A Proposal for Innovation in Psychoanalytic Education


CHAPTER 16




A Proposal for Innovation in Psychoanalytic Education


 


 


In this chapter, I propose that psychoanalytic education needs to advance into two apparently contradictory but essentially linked and indispensably complementary directions:



  1. A clear, precise, scientifically based body of theory that reflects its specific contribution to psychological science and its applications, a true science of the dynamic unconscious, in contrast to “ecumenical” tolerance of unproven parallel or contradictory belief systems. This scientific approach also should apply to a system of therapeutic technical interventions that is sharp, precise, and comprehensive and can be scientifically subjected to empirical testing.
  2. An honest, open, unashamedly subjective and existential exploration of emotional reactions and interactions in the treatment situation, what may be called a romantic attitude to what is actually alive—or dead—in the therapeutic encounter, within that technical frame. This discussion will illustrate steps in the direction of these objectives.

Renovation of the Structure of Psychoanalytic Education


I believe that the educational stagnation and underlying authoritarian structure of psychoanalytic education derive largely from the present-day training analysis system as a major source of inhibition of the educational process. In earlier work (Kernberg 2006a, 2007), I explored how the defensive conservatism regarding changes in our educational methodology, the dogmatic approach to the conceptual aspects of theory and technique, and the unresolvable, unanalyzable idealization of the training analyst as a combination of excellent clinician, ideal supervisor and seminar leader, and administrative leader of the institution are intimately linked. The protective segregation of psychoanalytic institutes from their scientific and academic counterparts, the restriction of the teaching faculty that excludes scholars in related disciplines from participating in the central educational venture, the infantilization of the candidates whose idealization of their training analysts cannot be fully resolved, the distrust of alternative ideas and schools of thought that differ from the dominant approach of any particular institute—all are major symptoms of the training analysis system and have been quite extensively analyzed and documented in recent contributions.


I propose that realistic quality control of the graduate psychoanalyst be assured by the development of a psychoanalytic specialty board that is similar to board-certified specialties in psychiatry. Such a board would offer certification in psychoanalysis to all graduates after a certain number of years of experience (probably somewhere around 5 years), which would provide the possibility for the graduate to have added one more “generation” of advanced or completed psychoanalyses since his or her graduation. Although we desperately need research on objective criteria for competence in carrying out psychoanalytic treatment, in practice it should be possible to assess the competence of all graduates. As part of the development of methods of selection of training analysts in recent years, we have gained empirical experience in evaluating their acquisition of technical expertise in carrying out psychoanalytic treatment. That experience, combined with the relative ease with which their theoretical knowledge may be evaluated, should allow the assessment of competence if and when seriously attempted. Körner (2002) has stated convincingly that psychoanalytic competence can be evaluated in terms of theoretical knowledge, technical expertise, and a psychoanalytic attitude. To develop instruments of theoretical knowledge should not offer major difficulties; also, there exists empirical evidence that the level of technical experience in psychoanalytic psychotherapy can be assessed (Mullen et al. 2002). Additionally, regarding a psychoanalytic attitude, Tuckett (2005) has suggested convincingly a method for evaluating the analyst’s attitude in terms of his or her intuitive understanding of the patient’s material, the analyst’s capacity to develop a corresponding formulation in his or her mind, and the analyst’s capacity to communicate it in appropriate interventions. This proposed method dovetails with the current practice of evaluating candidates for training analysis status by having the candidate present selected sessions from his or her analytic work and be prepared to discuss the patient’s dynamics and his or her understanding and interventions in this context.


The expectation that during the, say, 5 years of experience beyond graduation the candidate for certification has carried out sufficient analytic work could be realistically broadened with alternative pathways to achieving clinical competence. These pathways include psychoanalytic treatments proper as well as experience in psychoanalytic psychotherapies, psychoanalytically influenced publications, and research concerns that demonstrate that the graduate has continued to use his or her psychoanalytic education to develop further his or her knowledge and depth in the understanding of unconscious conflicts, as well as their motivational impact on personality and psychological functioning, and has applied this knowledge in psychoanalytically based treatments.


