Commentary on Kernberg and Michels

Having been involved all my professional life in psychoanalytic education, I am delighted to have been asked to comment on this paper by Otto Kernberg and Robert Michels on a matter close to my heart.

My own experience as a teacher differs somewhat from theirs. It involves less immersion in institute-based education and perhaps more work with professionals new to psychoanalysis, with psychoanalytically oriented therapists who are not fully trained analysts, and with analysts trained outside the American Psychoanalytic Association. My own analytic education was entirely outside APsaA, and so I have only a partial understanding of the complexities of its controversies about certification, the training analyst system, and similar issues.

Thus, although I am an insider to efforts to improve analytic education, I am an outsider to the battles in APsaA and the IPA, of which both Kernberg and Michels are veterans. Perhaps because of my outsider status, despite finding myself in accord with the spirit of their critique of analytic training, I have some questions about the means for improvement that they suggest, both jointly and separately. I am more radical than either author on questions of training, probably because I have not been part of the systems they are endeavoring to change.

The pleas in their paper for theoretical diversity, egalitarianism, and transparency mirror the sensibility that characterized my psychoanalytic training in the early 1970s at the National Psychological Association for Psychoanalysis. NPAP fostered a notably democratic learning culture in which a range of analytic ideas were taught. NPAP has never distinguished between a personal analysis and a training analysis, or between training analysts and other graduates. Its position was that if one had been deemed mature and competent enough to graduate, one could analyze and supervise candidates. Many other non-APsaA institutes have similar policies, or have an uncomplicated rule whereby a certain number of years after graduating one automatically becomes a training analyst. Such arrangements have the advantage of supporting graduates’ sense of adulthood and autonomy, especially their sense of agency with respect to getting postgraduate supervision and consultation when needed.

I know of no evidence that analysts trained under these more egalitarian arrangements are less competent, or subscribe to lower standards of practice, than other analysts. (Testing that belief empirically would make a worthy research project—challenging to design but by no means impossible). An immense amount of psychoanalytic creativity in recent decades has come from graduates of non-APsaA institutes that lack a training analyst system, institutes such as William Alanson White, the NYU postdoctoral program, and the National Institute for the Psychotherapies, to take three New York institutes I know fairly well. Their graduates seem to me also, as a group, to have been comparatively highly engaged with the larger world.

Whether or not my impressions are accurate, it is pretty clear that these institutes do not convulse every few years over questions of who has a special status in the pecking order (they have other organizational problems, but not that one). An acknowledgment of the value added to psychoanalysis by analysts from these groups seems implicit in the recent decision of APsaA to embrace the White Institute. The national organization in which I am most immersed, the Division of Psychoanalysis of the American Psychological Association, is open to anyone interested in psychoanalysis. It is a lively group, whose conferences seem to me more diverse on a number of welcome dimensions than those of APsaA. Lacking a credentialing function, it has not suffered chronically from the kind of internal struggles that have wracked APsaA.

The observation of Kernberg and Michels that inordinate time and effort have gone into internal conflicts, at the expense of concern about the relationship between psychoanalysis and the world outside its societies, seems incontestable—a grim foreboding of the future status of psychoanalysis unless something is done. I find myself wondering: If institute graduation requirements were to include the elements that the authors suggest for certification, and if training analyst status were conferred automatically to professionals in good standing upon graduation or a few years later, would not APsaA save vast amounts of professional energy at little cost? The “standards” often invoked to defend more authoritarian practices have always seemed to me to involve so much infantilization of capable adults, so much rationalization of training analysts’ interest in a steady stream of analysands, and so much damage to people in good analyses who are forced to change analysts when they seek institute training, that they are indefensible on educational grounds.

Let me raise some additional concerns about the authors’ analysis of current difficulties in analytic education and their recommendations for improvement. (The differences between the two men are interesting, but not with regard to the main issues I am addressing.) For example, I agree that “the barrier between psychoanalysis and the university . . . may well have become the greatest threat to its survival” (p. 487). But the remedies for that malady are not so clear, and the challenge looks to me even more overwhelming than their article suggests. A core relevant issue is why people seek analytic training, and the implications of the answers to that question.

