A National Survey of Candidates

Discovering Psychoanalysis and Deciding to Pursue Training

Candidates were asked about how they discovered psychoanalysis (Figure 1) and decided to pursue psychoanalytic training (Figure 2). Responses on both questions were almost identical. The most important factors, determined by combining extremely important and important categories, included (1) their personal therapist/psychoanalyst (84%), (2) supervisory experiences (75%), (3) the influence of a professor/teacher (58%), and (4) the impact of a mentor (54%). Local psychoanalytic organizations, journals/literature/movies, and institute psychotherapy programs were ranked as mid-range in importance, while graduate classes, family members, national psychoanalytic organizations, and undergraduate classes were ranked as least important.

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Figure 1.

Discovering the field of psychoanalysis (N = 206)

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Figure 2.

Decision to become a psychoanalyst (N = 189)

Candidates seemed eager to speak about their discovery of and decision to pursue psychoanalysis, with 62 electing to write in comments. Approximately 25% of the comments referred to the importance of (1) a personal therapist or analyst, (2) a mentor or supervisor, or (3) a graduate, postgraduate, or residency experience. In the comments about graduate or postgraduate training, there was often just one person or experience that provided the stimulus to pursue psychoanalytic training. Approximately 20% of comments referred to the importance of reading analytic articles, exposure to Freud, or attendance at psychoanalytic lectures. A number of candidates described early exposure to Freud or analytic literature in high school, college, or early graduate school. Approximately 10–15% of comments referred to the impact of a family member, the welcoming atmosphere of an institute, a specific institute program (e.g., psychotherapy or community education programs), or the desire to be a better therapist or clinician in inspiring interest in pursuing analytic training. Some of the narrative comments are presented below to highlight the importance and variety of these experiences:

I was analyzed before medical school. My medical training was in biological psychiatry in a program that was quietly hostile to psychoanalysis. But I had one attending that was trained at Menninger who encouraged me to pursue my enduring interest in psychoanalysis.

I discovered analysis when I was a control case in my twenties but began training at sixty.

I wish I could have “discovered” psychoanalysis during undergraduate and graduate school classes; however, exposure to analysts was minimal until practicum, internships, and postdoctoral training, when I began to meet analyst/teachers, eventually supervisors, and—thank heavens—my own analyst.

I was skeptical about the analytic approach, but intrigued after reading Freud as an undergraduate. I did a practicum at a psychoanalytically oriented hospital and was supervised by psychologists who were able to talk about patients with a depth of understanding that was unmatched by any of my other supervisors. Analytic training was, frankly, a way of maintaining a connection with like-minded clinicians—a community of treaters—when I was no longer in a communal therapeutic treatment setting.

As a medical student, the chief of psychiatry was an analyst and he interviewed an inpatient of mine for rounds and knew as much about the patient after fifteen minutes as I did from hours and hours with him. That impression (not about diagnosis but about the way the man functioned, his issues, his personality style) never left me. I wanted to be able to do something like that myself.

A faculty member in my psychiatry residency gave me Glen Gabbard’s book, Psychodynamic Psychiatry in Clinical Practice, as a gift for my work on his inpatient child psychiatry service. I read the book from cover to cover, and, from that point on, I wanted to become a psychoanalyst.

I feel almost that I was actively courted by members of the institute, and their interest in me was highly encouraging to me.

I was a fellow and then a psychotherapy student before beginning training. I felt welcomed by the analytic community from the beginning. My analyst and mentors were key in my decision.

The American Psychoanalytic Association Fellowship program had a strong and positive impact on me.

For what it’s worth, my graduate program was, or at least could have been, an impediment to beginning analytic training. Had I known only what I learned in graduate school about analysis (e.g., that it doesn’t work, that it may soon be considered unethical to practice analytically), I would never have sought out analytic training.

Extension division courses on psychoanalytic topics offered for continuing education to the general mental health community were particularly important.

I heard Jonathan Lear speak twice, and really enjoyed his talk and his presence. I bought his book, subtitled A Plea for Irony, and, when he spoke of psychoanalysts being always in a state of “becoming,” that spoke to me. Also, the way he wrote about the ideals of psychoanalysts: “As psychoanalysts, we. . . .” I decided I wanted to be part of that “we.” I began looking for a training analyst the following month.

Interesting Other Clinicians in Psychoanalytic Training

Candidates were asked to rate factors they believed would increase interest on the part of other clinicians in training in psychoanalysis (Figure 3). This question was designed to elicit information about what candidates thought would allow other clinicians to develop an interest in psychoanalysis. The most highly ranked factors, determined by combining extremely important and important categories, separated into three groups. The first group included some form of personal contact with psychoanalysts, such as personal psychotherapy, psychoanalysis, or supervision. The second group included educational outreach (e.g., fellowship or mentorship programs, institute psychotherapy programs, or other outreach activities) or the desire to improve clinical skills or develop a theoretical framework. The third group included media contact, such as analysts in popular media or websites about psychoanalysis, exposure to analytic research, and undergraduate classes. Twenty-four of 189 respondents (13%) provided write-in comments, which touched on topics including the importance of experiencing personal benefit from psychoanalytic treatment, the significance of exposure to psychoanalytic ideas, the benefits of belonging to a psychoanalytic community, and the importance of making clinicians aware of psychoanalytic research. The following comments are representative:

I think that personal and educational contact with psychoanalysis, and psychoanalysts, trumps some of the more experience-distant things such as websites/internet stuff every time. There is a lot that institutes and societies can do, as well as APsaA, and in fact, many are. These efforts need to be replicated and repeated as a part of the overall structure of psychoanalytic institutions, both local and national.

