Abstract
Otto Kernberg and Robert Michels, along with most readers of this journal, are intellectually and emotionally committed to psychoanalysis as a science, as a clinical practice, and as a moral-ethical framework. Both men are among our most distinguished psychoanalytic educators, and when they propose a new model for psychoanalytic education, anyone concerned with the future of psychoanalysis should listen and take note. 1
Their paper links the vulnerability of the educational system to the troubles that beset psychoanalysis. They point to the field’s increasing distance from the nucleus of modern culture and the central position it occupied for much of the last century. The standards that most psychoanalytic institutes use to assess appropriate knowledge, skill, and competence for qualification as either analyst or training analyst are loosely specified, subjectively assessed, and prone to perverse incentives, and therefore do not adequately protect individuals or groups from potentially iniquitous processes. The authors’ basic claim, that mechanisms for quality control in psychoanalysis are lacking, finds echoes in many recent appraisals of its systems (Coopersmith 2010; Schneider et al. 2014; Szecsödy 2008; Wallerstein 2007; Zimmer 2003).
Kernberg and Michels go on to link their pedagogical challenges to the far deeper problem of the relationship of psychoanalytic institutions to scientific endeavor and, closely linked to this, the role of higher education. This they in turn connect to the declining status of the discipline within the entire Western cultural nexus. They recognize that the loss of psychoanalysis’s once prominent status has multiple causes and that psychoanalytic training’s contribution to it is only partial. Consequently, it is unlikely that reforming education at this point will reverse any background process whereby psychoanalysis is increasingly marginalized and its key tenets coopted by neighboring, sometimes hostile, disciplines. While we may agree with their appraisal of the current status of psychoanalysis in the world, we believe that modifying only its educational superstructure, however critical, will not assure the survival of psychoanalysis as a major clinical force.
The problems that beset psychoanalytic institutions need to be considered in the context of the discipline’s epistemic status. We would argue that the current state of psychoanalytic training institutions is a symptom of an underlying intellectual weakness that has prevented the discipline from adapting to the massive cultural shifts that have dominated the last quarter of the twentieth century. The Kernberg-Michels thesis implies that for psychoanalysis to survive as a leading intellectual force it must appeal to and attract the most able young people, as indeed it once did. Without the creative energy that brought the likes of Michels and Kernberg into psychoanalytic scholarship, the profession is inarguably doomed. It is therefore reasonable to assert that without addressing our educational programs and procedures, we will not achieve the necessary reversal of fortune.
Certainly in most associations, the inexorable effects of the profession’s upward-drifting age profile (fewer than ten of over four hundred psychoanalysts in the British Society are under fifty years of age) will make at least an impact gully, if not a precipitous loss of influence, almost inevitable. If we are to emerge from this recession we will have to recruit young, able, and creative clinicians whose training inspires them to advance the discipline and make it appropriate to the extraordinary challenges that twenty-first-century Western culture faces: an increasingly disempowered and often disillusioned youth, an abandonment of the liberal values that facilitated the growth of psychoanalysis, empowerment of the service user and disempowerment of the “expert,” a radical remodeling of social communication, the proliferation of destructive weapons, the growing disparity between rich and poor, and so on. Humanity’s nature has not changed, and we do not need a new psychology; rather, we need to make our psychology relevant again, and in order to do this we need new generations of brilliant, culturally and racially diverse theoreticians and clinicians to inspire, as we were inspired by our educators.
The Kernberg-Michels Proposal for Change
How far along this road will the Kernberg-Michels reforms take us? Although we endorse their proposals, we are left with two concerns we want to address.
The central idea of their proposal is transparency. We need to agree on who can do analysis and who cannot and create an educational system that supports individuals to acquire these competencies, and systems of appraisal so they can demonstrate they have the required knowledge and skills to practice psychoanalysis.
Kernberg and Michels suggest that such criteria can be arrived at with objectivity and in the spirit of scientific inquiry. They are not alone (see, e.g., Watkins 2013). They propose a uniquely qualified group of educators to do the explication. In this model there would still be considerable reliance on tradition. It requires faith that we implicitly practice in an effective way and that these pieces of knowledge and rules of intervention can be made explicit and reliably assessed. Our view is that while this may be the case, in clinical practice techniques are quite varied and the evidence for what is helpful and what should be emulated is somewhat thin. While the current state of affairs in training would be materially improved if a small but representative expert group could arrive at a finite list of criteria, the process should not end there.
To make the profession genuinely evidence-based rather than founded on and shaped by tradition, the assumption that we already know how best to do things must be questioned. We may need to give up the notion that we know a priori what psychoanalysis is and how it is best practiced. We need to make training—and especially training in therapeutic technique—as much a question for research as any other aspect of the scientific inquiry we undertake.