These days, individuals become analytic candidates somewhat later in life than they once did, and at great personal expense. Their health insurance rarely covers analysis, and their day jobs are not nearly as financially rewarding as those of a previous generation of professionals eligible for candidacy. Their overriding motive for training is usually to become a better therapist, and they may specifically want to add the capacity to do in-depth, high-frequency, on-the-couch work to their clinical repertoire. They may be in a psychoanalysis or psychodynamic therapy that has been strikingly helpful, or they may unconsciously know they could use a personal analysis and view analytic training as a face-saving way to get the treatment they need.

Professionals no longer apply to institutes for the reason that that is where the consensually prestigious training is: psychoanalysis has been so effectively devalued in the larger mental health culture that only someone with internal reasons for pursuing psychoanalytic education would apply. (The upside of this reality is that institutes get fewer applications from problematic individuals whose motivations are predominantly narcissistic.) Because of the exclusion of psychoanalytic ideas from most current predoctoral training programs in all the relevant disciplines save pastoral counseling, today’s applicants may know considerably less than those of an earlier era. They may want basic training in transference, countertransference, defense, resistance, unconscious process, affective maturation, enactment, and similar concepts.

What they do not want is to become researchers. Many of them learned some research methodology in their preanalytic discipline and felt no temperamental affinity with the role of empirical investigator. Thus, while I am passionate about the need for good analytic research, I am dubious about requiring the amount of institute training in it that the authors recommend. I think it would be received the way therapeutically motivated students of clinical psychology regard their compulsory courses in statistics: as unpalatable medicine they have to take on the way to what they really want to do.

That said, an institute course in research design and evaluation would be invaluable if taught by an experienced scientist with skill at teaching, at least for candidates whose backgrounds did not include these areas. It is a serious problem that many analysts lack a mental image of how their work could be empirically studied; consequently, they may devalue research itself. Because we tend to dismiss what we do not understand, I am not surprised that many analysts warmly greeted Hoffman’s warnings (2009) that research can desiccate human experience. Much academic research on therapy has unquestionably done so. In order not to do so, scientists need to hear from practitioners about what is clinically useful for them to study.

The recent questioning of the scientific status of psychoanalysis that Kernberg and Michels rightly lament may be somewhat newer in psychiatry than in psychology, social work, and counseling. The devaluation of research per se by psychoanalysts, and the backlash against psychoanalysis it has triggered in people with other mental health identifications, has a long history. For example, psychologists still cite with dismay Freud’s 1934 letter to Saul Rosenzweig (see Aron 2012), who had demonstrated the phenomenon of repression in the psychology laboratory, in which Freud damned such research with the faintest of praise (“It cannot hurt”).

A related problem is that because of complexly determined tendencies of analysts to idealize several-times-a-week, on-the-couch treatment, with an accompanying devaluation of other analytic activities, the larger community tends to think of psychoanalysis solely as a method of treatment—one too expensive for most patients and helpful only to healthier ones—and not as a body of knowledge applicable to understanding group processes, politics, organizational dynamics, the law, the arts and humanities, short-term treatments, career counseling, therapeutic work with the psychotic, traumatized, or addicted, and many other areas. Analysts have paid dearly for this conceptual conflation, and we have not corrected it aggressively enough.

So long as the popular perception of “psychoanalysis” is as a treatment requiring several sessions a week on the couch, we will be unlikely to engage researchers in questions of core significance to analysts. Kernberg’s specific concern that we broaden psychoanalytic training is thus highly resonant for me, especially now that most graduate psychology programs and medical schools and residencies teach very little of this material.

Most scientists agree that the best way to learn research is to do it. And yet the challenges of raising funds to cover scientific projects within analytic institutes, without institutional support from universities, seem virtually insurmountable. Even in university settings, where professors are accustomed to designing research projects and applying for grants, money for psychoanalytic investigation has dried up. There are exceptions, such as attachment research, but overall, professors must use a carefully nonpsychoanalytic vocabulary to get any project funded. NIMH seems allergic to investigating psychoanalytic or even generally psychological topics, and privately funded grants tend to be infused with private agendas.