With increased emphasis on evidence-based practice, within insurance companies, professional associations, and government, I think enhanced exposure to research on psychoanalytic therapy is key.

I think people have to have personal experiences that convince them of the value of psychoanalysis. This could be with a mentor, professor, or one’s own analyst.

I would guess that many clinicians are not aware that analytic training is available to non-MDs. If more Ph.D.s, L.C.S.W.s, and L.P.C.s understood the benefits of training and that the opportunity exists, more candidates could potentially be recruited.

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Figure 3.

Increasing the interest of other clinicians in psychoanalytic training (N = 189)

Obstacles to Training

Candidates were asked to rate factors they perceived as past or current obstacles to training (Figure 4). The most highly ranked obstacles, determined by combining the extremely important and important categories, included (1) total cost (86%), (2) cost of a personal analysis (79%), (3) loss of income due to low-fee cases (66%), (4) time away from family (64%), and (5) difficulty finding cases (55%). Of note, financial issues figured in the first three obstacles, and issues regarding psychoanalytic cases in two (difficulty finding cases and lost income as a result of lower fees). Candidates appear less concerned with lack of telephone or videoconferencing capability, lack of workplace flexibility or support, the need to change analysts, and lack of perceived value by others than with issues of cost, time, and difficulty finding cases.

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Figure 4.

Obstacles to training (N = 189)

Fifty-two of 189 respondents (28%) provided write-in comments to this question, with approximately 30% remarking on the difficulty in finding cases, 25% on problems with money (cost of training, loss of income, cost of training analysis, unfair practices regarding tuition or supervision fees), 15% on problems with national standards (lack of flexibility regarding control case requirements, poorly monitored training standards), 15% on problems at candidates’ institutes (problematic peer or faculty interactions, poor handling of interpersonal conflict, political or hierarchical issues, paucity of candidates), 15% on the training analyst system (with half criticizing the need to switch to a training analyst and half stating that the switch led to a good experience), and 10% on graduation requirements (too nebulous, subjective, or rigid). Less frequent comments (less than 10%) were about experiences with impaired analysts, lack of workplace support for analytic training, difficulty writing up cases, and the devaluation of psychoanalysis in the community. The following comments regarding barriers to training are representative:

I have had a hard time finding cases. Of the controls that “count,” two were converted from my therapy practice. My institute does virtually nothing to help find cases for candidates. The American requirements have made progressing and/or finishing very difficult. Specifically, four sessions a week rather than three, and that one case has to be male is even harder to find.

The financial burden combined with the time away from work and family feels unmatched by the practice opportunities. I love the work but am not compensated commensurate to support my personal life or need for personal time. Also, institute dysfunction and perceived national organization dysfunction weigh heavily concerning cost/benefit analysis.

The cost, both financial and in terms of time lost seeing low-fee cases, traveling to four supervisions a week, etc., is extraordinary. I feel I am making a HUGE sacrifice to do something I love. I worry that paying analytic patients don’t exist and that I will always struggle financially.

Negative personal interactions, poor handling of impaired analysts, difficulty meeting graduation requirements since very productive analytic work at three times per week is not counted.

Ideas on How Local Institutes Could Improve Training

Candidates were asked in a write-in question what their local institute could do to improve their training experience (Table 1). This question generated responses from 120 of the study’s 226 participants (53%), with 17 (14%) writing positive comments such as the following:

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Table 1.

Areas identified to improve local institute training experience (N = 120)

	n	%
Institute atmosphere	31	26
Case-finding	29	24
Costs/financing	17	14
None	17	14
Classroom teaching	14	12
Flexible/decreased training requirements	13	11
Supervision	11	9
Interpersonal conflicts	11	9
Training analyst requirement	7	6
Public relations / publicity	6	5
National training requirements	6	5
Local graduation requirements	5	4
Writing up cases	5	4
Psychotherapy / analytic training integration	4	3
Boundary violations / impaired analysts	3	3

My institute has provided terrific opportunities and education.

They have always been very supportive. The institute has changed—more accepting of innovative ideas and other theories. Now they look at analytic process and not just number of hours in supervision.

Faculty keep supervisory fees low, help us find cases, and support our interests.

