, but tight administrative links can enhance recruitment, program development, and communication. Institutes need students, and residents (the potential students) are heavily influenced by the department of psychiatry faculty. Analysts within a department, for example, also influence those physicians going into general health fields, who will consider analytic therapies appropriate for help with psychological problems to the extent that they themselves have had adequate training and exposure. Undergraduate curricula, therefore, should shift from a cafeteria-style emphasis on numerous specific facts to pass National Boards, to a synthesis, a general approach to behavior best taught by analytically trained personnel. To become thus involved is a challenging demand on institute faculty, but it is also the means to have a real impact on future professionals; if it is disregarded, institutes may well shrivel and be reduced to “evening discussions with friends.” While the messenger with bad news may sometimes have to take it on the chin, Pardes cautioned that he may also be the one who has worked to insure that the message is not‘ as bad as it might have been. The analyst brings to academia an understanding of behavior and a contribution necessary to any academic department of psychiatry interested in the true seeking of knowledge. Academia brings to the analyst the respect of being a member of the academic community of scholars, and the placement of students, its most prized products, in their hands. William A. Frosch dealt more specifically with the needs of medical school and residency curricula and their relationship to psychoanalysis. He quoted Henriette Klein and Emily Mumford as having chided the American Psychiatric Association for failure to provide a clear, active, and important presence in medical schools. Psychoanalysis, too, with its obsessive concern for purity, has cut itself off from medical schools, a source of renewal and strength. In so doing, it has failed to contribute to the medical school
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curriculum that which is the unique distinction of psychiatry and psychoanalysis, an awareness of the psychic experience- the individual’s experience over time of himself and the world. Now that concerns over funding and National Health Insurance press toward a rapprochement with medicine] the time is optimal to reclaim our place in medical education.. Such a plea is not new, Frosch said. and he noted that several COPER papers had urged analysis to re-examine its emphasis on case reports to the exclusion of research, with the resulting isolation from the rest of the scholarly world. Wallerstein, too, had stated “we live in isolation from the university . . . [and] have suffered grievously . . . to the detriment of the entire scientific/intellectual community.”’ L. Robbins, at the same meeting, had criticized the exclusive analytic ideal in institutes, that of becoming a training analyst, as implicitly disparaging the academic researcher or analyst. If analysis is to achieve a significant role in medical education, it must become visible in departments of psychiatry, and to medical and surgical faculties as a whole. Analytic expertise can be important in student selection] in adaptation to stressful training, in framing certain segments of the curriculum, and in stimulating toward later psychoanalytic careers. The public appears to be quite aware of the frequent lack of humane qualities among physicians. Analysts serving on medical school admissions committees could bring a broader view than the emphasis on physical and biological science that may contribute to this situation. Analysts could also help other members of the committee develop more skillful use of the interview in the assessment of ego assets and coping strengths and the recognition of conflict and defense. As with outcome studies of analysis, there are few studies of studentselection criteria that bear on outcome or success in terms other than the ability to pass examinations. On how to select for human attitudes, or the results of such selection, there is very little. The Menninger study of resident selection and outcome might serve as a model for such work. More often than not, our predictions at the time of eva1,uation of what maturation may be expected are overestimates. The stresses that produce suicides, addiction, and alcoholism begin during medical school, and assessment and prediction of at-risk individuals fall within the realm of psychiatry. Thus, Frosch felt that analysts are uniquely suited to contribute in 1 See Goodman, S. (1976), Psj.choannZ_ytic Educafion and Research. New York: International Univefsities Press.
