Converted patients and clinic patients as control cases: a comparison with implications for psychoanalytic training

All twenty-eight respondents to a recent poll of the thirty institutes affiliated with the American Psychoanalytic Association reported that they now accept cases converted from psychotherapy to psychoanalysis as control cases. This study was designed to compare converted cases to clinic cases systematically with respect to patient characteristics, treatment, and the educational experience of the treating candidate. The study followed twenty-four candidates entering analytic training between 1992 and 1995, who treated thirty-four clinic cases and forty-three converted cases between February 1993 and July 2000. Clinic and converted patients were comparable with regard to demographics, prior treatment histories, structural diagnoses, and Axis I diagnoses. In addition, the two groups of cases were indistinguishable with respect to the rate at which candidates received credit toward graduation requirements. Candidates treating converted cases earned approximately dollars 7,600 per patient per year, compared to candidates treating clinic cases, who earned nothing. Eighty-four percent of converted patients diagnosed with a mood disorder by the treating candidate were on medication, in contrast to only 20% of clinic patients with the same diagnosis. Similar differences were seen in the case of anxiety disorders. Given the prevalence of affective and anxiety disorders in control cases and the availability of a variety of medications and psychotherapies with documented efficacy in treating these disorders, candidates should be trained to discuss treatment options with patients who present with Axis I disorders.     

Fostering the educational value of candidate evaluation

Approaches to fostering the educational value of candidate evaluation are presented, in view of the plethora of intra‐psychic challenges that combine with many other complexities of learning to work as an analyst. Four integrally interrelated practices have been found to address sensitivities inherent in candidates’ experience of training in general, and being evaluated in particular. When applied in concert, the institute's evaluative process not only becomes more considered, but also better promotes a psychoanalytic attitude and minimizes the intrusion of evaluators’ personal responses. The first is defining and employing in synergy criteria for clinical immersion based on demonstration of the development and deepening of an analytic process, as well as the development of psychoanalytic competencies. The second is mandating institute‐wide application of guidelines for assessment of progression/graduation that are clearly explicated to all candidates and faculty. The third is transparent and timely communication between candidates and their supervisors and progression advisors regarding progress essential to a sense of collaboration. Fourth the progression review process must be systematic and in‐depth, with built‐in consultative relationships serving as checks and balances on personal elements. The implementation and educational impact of these practices are considered in the case of one candidate.     

The Columbia Supervision Project: data from the dyad

Anonymous questionnaires were sent to all candidates and supervisors at the Columbia University Center for Psychoanalytic Training and Research (hereafter "Columbia"). Questions focused on the four domains most emphasized in the literature on supervision: logistical issues; the "teach or treat" question; the evaluatory function of the supervisor; and the affective experience of supervision. By coding the questionnaires, anonymity of respondents was maintained while allowing for a matched pair of analyses of supervisors and supervisees. Return rate was over 85 percent. In general, rates of satisfaction with supervision were high, and candidates and supervisors agreed on such issues as the "teach or treat" question, as well as the technical and theoretical frame of reference of the supervisor. However, there were striking disagreements between candidates and supervisors as to the role of the supervisor, what candidates find useful in supervision, the evaluatory function, and the relation between supervision and progression to graduation. Although 50 percent of candidates reported anxiety about receiving credit for cases, this was not routinely discussed in supervision, and the supervisory relationship itself was not discussed in over 50 percent of dyads. Despite high overall satisfaction ratings, 25 percent of candidates said they wished they had a different supervisor for the case, and 75 percent believed that a candidate who asked to switch supervisors would be labeled problematic. In contrast, over 75 percent of supervisors reported that switching supervisors carries no stigma. In a follow-up study conducted one year later, many candidates reported that they feared reprisals for switching, and some reported that their training analysts advised against "rocking the boat." Candidates felt that participating in the study emboldened them to think more openly about supervision and in some cases to make changes.     