Again, while acknowledging how little we have advanced in operationalizing criteria of analytic competence so that arbitrariness in the corresponding decision-making process cannot be fully eliminated, realistically the combination of knowledge, technical sophistication, and analytic attitude, combined with the nature of interests developed during the time span after graduation, should make it possible to confirm the expertise of the psychoanalyst to justify certification, and with it, the authorization to analyze candidates as well.


The supervisory function, in this proposed model, would be completely disconnected from the certification of the clinician in psychoanalysis. Talented supervisors would be recognized for their capabilities from their candidate years on, in terms of their creative and clarifying function in group seminars, which could be assessed further in the appointment of assistant supervisors at the time of graduation. Supervisors may also be selected from other sources such as colleagues recognized for their supervisory functions in study groups of the society, or for appreciated supervisory functions of psychoanalytic psychotherapy in departments of clinical psychology or psychiatry.


The stress on the evaluation of the scholarly productivity and research of psychoanalytic institutes leads to a related issue: the relationship between psychoanalytic institutes and the university. I have explored this issue in more detail elsewhere (Kernberg 2011), and I only wish to summarize here some major conclusions. I believe that the research function and scholarship in psychoanalytic education are essential to the survival of psychoanalysis as a profession and a science. In the long run, they will increase the need and objective pressures on psychoanalytic institutes to realign themselves within university settings. Various alternative models for such a relationship already exist, including a psychoanalytic institute within departments of psychiatry or clinical psychology, or a psychoanalytic institute as part of a psychoanalytic “center”—with various branches or structures throughout the university, or as an independent university institute in close liaison with several university colleges (Ferrari 2009; J. Körner, personal communication, 2009; Levy 2009). In any case, these various models of integration or rapprochement would facilitate research by combining the professional and clinical resources of psychoanalytic institutes with the research expertise and financial resources of university structures, thus fostering joint research projects related to or representing psychoanalytic theory, technique, and applications.


By the same token, such a relationship would break down the intellectual isolation of psychoanalytic institutes, permit the appointment of distinguished university professors as institute seminar leaders and scholars in residence, and open the executive structure of the psychoanalytic institute to scholars and research methodologists who may not have undergone psychoanalytic training, but who are strongly interested in psychoanalysis as a science. Theoretical, clinical, and applied seminars within psychoanalytic institutes thus could lead to depth and excitement of interdisciplinary studies, further increased by opening institute seminars to university faculty and students, so that only highly specialized seminars in psychoanalytic technique would be reserved for psychoanalytic candidates (and, it is hoped, at some point, to high-level trainees in psychoanalytic psychotherapy as well).


Another significant change in the proposed model of psychoanalytic education is that the analysts of candidates would no longer automatically occupy a position in the organizational structure and leadership function of the institute. The proposed model conceives the executive leadership of the institute as constituted by representatives from the supervisory body, seminar leaders, the research body, and representatives from the student body. The entire faculty would be involved in the selection of the director of the institute. The director of the institute would have the authority to appoint the various committees’ leadership and would be responsible to the faculty, the psychoanalytic society, and/or the university setting within which the psychoanalytic institute may function. While variable arrangements may develop between the executive committee of the institute and the faculty at large, this model stresses the “functional”—in addition to the “democratic”—selection of supervisors, research faculty, seminar leaders, and student body representatives as the members of the executive committee of the psychoanalytic institute.


The seminar leaders in turn would be appointed separately from the certification process. Theoretical, clinical, research, and applied psychoanalytic subjects should be taught by recognized experts in the field, including non-analysts interested in psychoanalytic theory as it applies to related disciplines and experts in research methodology.