In addition to supporting research via changes in institute coursework, I would emphasize getting analysts engaged in nonanalytic organizations, including both universities and national groups that discuss and evaluate mental health education. Perhaps if training analysts did not have guaranteed access to a reliable source of income, they would get out in the world more and be motivated to demonstrate the value of the concepts that support their work. It is my experience that organizations welcome an analytic perspective when they have come to appreciate other qualities an analyst brings to their mission. Once they see that an analytic idea helps to solve a problem, they get interested. The days are gone when one’s analytic training confers automatic prestige; in fact, many groups have had pretty unpleasant experiences with members who thought they should be valued simply because they were psychoanalysts.

We need, then, to engage humbly but doggedly with the larger mental health community, including various parts of academia. But getting institute graduates into full-time academic careers may be extremely difficult. Already there is a serious problem in universities and medical schools because of the dearth of researchers clinically experienced enough to design clinically meaningful studies. The problem is in part due to how difficult it has become in academia to achieve tenure and promotion, and how much that process includes pursuing externally funded grants. Thirty years ago, a professor of clinical psychology was likely to have a small practice, but to do so now would be professional self-sabotage. There simply is no time.

This reality has contributed to an increasingly large chasm between the worlds of clinicians and researchers. It has prevented scientists from having empathy with real-world clinical practice and has alienated clinicians from the academics who then unempathically demean their work and complain to policy-makers and the media that therapists are wasting their time with archaic, empirically discredited treatments (see Shedler 2006). A better solution than training analytic candidates to do research might be to recruit university professors—ideally, tenured academics who are past the consuming early-career challenges—to sit in on courses at institutes. Hearing real cases presented might inspire them to ask researchable questions not currently found on their mental maps.

An initiative is currently under way by some psychologists, notably those in the Society for the Exploration of Psychotherapy Integration, to do more “practice-oriented research,” conceived as an antidote to the current “empirical imperialism” in psychotherapy research, a system in which full-time academics, with no input from practicing therapists, have a dominant voice in what should be studied and how (see, e.g., Castonguay et al. 2015). Analysts would be wise to ally with this movement.

On a somewhat different topic, courses in institutes should certainly be expected to teach not only theory, including comparative theory, but empirical work relevant to the real-life clinical questions with which the various theories engage. As the authors’ recommendations imply, courses in institutes can be remarkably narrow in vision and resistant to change. A close analytic colleague who works with schizophrenic patients among the urban poor informs me that it took years for his institute to make room in the curriculum for even a brief course on psychosis. When Jeffrey Lieberman (2014) recently trashed psychoanalytic therapy for schizophrenia in a best-selling, widely reviewed book, few analysts knew enough to counter his inflammatory claims with existing empirical data. More generally, few analysts know how to respond to claims that psychoanalytic concepts and treatments lack empirical support, despite the accumulation in recent decades of considerable high-quality empirical evidence.

Many of the specific ideas of Kernberg and Michaels that I have not discussed are welcome ones, such as the value of rotating teachers, the role of candidates in advising the powers that be, the need to value psychoanalytic therapies on a par with psychoanalysis proper, the importance of avoiding mindless eclecticism in teaching, and the value of video recording sessions. I would hope that senior analysts, not just those in training, would show videos of their clinical work. Without that, the culture of greater transparency and reduced idealization that Kernberg and Michels seek is unlikely to evolve.

I admire the spirit of this paper. My main reservation about it is a sense that some of the authors’ proposed improvements, though from one perspective quite revolutionary, may be still too burdened with remnants of authoritarian practices. I worry about institutionalized procedures that insufficiently recognize and support the natural motives toward growth and increased competence that characterize almost anyone motivated enough to seek institute training in these times. Conferences are full of psychoanalytic practitioners who are trying to become better at what they do. Why would self-motivated, mature professionals be attracted to a training model in which they continue to jump through hoops set by others for years after they graduate?

The academy has its troubles, but it has succeeded for a long time in creating an environment where self-directed individuals thrive without this degree of oversight. I would thus like to see more democratic, egalitarian psychoanalytic societies that have more trust that their own training is a good-enough basis for becoming a mature psychoanalyst, supervisor, and teacher. I hope this rich paper will stimulate some widespread institutional soul-searching.