Of the 103 comments that offered ideas on improving training (86%), the two most frequent issues identified were the wish to improve the atmosphere at the candidate’s institute and the wish for help in finding cases. Approximately 25% of respondents expressed the wish to improve institute atmosphere and for help with case-finding. Wishes to improve institute atmosphere touched on a wide variety of concerns: (a) addressing problems candidates raise; (b) treating candidates as competent professionals; (c) reducing authoritarian attitudes; (d) minimizing the impact of institute politics; (e) enhancing candidate morale; (f) providing more support and mentoring; (g) having more collaborative (vs. critical) progression discussions; (h) enhancing openness and transparency; (i) attending to peer difficulties and group process within the candidate group; (j) encouraging candidate involvement on committees; (k) improving administrative organization of training (e.g., better scheduling and clear communication about progression and graduation requirements); (l) providing and soliciting more feedback from candidates.

Wishes for help finding cases included (a) more institute referrals; (b) better screening of potential referrals; (c) help with case development and practice building; (d) assistance with publicizing psychoanalysis and institute clinics to generate referrals.

Approximately 10 to 15 percent of respondents wished for financial help or a reduction in costs, improved classroom teaching, greater flexibility or a decrease in training requirements, improved supervision, and greater awareness of difficult relationships between candidates and with faculty. Regarding supervision, specific issues included requests for help with analytic case development, better matching of candidates and supervisors, a wider choice of supervisors, and a reduction in its cost. Issues regarding greater flexibility or a change in training requirements included requests for more flexibility regarding what “counts” as an analytic case (especially regarding frequency and termination), delinking candidate progress and patient progress, and reducing the rigidity of requirements overall. Less frequently mentioned wishes included eliminating training analyst requirements and broadening analyst choice, working on a national level to publicize psychoanalysis, making changes in national requirements so that training is more affordable, changing local graduation requirements, providing assistance with writing up cases, providing a better interface between psychotherapy programs and analytic training programs, and addressing issues of analyst impairment or boundary violations more actively. The following comments regarding ideas on improving training are representative:

Stronger teaching, more recognition of the sacrifice of training with help finding cases, financial help, and a warmer and more inviting environment.

Pay attention to regressive pull and aggression in classes and intervene; make clear from the beginning the exact requirements regarding duration of cases, etc.

Set examples of integrity and leadership, especially related to impaired analysts. Have more thoughtful and flexible graduation requirements.

I have experienced that the institute can treat me as though I am a patient and not a student. . . . I think it would be valuable for the faculty to specifically hold in mind and empathize with the very real financial and time costs of training, and recognize that a healthy balanced life does not set everything else aside for training.

Address the shortage of cases in some more proactive way (for all of us) and address the cost of personal analysis so that no one is discouraged by lack of income.

Phone me, regularly, to ask about my case-finding success; work with me to find cases by discussing my whole caseload; support the advisors in being more aware of institute issues; personalize, generally, the training experience by reducing the authoritarian attitude about progression and transforming “progression” into a program of enhancement and coaching.

Consistently outline the key areas of assigned readings and provide questions related to the articles.

More flexibility in costs and no cap on supervision. Tuition is not insubstantial, and analysts do not slide enough for people who really need it. Costs outweigh income.

Fight for changes at the national level so that training becomes more feasible and realistic in the twenty-first century.

How Local or National Organizations Could Increase Interest in Psychoanalysis

Candidates were asked in a write-in question what local or national organizations could do to increase interest in psychoanalytic training (Table 2). This question generated responses from 111 study participants (49%). The most frequent response, in approximately 60% of the comments, was to increase outreach activities and to publicize psychoanalysis widely. Suggestions included teaching in undergraduate and graduate classes, increasing the presence of analysts in psychiatry residency programs, holding more community events, speaking and writing in popular media, using social networking media, more widely advertising institute psychotherapy programs, offering consultation to community mental health practitioners, developing a national public information campaign (with short but engaging messages about psychoanalysis), promoting speakers who can comment on popular or political events and inviting celebrities or other well-known people to talk about their positive experience with psychoanalysis. A number of comments stressed the need for speakers to be charismatic, to demonstrate their enthusiasm for psychoanalysis, to avoid the use of jargon, and to gear the presentations to the level and needs of the audience. The next most common response, in approximately 20% of the comments, was to lessen both local and national infighting and to enhance openness and flexibility. There were a number of suggestions to “stop fighting,” to eliminate elitist attitudes (especially toward psychotherapists and nonmedical analysts), to make graduation and certification procedures less cumbersome and rigid, and to allow greater flexibility with the start of training (e.g., in relation to the training analysis, acceptance of telephone and videoconferencing).

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Table 2.

Ways identified for local and national organizations to increase interest in psychoanalytic training (N = 111)

	n	%
Increase outreach and publicity	65	59
Decrease infighting and enhance flexibility	21	19
Promote change in national organization	15	14
Reduce costs	12	11
Improve teaching	11	9
Enhance exposure to enthusiastic analysts	8	7
Publicize psychoanalytic research	5	5
Offer supervision to nonanalytic trainees	5	5
Creative use of technology	4	4

Fewer than 15% of the comments focused on promoting change and publicizing the work of the national association, reducing costs, increasing and improving teaching at all levels, increasing exposure to vibrant and enthusiastic analysts, publicizing psychoanalytic research, offering supervision to trainees not analytically oriented, and using technology to enhance outreach (e.g., streaming video of national meetings, telephone supervision, videoconference seminars). The following comments are representative:

Be more interesting. More wild. More advocating for what psychoanalysis is than how it’s like everything else around.