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medical school faculties so as to foster maturation of medical students, resolve the normal developmental crises of medical training, anticipate maladaptive patterns and intervene preventively, and to treat acute breakdown. Freud, in “On the Teaching of Psycho-Analysis in Universities” (1919), recognized two roles psychoanalysis plays in the medical school curriculum: to make plain the significance of mental factors in different vital functions and illnesses, and to prepare for the study of psychiatry. The way in which such teaching is conducted is crucial to its success or failure. Medical students are addicted to facts, relevancy, interweaving with other sciences, and avoidance of pat phrases and formulations. A negative image of psychiatry is often reinforced by a poor quality of psychiatric teaching, because good people, especially psychoanalytic candidates and graduates, drift away just as they gain the experience and expertise that would make them still more valuable. Frosch illustrated the power of excellent teaching with a vignette in which a student opted for analysis as a career after hearing a senior analyst describe a case in such a way that the student felt “from his knowledge of analysis, he [would] know about the way I thought and felt, too.” Frosch closed by stressing the need for senior full-time role models, and noting that only from the context of function within medical school can new opportunities be seized to attract candidates to enter analytic training earlier-perhaps through new developments and specialized tracks -and to influence student selection and over-all curricula. Before giving his own presentation, Fink commented that the medical student had difficulty in understanding the symbolic process because his education discouraged thinking and was obsessed with numbers. He then addressed the issue of the senior analyst in academia. Following World War Two, Allan Gregg predicted that psychoanalysis would find difficulty in surviving its new prosperity; the prediction may well have come to pass. The senior analyst of today in academic departments does not have the esteem he enjoyed in the postwar years. He is primarily a private practitioner who donates time to his institute; he may hold an academic appointment in return for minimal supervision: his visibility is limited and his clout minimal. Residents have an opportunity to compare him and his abstruse language and analytic uncertainty with others who display no uncertainty and who convey concepts crisply without cant; in these comparisons he may
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also be found wanting in his knowledge of other theories and therapies in psychiatry. From his vantage point as analyst-department chairman, the senior analyst has a number of important contributions to make: he can serve as a role model for medical students and residents, aid in the recruitment of candidates into psychoanalysis, and discharge well the public relations needs of the profession. Analysts must realize that while nearly all psychiatrists learned analytic theory in the past, this is unlikely to continue in the next two decades unless a positive effort is made. The failure to see where psychoanalysis fits into the over-all care of the mentally ill. the fatigue at fighting negative press, and their own doubts may at this point cause analysts to serve as negative role models. Psychoanalysis must respond accurately, cogently and without cultism to questions and derogations in its public relations role. The academic analyst must be a capable teacher, must extend his ideology to interpersonal relationships he fosters with trainees, be a credible member of the medical faculty, and be comfortable in converting analytic language to understandable concepts. Analytic principles which should be taught would include the unconscious (most unbelievable to medical students), the structural theory, child development, as well as pathology and the meaning of transference and countertransference. Psychiatry is under attack because there are not specific bodies of knowledge or sets of skills that identify it, as a separate specialty of medicine. There are those who believe that the nonpsychiatric physician or the nonmedical mental health professionals can deliver mental health care equivalent to what psychiatry offers. Defining the worried well and who will care for them are further points of contention. Teaching the analytic approach in the face of such difficulties, we must avoid cookbook medicine. The individualized approach and in-depth investigation of dynamic factors must be re-emphasized, along with the distinct concern of analysis to combine the search for conflict and defense with the capacity to be humanistic and to listen. The analytic teacher must also know and be able to articulate when to turn understanding into definitive action and when directive therapy is appropriate. Only by clarity in these areas can analysis avoid the encroachment of those who espouse conscious psychologies and who are not equipped to fully orchestrate the total care of the patient. The further failure of analysis to develop bona fide research extends to the medical schools, too, where there is rarely a cadre of research analysts. Indeed, analytic education militates