I have mentioned at several points the participation in the institute’s academic life of a research faculty, both analysts and non-analysts, throughout the educational activities and the organizational structure of the institute. A specific department of research within each psychoanalytic institute is a highly desirable goal and should not be difficult to achieve once the fundamental importance of the development of new knowledge is recognized as an essential component of psychoanalytic education. Research faculty represented across the entire committee structure of the institute, including the executive committee, without consideration of whether the research experts are psychoanalysts, should provide support to seminar leaders in raising important questions of research interest and inviting and facilitating candidates and faculty to participate in specific research projects, provide research consultation and counseling to candidates, carry out a mentoring function for specifically research interested candidates, and present specialized seminars as electives on research methodology (Kernberg 2006b).


The proposed model also implies the selection of academically interested and motivated candidates and the fostering of their academic careers simultaneously with their psychoanalytic education. This represents a sharp contrast to the past tendency of many institutes to foster an almost exclusive dedication to psychoanalytic training and practice proper, with the idealization of “training analyst” as the only desirable career ladder inspiring the psychoanalytic candidate.


One other major but presently underdeveloped function of psychoanalytic institutes would implement teaching and research on the application of psychoanalytic theory and technique to a broad spectrum of derived psychotherapeutic approaches: individual, couple, family, and group psychotherapies based on psychoanalytic principles—in short, the development of a broad spectrum of psychotherapeutic modalities and expertise that increases the relevance of psychoanalysis for the mental health professions. A natural outgrowth of this effort would be to study the effectiveness of different treatment modalities and their indications and contraindications, thus eroding the present-day contradiction between psychoanalytic training geared almost exclusively to teaching the technique of standard psychoanalysis, while in their dominant daily practice psychoanalysts employ precisely the psychoanalytic psychotherapies that are not taught, or given only cursory attention, and are generally undervalued in traditional psychoanalytic education.


A Contemporary Approach to Psychoanalytic Theory


I propose that a clear outline of classical psychoanalytic theory, as reflected in the final theoretical view of Freud, should be taught together with the contemporary modifications, questions, and controversies that have been raised regarding all aspects of these theoretical formulations. This includes the contemporary controversies among the ego psychological approach and the Kleinian, British Independent, relationist, and Lacanian schools. This exploration would include consideration of the theory of the mental apparatus; its motivation, structure, and development; the nature of unconscious processes; the topographic theory; and the spectrum of defensive mechanisms. This review would reevaluate the structural theory; the drive theory; the oedipal complex and the nature of the id, particularly with relation to infantile sexuality; and the role of aggression. Study of the structure and functions of the ego should include considerations of identity and the theory of the self as well as the role of the superego in normality and pathology.


What I wish to stress is that all these areas of the educational task would have to include the alternative, complementary, or questioning approaches that have been developed in the boundary sciences, with an ongoing exploration of the psychoanalytic theory from the viewpoint of neurobiological developments, evolutionary psychology, developmental psychology, experimental psychology, social psychology, and current knowledge in sociology and cultural anthropology that relates to various assumptions of psychoanalytic theory. Obviously, much of this needs to be taught by specialists who may not be available within the realm of a psychoanalytic faculty, therefore experts in these fields should be recruited to contribute their specific knowledge. In short, psychoanalytic theory needs to be examined in the context of the developments of modern science in other related fields.


Let me illustrate this approach with one example: the contemporary analysis of Freud’s dual drive theory, in and of itself controversial within psychoanalytic approaches. Drive theory raises questions regarding the relations between this theory and the evolving contemporary knowledge of motivational systems in neurobiology. Specifically, the discoveries regarding the neurobiological origin, structure, and functioning of affects as primary motivational systems, and the early interactions among genetic dispositions, brain structures, and environmental influences from the beginning of life on (Kernberg 2012). Affective neuroscience, in short, must be explored in the context of the analysis of the theory of drives. Obviously, in clinical studies of mental mechanisms, particularly the relationship between impulsive and defensive pressures, affect-driven desires and opposite mechanisms tending to control, suppress, or repress them have been subjected to psychoanalytic studies. For example, we have empirical investigation of the mechanism of projective identification, relating it to the exploration of affective communication, by Rainer Krause and others. The study of early cognitive and affective interactions and their relations to primitive defensive operations, particularly in the study of attachment, is another example of parallel and sometimes even combined research from a psychoanalytic, behavioral, and neurobiological perspective. Development and psychopathology are vast areas where psychoanalytic clinical observation and theory may be enriched, contrasted, and developed in interaction with related sciences.