If the national organization could stop bickering about internal organization, there might be more time and energy for outreach which would make the field more attractive and visible.

Publish and publicize outcome research on psychoanalytic psychotherapy—build alliances with other (nonpsychoanalytic) professional associations.

Promote psychoanalysis from the standpoint of it standing alone as a depth psychology that treats the sources of symptoms, builds understanding of one’s self, and enhances emotional growth.

Put fresh young faces out there like myself, as in rebranding with the message, “This is the new face of psychoanalysis!”

Additional Thoughts

Candidates were asked in an open-ended question whether they had additional thoughts on positive or negative influences on their desire to pursue training. Fifty-six of the 226 (25%) responded, with the most common responses mentioning positive aspects of training but also cost, time, negative atmosphere, and negative influences or experience. Positive responses include the following:

When I was stuck about making the decision to pursue training my analyst said, “You belong there.” That was a positive influence.

The analyst teachers in my residency program, and the analyst supervisors, were key in my decision. And so was the sliding-fee analysis for candidates.

I had a mentor in medical school that was a psychoanalyst and head of psychiatry clerkship in third-year med school. He had a way of talking to patients and students, including me, that was special and psychoanalytic. I wanted to be him, and I am not sure I would have ever ended up here had it not been for him. He taught me the power of verbal communication.

I am extremely dedicated to psychoanalytic training and have no regrets about having pursued training. I just wish that more was done to promote psychoanalysis.

Despite some difficulties, I am very glad to have had this experience. It has made me a much better therapist, allowed me to learn so much about myself, allowed me to “sit in my seat” with some very difficult patients. It saddens me, however, that more and more this training is out of reach for many people.

The two biggest things for me were (1) mentors who took a personal interest and had faith in me, and (2) my desire to increase my skills. It was very clear to me that analysts as a whole had a very deep and powerful way of working.

I am so impressed by the willingness of my teachers to volunteer their time. I wish they received greater recognition.

Comments that focused mainly on negative factors include the following:

I will have to go into debt due to tuition cost; no analytic patients available so far.

Discrimination and pathologizing in general presents a very negative side to psychoanalysis that should be rooted from the mainstream of psychoanalysis.

Very frustrating, uphill battle to figure out the “game” that allows some of my cohort candidates to whiz through the program in four or five years, and has held myself and others back for ten or more. Is it the wealth of the spouse or candidate that allows them to take more low-fee cases and pay full fee for supervision, and serve on committees so as to make themselves known to possible referral sources in the institute? Is it that they are less neurotic or more narcissistically power-driven—so they just push their way through? Is it that they are able to see through and push through the authoritarian presentation of the institute officers and structure to get their cases accepted and graduation secured? The graduation policies are stated openly, but some graduates, in confidence, have expressed to me some surprise and amazement that they graduated under those policies, so are there “other” criteria?

I was in the unlucky position of moving to a city with only one institute, and was required to repeat the four years of didactic training that I had already completed at an international institute in my former city. This was a blow to me, and the years I had spent learning and putting in my hours and money, including analysis. I have a difficult time now accepting the legitimacy of the American and would not readily recommend this institute and the training to anyone. As you can see, the whole experience has left me very angry and bitter.

Several of the analysts in my workplace were distant and aloof, which had the effect of making me feel the institute would be equally unwelcoming. One was really rude to me on a regular basis. For several years I actually gave up my earlier plan to train, partly for financial reasons, but I really believe the negative impact of these individuals was significant as well. I saw them as individuals with whom I did not want to identify in any way. I now regret my previous inability to look past them, as I find the institute quite welcoming.

We are shutting off an important avenue for potential candidates by requiring them to switch to a training analyst should they develop an interest in training while in analysis with a non–training analyst, another archaic, rigid, and unenlightened rule of the Board on Professional Standards (BOPS).

The biggest obstacle I faced had to do with my analyst’s initial non–training analyst status. I have heard many stories from others who have decided not to enter training (despite their love of analytic theory) because they are unwilling to leave a meaningful current analysis in order to fulfill a requirement that seems increasingly arbitrary.

A number of respondents commented poignantly on the significant sacrifices involved in training:

Although my love for psychoanalysis is deep, in some ways it must be in order to sustain the energy required to satisfy all the components of training while also maintaining a reasonable income. I worry about my ability to sustain ten- or twelve-hour days in order to complete training. I work full-time, nine hours per day—plus two hours per day commuting, being in analysis, seeing private patients, etc. I think it is hard to encourage others to do the same when the position of psychoanalysis in psychiatry and the public image has diminished.

The total economic cost and the conflict with my other career as a professor were almost devastating. I had to leave my tenure-track academic position in order to do the training because it was geographically far away, and then, when I did get teaching near the institute, they were not supportive of the private practice, and ultimately I had to choose.