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against the fostering of such a group. Thus, nonanalytic psychiatric researchers almost inevitably fail to include concepts such as Waelder's principle of multiple function, for they are left to pursue legitimate samples and double-blind designs that will stand the scrutiny of statisticians. Barriers to a full-time academic career for the senior analyst stem from both the analytic institutes and the university. The institute's training fosters one's clinical skills and desires to become a training analyst who will spend at least 50 percent of his time in actual psychoanalytic practice. Due to institute ethnocentrism, trainees are often criticized if they show an interest in anything nonanalytic. Community mental health, pharmacology, directive therapies, and the like are all suspect, and Piaget and child development are tolerated only if clearly related to analysis. Confidentiality, visibility, and notoriety are other inhibiting factors, for students may end up as patients of the senior analyst. Barriers from the university consist of low full-time salaries, difficulties in advancing in rank because the least credit is given to clinical practice, and diminished autonomy in conducting analytic practice because of university priorities. Fink concluded by saying that analysis and academia needed each other. Analysis needs psychiatry because its future, and especially payment for long-term psychotherapy, require an unambivalent view of analysis as a medical treatment. The future of psychoanalysislicsin reducing its elitism and ethnocentrism and in clarifying psychoanalysis to the community through the good offices of the university. A concerted effort must be made on both sides to reduce the barriers to having a dual role for the senior analyst. In the open discussion, Kenneth Altshuler commented that, for junior faculty to stay in universities and undertake the additional burdens of analytic training, a certain amount of masochism must be present. Traditionally, the masochism related to pursuing an academic career is analyzed out rather than the masochism related to pursuing analytic training. Junior faculty need assistance so that they can maintain both career choices: they could, for example, be excused from supervisory fees or by the departments with regard to tuition or such fees. Altshuler thought that the excessive zeal with which we protect our analytic purity would suggest that'we have an exaggerated fragility in the sense of self. Perhaps we are safer than we have realized in allowing scrutiny, openness, questioning, and disagreement. Finally, he cited a recent
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report that general physicians found psychoanalytic theory to be the least valuable part of their psychiatric training, and interview technique and management to be the most important, yet most neglected, part. The fact that these graduate physicians did not perceive the close relationship between interviewing and analytic theory is a clear indication that we were not getting our message across well, even when more analysts were teaching. Fink noted that consideration of an analytic career is also limited by the fact that some 50 percent of students have had loans and scholarship help, with time limits on when they must start paying it back. From the audience, Herbert Weintane (W. Virginia) recalled Kubie's plea that to avoid the inadvertent rape of the young when inexperienced psychiatrists become professors with little clinical knowledge, senior analysts with greater experience and income be part of the senior faculty. Pardes responded by wondering whether senior analysts would be willing to take on academic schedules and demands: Fink added that even were they willing, they usually couldn't be hired into these positions because they "hadn't done enough. " Anthony Kowalski (Oklahoma City) recalled Sharpe's admonition that analysts must free themselves of the sadism of looking. He advised that the analyst must go out and be willing to be scrutinized, and he must surely scrutinize himself to recognize if he retreats to a pseudo-analytic, opaque position or defensively puts aside his values. William Shanahan (Denver) described having allowed students or residents to get therapy and pay him back as their income increased. He had done this for some 25 years, and while it complicated therapy, it did not prevent it. He believed it was better t o , provide the treatment than wait. He and Jose Barchilon have discussed this in connection with institutes, possibly arranging for later reimbursement, or with the training analyst putting aside sums for a training fund. Reiser concurred, but noted that residents start with such debts that further borrowing capacity may be limited. He recalled that some people had thought subsidization by NIMH would complicate analysis, but it had not. Frosch felt that the issue of cost produced an increasingly selective group going into medical school, as tuitions rose precipitously, and even more selection about who entered psychiatry and analytic training. He added that the panel had dealt only with analysts and departments of psychiatry, but he reminded the group that there should be