A central, unifying concept of all psychoanalytic approaches is the theory of the dynamic unconscious and its influence on conscious life. The empirical evidence of the operations of the dynamic unconscious appears to be sufficiently powerful to signal a key function of psychoanalytic theory within the general contemporary research on different states of consciousness and the relationship between declarative and procedural memory. In short, general psychoanalytic theory, theory of development, and theory of psychopathology need to be correlated with related contemporary scientific approaches. Regarding psychopathology, obviously, psychoanalytic theories of depression must be related to the new knowledge regarding neurobiology of depression, and psychoanalytic theory of character pathology with the developing knowledge regarding neurobiological and psychosocial influences in the development of personality disorders. Again, psychoanalysis may have fundamental contributions to make to other sciences that have not been exploited and only expressed in hypotheses or assumptions that, under the present circumstances, have not been taken seriously by other scientific fields because of the lack of empirical and interdisciplinary research initiated by psychoanalytic educational institutions and a neglect of investment in research.


Psychoanalytic Technique and Its Application


The lack of teaching and awareness of psychoanalytic technique and its application to the derivative forms of psychoanalytically derived psychotherapies represents, I believe, a major failure of psychoanalytic education. It is significant, and dramatic, that to this day there does not exist any comprehensive text on psychoanalytic technique! Insofar as competence in psychoanalytic technique is assumed to represent the objective criteria for graduation and advancement within one’s institute, it is not surprising that this process has been sufficiently mystified to leave open a vast area of uncertainty and vagueness regarding the criteria used to assess this competence, and to enshrine, within the “training analyst” system, the tremendous subjectivity in these evaluations.


I believe that we have sufficient evidence of the basic commonality of technical psychoanalytic principles of various schools to justify a clear, common, basic psychoanalytic technique and to define how different psychoanalytic approaches vary in their use of core techniques. I will not go into details about the analysis of this problem in this chapter, but I believe that interpretation, transference analysis, technical neutrality, and countertransference analysis compose the basic components of the technical psychoanalytic approach and that the combined use of these four techniques are then applied to other aspects of the psychoanalytic situation such as character analysis; dream analysis; analysis of acting out, enactment, repetition compulsion, and working through; and the analysis of termination (see Chapter 4, “The Basic Components of Psychoanalytic Technique and Derived Psychoanalytic Psychotherapies” and Chapter 6, “The Spectrum of Psychoanalytic Techniques,” of this book). The preconditions for carrying out this technical approach in the treatment of patients are given by the instructions of free association for the patient and the evenly suspended attention of the analyst. Clear definition of those four basic techniques permit one to define their specific modifications by alternative psychoanalytic approaches. In this field, we do have significant empirical evidence on effectiveness, stemming largely not only from research in psychoanalytic psychotherapies that have been employing these techniques with specified modifications, but also from empirical clinical research on psychoanalysis proper and on comparison between psychoanalysis and psychoanalytic psychotherapy. Evidence is accumulating that is relevant for the educational processes involved in teaching psychoanalytic technique in psychoanalytic institutes. It is discouraging how little this empirical evidence has been used in psychoanalytic education.