I love my training, but the cost is extraordinary. Between my own analysis, four cases, four supervisions, and hours given to class time and reading, I feel training is a full-time job that pays for itself intellectually but not financially.

I wish I had begun training twenty years ago after I got my degree and state license. I made the choice to devote myself to parenting my four children and working part-time as a clinician. My husband was not supportive of any of my professional activities, and I acquiesced by assuming full responsibility as the active parent. I probably could not have done things any differently, but I do regret starting so late in life on the career I always wanted.

As a woman, the realities of the biological clock factored deeply in my need to postpone analytic training until my children became older adolescents with more independent lives, freeing me to develop my professional career as I chose.

It is a huge investment of time, money, and of oneself emotionally. It is also a life-changing experience with personal growth and increased level of intimacy with patients and others.

Study Limitations

This survey provides detailed information, including lengthy narrative responses on many questions that allow the reader to “hear” directly from candidates, but there are a number of limitations of this study. As summarized in Part I of this study (Katz, Kaplan, and Stromberg 2012), this survey had a 40% return rate, and respondents were by definition candidate members of APsaA. While a 40% return rate on an e-mail survey is considered average (Instructional Assessment Resources 2010), it is possible that some important issues, such as the training analyst system or certification, would be more prominently identified by candidates who elected to train at non-APsaA institutes or by nonrespondents, but it is also possible that this would not be the case. This survey represents a significant portion of candidates who are in training at APsaA institutes and so may be of particular benefit in looking at issues specific to APsaA. Candidates who agreed to fill out the survey were assured of anonymity, and the questions were phrased in a neutral manner to reduce the possibility of response bias. Those who responded may have been motivated because they were more satisfied with training and wished to participate; it is equally possible they responded because they were less satisfied and wanted to voice their concerns.

Many of the questions in this study elicited narrative responses that were reported after coding responses into recognizable groups. Questions that asked for write-in responses were not mandatory, so candidates had to be motivated to write in a response. The fact that so many candidates elected to do so speaks to the interest they had in being heard on the issues addressed in the survey. While the narrative responses reported here are only a small portion of those elicited, the goal was to capture the breadth and feeling of the majority of responses. It would be helpful in future studies to gather more details on specific aspects of this study. For example, information regarding the nature of therapeutic or supervisory engagement that led to interest in analytic training would be helpful.

Motivations

Personal relationships appear to have the most profound influence on candidates’ discovery of psychoanalysis and decision to pursue psychoanalytic training and on how they believe the interest of other clinicians could be engaged. Although the differences were not statistically significant, relationships with therapists or analysts were consistently ranked highest in terms of importance, as seen in Figures 1–3. In a sense, this finding should not come as a surprise since the analytic or therapeutic relationship impacts powerfully, and often unconsciously, on both participants. Bosworth, Aizaga, and Cabaniss (2009) described the multiple, complex, and often unrecognized roles the training analyst plays in relation to the analysand. These include educational roles, with the training analyst serving as teacher, supervisor, advisor, and mentor. Complex ethical and technical issues have long been debated concerning the role of the analyst in relation to the candidate analysand (Calef and Weinshel 1980; Gitelson 1948, 1954; Greenacre 1966; Orgel 2002; Weinshel 1982; Wilson 2010), but it appears from our findings that a personal therapist or analyst may play a key role in both the discovery of psychoanalysis and in encouraging candidates to pursue training. This study did not specify the degree to which therapists or analysts directly encouraged candidates to pursue psychoanalytic training, or if these decisions were made on the basis of complex identifications, transference fantasies, or other factors. It is also not known what percentage of current candidates entered analysis with the therapist or analyst who inspired their interest in psychoanalysis. While personal treatment may be the most powerful way for analysts to inspire interest in psychoanalysis, unquestioning acceptance of the role of mentor or advocate may foster the development of an “unobjectionable” positive transference on the part of the candidate, may lead to the avoidance of analysis of aggression, and may ultimately corrupt or derail the treatment (McLaughlin 1967; Orgel 2002; Shapiro 1974; Stein 1981).

Personal psychotherapy and supervision exert powerful influences on the desire to pursue psychoanalytic training, but current trainees engage less often in personal treatment (Haak and Kaye 2007; Habl, Mintz, and Bailey 2010; Weintraub et al. 1999). Among psychiatric residents, being in a Northeast or West Coast program or in a program affiliated with an analytic institute led to an increase in personal psychotherapy during training (Haak and Kaye 2007; Habl, Mintz, and Bailey 2010), but many potential trainees do not have access to these resources. A recent study found that despite the barriers, psychiatric residents are still interested in psychodynamic psychotherapy and psychoanalysis, value personal psychotherapy, and are a viable pool of applicants for psychoanalytic training (Katz and Kaplan 2010). Providing potential candidates access to psychotherapy or psychoanalysis is crucially important in inspiring interest in psychoanalytic training.