How do we evaluate learning from the curriculum? Thirty phone interviews with Institutes of the American Psychoanalytic Association

A telephone survey of curriculum directors of the thirty institutes of the American Psychoanalytic Association revealed that 75 percent of institutes highly value the importance of evaluating what candidates learn from the curriculum. Paradoxically, however, most institutes do not do evaluations in this area. Typically, institutes evaluate candidates' satisfaction with courses, or their attendance and conduct in classes, rather than learning per se. Some institutes have more rigorous evaluation methods, including oral exams. Objections to evaluating what candidates learn included (1) evaluations involve too much work; (2) evaluations of learning are considered inappropriate or invalid; (3) evaluations would hurt candidates, faculty, the learning process, and the institute. Some curriculum directors dismissed these objections, contending that it is the responsibility of psychoanalytic educators to set teaching goals and evaluate learning.     

A national survey of candidates: I. demographics, practice patterns, and satisfaction with training

To better focus efforts in recruiting psychoanalytic candidates, current candidates' demographics, practice patterns, and satisfaction with psychoanalytic training were investigated. An anonymous web-based survey was distributed by e-mail to all candidates subscribing to the affiliate member e-mail list in 2009-2010. Surveys were completed by 226 of 565 affiliate members, for a return rate of 40%. The majority of respondents were women 45 to 64 years of age, married, with a doctoral degree, in private practice, with an annual household income of over $100,000. Most candidates devoted 11 to 30 hours a week to training and had no analysts or candidates in their workplace. Almost half had considered training for more than four years before matriculation, with financial issues cited most frequently as delaying entry. Over 80% of respondents were satisfied with their training. The most frequently cited reasons for dissatisfaction were a negative institute atmosphere, concerns about teaching or the curriculum, and difficulty finding cases. Candidates in training for eight years or more accounted for almost 20% of the group and were more often dissatisfied with training. This study demonstrates that the majority of current candidates are satisfied with training but suggests that recruitment may become increasingly difficult unless factors related to time, cost, case finding, graduation requirements, and institute atmosphere can be addressed.     

Like a phoenix from the ashes – or “sack cloth and ashes”?:1 The reconstitution of psychoanalytic institutions in Germany since 1945 and its consequences

Abstract

Here, I attempt to formulate some thoughts about the past, present, and future of psychoanalysis and its institutions in Germany. To do this, I have employed my varied experience as a supervisor and consultant to many such psychoanalytic institutes over the past several years. Themes discussed include the history of psychoanalysis in postwar Germany, the organizational structure of German psychoanalytic institutes, and their cultures in regard to group and organizational dynamics, and political and economic aspects. Finally, I add brief thoughts about the future, taking into account recent developments relating to planned changes in laws governing psychotherapy in Germany. Further, I attempt to analyze and comment on: coming to terms with the past; how to begin after the “Zero Hour”; the form of organization of psychoanalytic institutes in Germany; missing patients and missing candidates; constructive debate and hurting people’s feelings; the lack of “detoxification” and “recycling” of the poisonous remains of psychoanalytic processes; and the future of psychoanalytic institutions in Germany. I end with an example of a typical primary task used in conducting large groups in the institutes in which I worked, and include an anonymized table listing individual interventions, their duration, and frequency. These should provide an idea of my way of working, and an overview of the dimensions of the task.     

Losing a training analyst for ethical violations: A candidate's perspective

The author presents her experience as the analysand of a training analyst who was investigated and expelled for ethical violations with another patient, including sexual-boundary violations, during her analytic training. While boundary violations by training analysts are not uncommon, the particular trauma experienced by 'bystanders' such as candidates and supervisees is not discussed in the literature, nor the response of institutes to the educational problems that are generated. The author illustrates the complications for candidates that arise from the dual roles of training analyst as educator and analyst when he or she faces investigation or censure, including isolation and secrecy, which promote various splits in the candidate, analytic dyad and group, as well as loyalty conflicts. The discussion covers three phases of the author's experience as a candidate-analysand, namely the period encompassing the institute's ethics investigation, the announcement of findings to her and to the institute as a group, and the ensuing individual and group dynamics generated by her analyst's expulsion from the institute and revocation of his medical license. Theoretical perspectives are utilized to understand the group regression, including contamination and contagion fears, which occurred in the wake of the training analyst's expulsion, and the impact of these processes on the candidate, including the pressure to function as a 'container' for projections of the group. Implications and recommendations for candidates and institutes are made for dealing helpfully with trainees who are affected by the process of dealing with a training analyst's ethical violations. Short-term and longer-term outcomes of the experience are considered.     