The use of contemporary educational techniques, combined with computer-based analyses of content of psychoanalytic sessions and the direct study of therapeutic interactions by audio and video recording (strenuously objected to by psychoanalytic educational institutions until a few years ago), has not proved to be detrimental to the analytic process. The specific effects of interpretation, in contrast to supportive psychodynamic psychoanalytic approaches, have been clearly demonstrated. The systematic analysis of transference has been shown to be an important therapeutic tool in the treatment of severe personality disorders, whereas until about 30 years ago, psychoanalytic assumptions of the various schools, with the exception of the Kleinian school, were that analytic approaches to such very severe cases were risky and mostly contraindicated. We now have evidence for indications and contraindications of various psychoanalytical psychotherapies for severe personality disorders.


It is realistic and feasible now to develop precise techniques for psychoanalytic psychotherapy and supportive forms of therapy based on psychoanalytic understanding and principles. Our training institutes have been reluctant to teach these approaches in an effort to preserve a “pure culture” of psychoanalytic technique proper against all the evidence of the possibility of differentiating these approaches, and the possible expansion of the application of psychoanalytic principles for a vast number of conditions in which psychoanalysis is not possible or not indicated. This has led to the development of psychotherapy institutes specializing in these particular techniques, in competition with pure psychoanalytic cultures, and with a social chaos in this field that also contributes to the loss of prestige of the profession that we have been witnessing.


Preservation and Enrichment of the Subjective, Intersubjective, and Existential Approaches to Psychoanalytic Treatment


The major obstacle to synergy between psychoanalysis and other scientific endeavors stems from the assumption that each psychoanalytic situation is a unique relationship between two individuals and therefore does not lend itself to objective scientific measurement. There is a naïve assumption that the analyst listening with evenly suspended attention, or with an effort to enter each session “without memory or desire” and open to reverie on the patient’s material, will provide the essential and exclusive precondition on which psychoanalytic understanding and interpretation are based. I believe that this assumption is a bias derived from a lack of understanding of what a clear and precise technical approach means. The intuitive sense of what is going on between patient and therapist is obviously the basis of all understanding and analytic work. The content of free association, the patient’s verbal communication and affect expression, the nonverbal manifestation of his or her behavior, and the affective tonality of this communication all influence the analyst and constitute the basis for his or her intuitive understanding. The combination of verbal communication, nonverbal communication, and countertransference constitutes the raw material on which interpretation and transference analysis are based. The analysis of countertransference is the source of important information, and the analyst’s intervention from a point of technical neutrality—not implying indifference or distancing but rather a concerned objectivity—opens the field for the expression of a specific emotional experience that the patient introduces in the analytic encounter. Openness to this experience by the analyst is not in contradiction to a clear understanding of how this knowledge is to be captured and used or how the analyst’s understanding can be transformed into new understanding and communicated to the patient. All recent technical analytic approaches, as has been pointed out by Fred Busch (2014), have evolved into giving primary attention to the enacted object relationship in the transference in the here and now, and to transformation of the material intuitively captured by the analyst into representational consciousness by the patient that reflects what previously could not be experienced and reflected on. I believe that the main controversy regarding “What is the correct interpretation?” usually relates to the genetic element of what is enacted, and here clearly theory influences analytic technique and should be spelled out and subjected to empirical investigation. I am referring to whether conflicts stem from a preverbal period of development or from archaic or advanced oedipal levels of development and dominance. With an optimal understanding of the unconscious processes that are developing in the here-and-now interaction, the question of genetic origins can be clarified throughout time. My point is that open, intuitive awareness of the present psychoanalytic situation within one’s theoretical orientation not only is essential but can be closely studied. Theoretical differences should not be an impediment to the study of clinical and applied psychoanalysis. Theory counts, regarding the scientific nature of the psychoanalytic theory of personality, development, psychopathology, and treatment, and its scientific evaluation, as well as evaluation of the techniques of therapeutic intervention and their theoretical basis, will determine the future of the profession as well as of the theory itself.


References


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Mar 29, 2020 | Posted by in PSYCHIATRY | Comments Off on A Proposal for Innovation in Psychoanalytic Education
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