Other factors that were mid-range in importance included local psychoanalytic organizations, exposure to psychoanalytic ideas in journals, literature, and movies, and institute psychotherapy programs. Candidates commented that sometimes a single experience can be critical in sparking interest in psychoanalysis (e.g., watching a supervisor interview a patient, being exposed to Freud, reading a book, hearing a talk by a contemporary psychoanalytic thinker, or feeling welcomed or “courted” by an analytic institute). These small degrees of contact can lead to the development of significant interest.

Candidates endorsed similar findings in thinking about factors that would inspire interest in other clinicians. These separated into three groups including (1) personal contact (e.g., psychotherapy, psychoanalysis, or supervision), (2) educational outreach (e.g., fellowship or institute psychotherapy programs) and the wish to improve clinical skills or develop a theoretical framework, and (3) media contact, websites, exposure to psychoanalytic research, and undergraduate classes. Candidates indicate that as the contact becomes more distant in both time and proximity, the influence on the potential trainee decreases. This finding has implications regarding the direction of future efforts. Although websites, media programs, and undergraduate courses might reach larger numbers of potential candidates, current candidates see these efforts as less valuable than smaller-scale, traditional approaches such as psychotherapy, psychoanalysis, supervision, or mentorship. It is clear that when analysts are available, as in major metropolitan areas, personal contact is most effective at engaging potential candidates. However, large-scale efforts such as videoconferencing seminars or traveling to distant settings to meet potential candidates might be required in some areas to facilitate access to more personal relationships. In summary, it appears that what matters most is personal contact and the development of a relationship—something analysts typically do well. Having this kind of contact for current candidates seemed to fuel the desire to belong to an analytic community and led candidates in this study to enter psychoanalytic training.

Obstacles

The overall cost of training was the greatest obstacle, especially the cost of the personal analysis and loss of income from taking low-fee cases. This was followed by time away from family and difficulty finding cases. These findings are consistent with earlier studies (Katz and Kaplan 2010; Katz, Kaplan, and Stromberg 2012) that endorse similar concerns about entering or progressing through analytic training. The financial demands of training appear to contribute to the delayed age of entry and long contemplation period for current candidates. The difficulty in developing analytic cases, loss of significant income due to low-fee cases, and the cost and time demands of supervision all compound the financial issues for candidates and may lead to a sense of demoralization with training. It seems clear that in this study and in earlier ones, concerns about cost, time, and case-finding are much more relevant to candidates than conflicts about the training analysis, certification, or other nationally debated issues. It must be kept in mind, however, that this is a sample of candidates at APsaA institutes and does not represent candidates who chose to train elsewhere because of training standards or training analyst issues. Efforts to formally accredit psychoanalytic training programs by independent groups such as the Accreditation Council for Psychoanalytic Education may legitimize training with subspecialty organizations such as the American Board of Psychiatry and Neurology. This would ultimately allow psychoanalytic training to be recognized as an accredited subspecialty and would result in a variety of benefits, including independent accreditation reviews, certification examinations, and possible federal student loan options to underwrite the cost of training.

To preserve psychoanalysis for future generations of trainees, organized psychoanalysis may need to develop a training model radically different from the one currently in existence. Some ideas regarding the scope of changes are discussed in Part I of this study (Katz, Kaplan, and Stromberg 2012) and have been discussed extensively by other authors (Auchincloss and Michels 2007; Berman 2004; Garza-Guerrero and Laufer 2004; Glucksman 2006; Kernberg 2000, 2006, 2007, 2010, 2011; Wallerstein 2007). Although many aspects of psychoanalytic education have been discussed, most notably the training analyst system, there has been a silence in the literature on the cost of training. The financial arrangements between patient and candidate are usually discussed in supervision, and there is literature regarding the fee in psychoanalytic treatment, but the complex issues of cost of analytic training, including what the candidate pays for personal analysis and supervision and how these fees are negotiated, have largely been ignored (Dimen 1994; McCarroll 2007; Shields 1996). This contrasts with typical academic settings where the costs, timetable, and expectations of training are communicated clearly in advance and are usually not subject to negotiation. Several authors (e.g., Cabaniss 2008; Tuckett 2005) have made efforts to clarify and objectify educational expectations in psychoanalytic training; however, expectations regarding cost and time required to complete training have remained nebulous. Candidates in this study are confirming their very real concerns about their ability to afford psychoanalytic training in the current economic climate.

The model for psychoanalytic training at local institutes was developed at a time when there were waiting lists of potential trainees and patients interested in being analyzed as control cases. Further, graduate analysts had full psychoanalytic practices and adequate income streams from their work. The acceptance of short-term psychotherapies, pharmacological treatments rather than psychological treatments, and lack of third-party reimbursement have all changed the basis for this model. Individual institutes, particularly those in smaller metropolitan areas, may no longer be able to afford to offer free-standing psychoanalytic training programs; economies of scale may require development of consortia that teach via distance methods so that small numbers of students from around the country may train at a reasonable cost.