We have so far failed to research our techniques adequately. Consequently, although our techniques have changed dramatically over the past fifty years, these modifications have largely been driven by social and cultural forces external to psychoanalysis (e.g., the number of hours per week an individual can afford and is willing to spend on self-improvement, the availability of alternative therapies, transport challenges due to traffic problems in large urban areas), rather than by any kind of systematic knowledge-gathering. What is or what is not acceptable clinical practice remains to be codified beyond what is defined by tradition and ideally, as Kernberg and Michels suggest, to be linked to research. 2
Kernberg and Michels’s practical recommendations do not go far enough. We agree that knowledge, capability, and attitude can be defined, taught, and evaluated. We also agree that qualification and certification are probably usefully separated and that the latter is sufficient for ensuring that psychoanalytic candidates receive appropriate training. We have concerns in relation to the process for developing criteria of competence but feel that an objective assessment at admission, qualification, and certification based on observed competence is critical. We are still in the shallow waters of developing such methods of observation but must proceed rapidly with testing out innovative methods that include role playing, recorded sessions, objective measures of knowledge and the capacity to apply it to clinical situations, patient-rated outcomes, and systematically acquired indicators of the change process. Objections to such methods as “unacceptable distortions of the analytic process” should be met robustly, pointing out the absence of any valid reason for preserving the process unchanged.
A lingering concern we have with Kernberg and Michels’s proposal relates to the potency of the practical recommendations to mitigate what they describe as the organizationally fostered idealization of the training system. We doubt whether changes limited to rotating teachers, the involvement of candidates in shaping their training, improved dialogue between the education committee and institute leadership, the involvement of universities in the training of psychoanalysts, the encouragement of systematic research, and opening up the community to knowledge beyond the traditional psychoanalytic will be sufficient to alter the course of psychoanalytic education.
While we endorse all the suggestions made, particularly those in the section on specific function of institutes, we fear they do not go far enough. We believe that psychoanalysis must open itself to external scrutiny. There should be a body of external mental health experts, as well as patients, educators, and cultural experts, to whom the training is accountable. Seventy-five percent of the membership of the British General Medical Council (responsible for overseeing medical education) is composed of lay members. Similarly, psychoanalytic educational and clinical programs should be able to demonstrate the validity of their procedures to those outside the “magic circle” of the initiated. It ought to be possible to explain to reasonable people why we treat and teach in particular ways. Here, of course, the discipline of the university, which requires rational argument to substantiate points in balanced dialogue, would pay dividends, as would research findings consistent with the claims being made. But there would remain ample room for assertions not based on randomized controlled trials but rooted in clear, coherent argument with clearly stated assumptions.
Conclusion
In essence, we are in total agreement with Kernberg and Michels that transparency and rationality are the keys to our discipline’s future. We have no doubt that psychoanalysis provides the best available model to explicate human behavior and that training in psychoanalysis is the royal road to acquiring this psychological understanding fully, which in our view remains invaluable in a range of applied social science and humanities contexts. We need to train in clinical psychoanalysis for this intellectual discipline to continue to thrive.
We may need to be more playful and innovative in relation to technique (as in practice we already are and probably always have been), to ensure that the clinical relevance of our approach is maintained. The codification of technique must not be used inappropriately to ossify the profession but should rather lay the foundation for a dynamically changing collection of empirically validated techniques that we enthusiastically rediscover each time we take on our pedagogic brief.
As Kernberg and Michels suggest, we need to open up to universities, along with other key cultural institutions. Such opening up may bring forth a renaissance of psychoanalytic approaches progressing hand in hand and with mutual respect for other disciplines, so that together we can meet the overwhelming challenges that face us in the so-called modern world, which is as troubled by primitive desires as it has ever been.
Footnotes
Peter Fonagy, Freud Memorial Professor and Head of the Research Department of Clinical, Educational and Health Psychology, University College London; Chief Executive, the Anna Freud Centre. Elizabeth Allison, Director of the Psychoanalysis Unit, Research Department of Clinical, Educational and Health Psychology, University College London.
1
Peter Fonagy and Elizabeth Allison both trained with the British Psychoanalytic Society at the Institute of Psychoanalysis in London, qualifying in 1985 and 2010 respectively. They share a concern with the future of the discipline and its relationship to scientific inquiry and higher education.
2
Currently, research would seem to be a contraindicator of acceptable practice. Last year Peter Fonagy’s continuing professional development experience was rejected by the committee overseeing CPD activities in the British Psychoanalytic Council because the clinical work and supervision listed pertained to mentalization-based treatment (MBT) rather than more traditional approaches. Intriguingly, the explanation offered by the council’s committee was framed in terms of the need to protect the public from those who do not practice what is more recognizably the traditional psychoanalytic technique. The riposte—that at least MBT had some (limited) empirical basis for its techniques—did not elicit a reprieve.