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linkages with analysis in other university departments, such as psychology and sociology, as well. Abraham Freedman (Philadelphia), commenting on Pardes’ discussion of institutes’ continual scrutiny of candidates, noted that despite eight to ten years of analytic training and scrutiny, some problems still existed in terms of those who graduated. He reiterated that analysts should serve on admissions committees in medical schools and suggested they might also participate in student health programs; a good psychiatric experience by medical students with medical therapists will engender respect for analysis in physicians later. Pardes noted that blind predictions by psychiatrists of medical students at risk for emotional troubles had proved true, a clear demonstration that we have something to offer. He encouraged the health service as a critical contact point and pointed out that when his school had asked students about willingness to pay higher insurance premiums to cover therapy, they agreed. Whether other students, without the good relationship established by teachers in the department would do so is, of course, uncertain. He described the practice of Drs. Brandt and Eleanor Steele in Denver, who often act as hosts to the incoming faculty to the medical school, as having great public relations ramifications for psychoanalysis within the community. Robert Michels (New York) complimented psychoanalysis for being able to assemble a panel of full-time analysts in academia. He proposed that a major problem for psychoanalysis is that there are no criteria for excellence. Analysts who do research and write have acceptable credentials, but the superior senior analystteacher who hasn’t published and isn’t known outside the analytic establishment is not considered acceptable by search committees, and other institutions also have difficulty evaluating him. This further separates analysis from other areas of scholarship, since in the absence of concrete evidence of scholarship, such as published articles, the analyst must, in his evaluation of an individual. lean heavily on members of the same discipline, whereas in other departments evaluations and selection may be done by peers in other areas of medicine. Pardes reiterated the importance of developing criteria to measure excellence and suggested that the energy spent in “making sure one tainted soul doesn’t get in” would better be diverted to such efforts. Norman Decker (Houston) suggested that possibly the de-
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creased prevalence of analysts in medical schools is correlated with the increasing insistence on full-time positions for academic faculty. He questioned the need for full-time academic purity and proposed part-time positions as a solution to some of these problems. Reiser responded that these decisions are made mainly by schools, not individual departments. When there are individual exceptions made to a full-time rule, it usually creates a morale problem for the full-timers. Pardes said that although there may be decreasing numbers of analysts in academia overall, Seven appointments of analysts as chairmen have recently been made. Arnold Cooper (New York) discussed the fact that analytic organizations were suspicious of psychoanalysts who become chairmen and often placed unrealistic practice or other demands on them, in effect asking them to demonstrate that they are still analysts. What is needed is some effort to clarify what the identity of an analyst is, whether there are multiple identities possible for an analyst, and realistic criteria for how the identity as an analyst is maintained. Amplifying Cooper’s point, Altshuler said since analysts more than any other group believe in the integrity of history, history should be replied upon in establishing the analyst’s identity. Years of one’s own training, teaching others, and practicing analysis are good predictors that the individual’s identity and talents will not be altered by acceptance of a chair. Fink believed that the analyst in academia must consistently and unashamedly identify himself as an analyst and tolerate the disapproval of institutes despite his performing tasks for them in academia. Ghislaine Godenne (Baltimore) proposed that medical students might be more receptive to a psychoanalytically trained student health service if the name “counseling” rather than “psychiatric counseling” were used. She also said it was time for institutes to rid themselves of the myth that people who remain in academia have dependency problems. Robert Stoller (California) suggested that one of the things that separates academic from nonacademic analysts is that academicians state their ideas as hypotheses to be tested. He proposed as such a hypothesis: “If institutes don’t change the style in which they train. we may not have another generation of analysts who could sponsor seminars at our association meetings such as the present one.” Pardes agreed and noted that even with a panel such as the present one, those who come are already the most sympa-
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thetic, and those who should most hear the message are not present. Fink urged there should be no dichotomy between research and psychoanalysis. Tinbergen, he said, had acknowledged that psychoanalysis was the onIy science which approached an understanding of autism in a manner with which he as an ethologist could agree. Such proponents are available from other areas of science to meet and work with psychoanalysis, and should be encouraged to join us in looking at the future of psychoanalysis. He proposed that the two institutions, academia and psychoanalysis, be happily married. 5323 Harry Hines Blud. Dallas, Texas 75235