Most institutes in the U.S. now offer one- or two-year psychoanalytic psychotherapy programs. Weekly psychotherapy constitutes an increasing proportion of clinical work on the part of dynamically or analytically oriented practitioners (Alfonso and Olarte 2011; Cherry et al. 2004). Preliminary data from a recent APsaA practice survey show that psychoanalysis no longer provides a significant portion of income for the majority of analysts surveyed (Warren Procci, personal communication, 2011). While 98% of members are satisfied or very satisfied with their choice of psychoanalysis as a profession, difficulty recruiting candidates may be traced at least in part to the lack of “value-added” benefit in psychoanalytic training today. In effect, candidates may be attempting to master a form of treatment they will be able to use only in a very limited manner. Similar findings regarding the decreasing numbers of analytic cases have been documented in recent surveys on psychoanalytic practice (Cherry et al. 2004; Cherry, Aizaga, and Roose 2009; Pretsky, Aizaga, and Cherry 2009; Hoffman et al. 2009).

Issues related to finding cases were among the greatest barriers to training and were the most commonly cited concern, accounting for 30% of write-in responses to this question. Inability to develop cases interferes with the development of an analytic identity and is associated with demoralization, frustration, and disappointment. The sacrifices of training are called into question if candidates cannot do the work they have trained for at so much expenditure of time, money, and energy. This problem raises several questions. Should the scope of psychoanalytic training be broadened to include psychoanalytic psychotherapy? Should requirements regarding session frequency, use of the couch, and other external parameters be eliminated or modified in favor of a focus on analytic process? What educational initiatives should be undertaken to help candidates develop analytic cases? How can supervisors and educators delineate the issues that interfere with candidates’ development of analytic cases?

Recent literature provides some answers. A unique educational initiative involving both supervisory and curricular interventions affirms the importance of helping candidates deepen their work with patients from the very beginning of training (Rothstein 2010). This program involves supervisors and teachers working actively with candidates, often in very individualized ways, to help ready them for analytic work. This is in contrast to the emphasis, in much of the earlier literature, on analyzability, and, in many of the responses in this study, on “finding” or “recruiting” patients. A focus on analytic identity, including the capacity to maintain an internal analytic frame and to hold an analytic process in mind, may be especially important in helping candidates deepen their work with patients (Levine 2010).

The shift away from concepts of analyzability or diagnostic criteria determining fitness for analysis is supported by a recent study. One hundred patients applying for analytic treatment were systematically assessed and showed no significant differences in psychopathology between those accepted and those rejected for analysis (Caligor et al. 2009). This supports the idea that supervisors should broaden consideration of all cases in candidates’ practices as potential analytic cases or consider a trial of analysis (Rothstein 1998). Recent literature suggests also that converting cases from candidates’ psychotherapy practices has significant advantages over starting analytic work with new patients or with patients referred from psychoanalytic clinics. These advantages include lower dropout rates and higher fees, two extremely important issues for candidates, given the concerns they expressed in this study about finances and progression through training (Caligor et al. 2003; Hamilton, Wininger, and Roose 2009). Because many current trainees come to analytic training with less experience in psychotherapy than in the past (Katz and Kaplan 2010; Katz, Tuttle, and Housman 2011; Lanouette et al. 2011), writing and speaking openly with candidates about intensification of treatment and the transition to analytic work assumes greater importance (Bernstein 1983, 1990, 2010; Gann 2000; Glover 2000; Levine 2010). Finally, candidates and supervisors need to be mindful that analytic training in and of itself impacts on the conduct of control analyses (Ehrlich 2003; Goretti 2006). Because candidates today have a harder time developing analytic cases and gaining experience with analytic work, listening to faculty case presentations and reading and writing about detailed clinical material to get a sense of analytic process assumes greater importance (Azara 2003; Coen 2000; Dewald 1973; Glick and Stern 2008; Power 2001).

Ideas

Candidates have a number of ideas about how their local training experience could be improved and national organizations could increase interest in psychoanalysis (Tables 1 and 2). Improving institute atmosphere was the most commonly mentioned way that local institutes could improve training, followed closely by assistance in finding cases. It should be noted that 14% of candidates made uniformly positive comments about their training experience in response to this question. This is a strong endorsement of how well some institutes are doing in creating supportive and stimulating environments for training. Candidates at these institutes specifically noted help with case-finding and costs, acceptance of alternative viewpoints, and an emphasis on analytic process rather than rigid adherence to requirements. These respondents felt that their institutes understood the stresses of being a candidate and conveyed this both by their respectful, empathic attitude toward candidates and by concrete offers of support in assisting them with progression through training.

The majority of respondents to this question, however, remarked on problems at their local institutes. Concerns about institute atmosphere and case-finding were the two most frequent issues noted and accounted for 50% of the responses to this question. Candidates appear distressed by a negative or conflictual atmosphere at their institutes. Problems in institute functioning and conflicts over training standards have in recent years been recognized with increasing frequency and urgency (Berman 2004; Kernberg 1996, 2000, 2006, 2007; Reeder 2001; San Martino 2003; Wilson 2010). The training analyst system and its impact on psychoanalytic education have been debated actively on psychoanalytic list serves and in the literature, but in this study these issues were not of major importance to candidates. Comments in this study about the training analyst system, boundary violations, impaired analysts, and interpersonal conflicts at institutes were not frequent; however, when they were commented upon, they seemed to have had a damaging effect on the candidates involved and sometimes on those who witnessed the problems. As seen in another recent study of candidates, when one candidate experiences a problem it is often keenly felt by the peer group (Ward, Gibson, and Miqeu-Baz 2010). It is hard to gauge the effects of such experiences, since this study does not capture the feelings of candidates who dropped out, elected to train elsewhere, or did not respond to the survey.

When asked what local and national psychoanalytic organizations could do to enhance interest in training, candidates’ narrative comments indicate that outreach and publicity efforts are most important; they were mentioned in 60% of the responses (see Table 2). Next in importance were wishes to decrease infighting, enhance flexibility, and promote change in the national organization. It appears from the breakdown of these responses that candidates believe the energies of the national organization are misdirected and that the focus should move toward greater dissemination of psychoanalytic ideas, increased publicity of psychoanalytic training, greater flexibility in meeting requirements, and change in the functioning of APsaA. Candidates express the wish for improvement in both the local and the national atmosphere regarding training and want analytic leaders to turn their attention away from infighting and toward outreach and publicity for psychoanalysis.

Candidates endorse wide outreach efforts to engage future candidates. Casting a wide net, it is hoped, would lead to the development and fostering of individual relationships. The APsaA fellowship program is one example of this kind of effort. Some of the narrative comments indicate that a single experience, such as reading a book or hearing a talk, may be pivotal in stimulating interest. These experiences seem to allow candidates, often in unsupportive academic or training environments, to feel connected to authors or speakers who may inspire interest in analytic training. Although such experiences are reported in only a small portion of responses, they underscore the importance of analysts writing for and speaking to nonanalytic audiences. The most direct and personal ways of making contact with potential trainees include treatment, supervision, and teaching, but other, more creative ways such as staffing inpatient or emergency services (Sulkowicz 1999), serving as a guest scholar at training programs (Eifermann 1993; Sonnenberg 1990), or using technology to reach distant trainees (Moran 2009; Fishkin et al. 2011; Van Deurzen, Blackmore, and Tantam 2006) should be considered. Candidates specifically mention that exposure to enthusiastic analysts, publicizing psychoanalytic research, offering supervision to nonanalytic trainees, and creatively using technology are effective modes of outreach.

While outreach and personal contact will engage candidates who can afford the cost and time demands of training, we believe that the structure and goals of training should be reconsidered. Psychoanalytic education could move in several possible directions. It could retain the current training model and become a subspecialty field that attracts a small number of professionals who want to offer a highly specialized service. Alternatively, training could be modified to make it accessible to a larger pool of trainees, especially residents and graduate students. Several studies document that psychiatric residents believe they are not graduating with adequate psychotherapy skills and want more training (Calabrese et al. 2010; Hadjipavlou and Ogrodniczuk 2007; Katz, Kaplan, and Stromberg 2012; Khurshid et al. 2005). This approach relies on a broader definition of psychoanalytic treatment, one not limited to four sessions a week on the couch but focused instead on ways of deepening work with patients based on psychoanalytic principles.

Candidates in this study state clearly that reducing the time and the financial burden of training would make psychoanalysis available and attractive to a wider pool of young trainees. This could be accomplished through developing psychoanalytic centers or institutes that offer a broad array of training opportunities, from beginning psychotherapy to psychoanalysis, that allow trainees to progress at their own pace. Locating psychoanalytic institutes within universities may be a viable option in some areas and would provide the advantages of educational accreditation, administrative support, interdisciplinary collaboration, and access to a large pool of potential students. Since the main obstacle to training in this study was its cost, we believe it is crucial to address this issue by working to secure financial aid, developing realistic sliding-scale or low-fee arrangements, and increasing access to loans, grants, and research fellowships. Candidates also voice a wish for more transparency regarding the overall cost of training. On a smaller scale, if each analyst were willing to supervise or treat a potential candidate at a low fee, costs would be reduced and personal contact would be fostered. Reduced cost and personal contact are the two most important areas identified by candidates in this study that would improve access to training. Offering low-fee personal psychotherapy to potential candidates involves some sacrifice by practicing analysts but would give trainees the pivotal personal experience that our respondents identify as most powerful in having inspired them to undertake.training.

Current trainees often work in university or community mental health systems with colleagues who are trained in short-term treatment modalities and are unaware of or hostile toward psychoanalysis. In an era of evidence-based treatments, we consider it vitally important to disseminate research regarding both psychodynamic psychotherapy and psychoanalysis; further, psychoanalytic organizations must invest in research that addresses effectiveness and outcome. Educating analysts about the evidence base for psychodynamic and psychoanalytic treatments allows them to respond to questions by trainees and to prepare future analysts to take on the challenges involved in these studies (Leichsenring and Rabung 2008; Shedler 2010; Weerasekera, Manring, and Lynn 2010). Discussions about outcome literature may lead to better understanding of the distinction between the goals of analytic treatment and those of treatments focused solely on symptom relief, and to recognition of the sustained benefits of analytic treatment.