The capacity to be an analyst: A contribution from attachment research to the study of candidate selection

In this paper the author discusses how the study of candidate selection, once a topic of vibrant research, has unfortunately languished. Certain qualities were thought to characterize the successful candidate. However, they were never successfully operationalized nor empirically tested. Possibly because of this lack of empirical data, selectors today have difficulty articulating their criteria and are relying on intuition. In order to provide a more rational basis for contemporary selection, the author looks to the attachment literature. This makes sense because attachment theory shares some basic assumptions of contemporary psychoanalysis. The Adult Attachment Interview (AAI) is a research tool that predicts the ability of a parent to convey attachment security. It is scored by attending to how a person speaks about his early attachment experiences. The AAI appears to tap into similar qualities to those selection researchers have sought in their candidates. Further, the scoring method of the AAI appears to be similar to the last attempt by selection researchers to operationalize them. Given these similarities, the author recommends an empirical study using the AAI to operationalize these qualities in analytic candidates. The study would test their importance for success in the training program, thus offering selectors some empirical grounding for their choices.     

The impact of graduation from psychoanalytic training

To examine candidates' experience of graduation from psychoanalytic training, 1997-2001 graduates of the Columbia University Center for Psychoanalytic Training and Research were sent a confidential questionnaire about their first year after analytic training. Of this group, 72 percent (23/32) returned the survey. Questions focused on the impact of graduation on time availability, net income, professional advancement, and sense of personal and professional autonomy. Graduates from analytic training were found to have more income in their first postgraduate year, a mean increase of 30,000 dollars, and more available time, a mean increase of sixteen hours. Increased earnings came primarily from seeing more patients during the time made available with the end of classes. In addition, graduates did not terminate their control cases or stop supervision. Graduates most valued their sense of professional accomplishment and ability to spend more time with their families. Although graduates also experienced relief from evaluation pressure, they did not rank this high in importance. For candidates, graduation profoundly impacts the structure of professional and personal life, but does not mean an end to learning.     

Psychoanalytic training experience and postgraduate professional development – Part II

This exploratory study looks at the training and postgraduate experience of the 2008–2014 graduates of the Chicago Institute for Psychoanalysis. It follows our former study of all living graduates through the year 2007 (Schneider et al., 2014). The survey developed and used in the first study, with a few additional questions added to increase our understanding of the training experience, was sent to 38 graduates with a return rate of 58%. As with the first survey, graduates were invited to assess, among other training experiences, their training analysis, classroom work, and supervision, and to tell of their post‐graduation involvement in teaching, supervising, study groups and other professional endeavors. They were also asked to rate their satisfaction with themselves as psychoanalysts and with their analytic career. The questions added to the previous survey related to the graduates’ theoretical orientation, the influence on their training experiences of the change in gender distribution, and of the diversity of professions now represented in the analytic training program. They were also encouraged to provide spontaneous narrative data. The data from our second survey showed important differences when compared with our first. In the first survey male respondents were in the majority; in the second, women held the majority. Of the professions represented in the training program, psychiatry was the majority in the first survey, psychology and social work held the majority in the second. Most respondents claimed an object‐relation theoretical orientation. Analytic immersion continues to decrease, with most respondents having two patients at the time of graduation and one at the time of the survey.     

Authors who have an impact on candidates' training

The authors consider the influence that a sense of geographical and cultural ties of candidates from different regions has on their theoretical interests. They question the way that this is taken into consideration in psychoanalytic training. The function of theory, both in terms of its transmission and the creation of new knowledge, is explored from this perspective. The results of an Internet survey are presented. The candidate sample for this survey (N = 250) was drawn from Europe, Latin America and North America, and candidates were asked to indicate their degree of interest for each of the 55 authors in a given list. The results showed that there were significant differences in the areas of theoretical interest of the candidates depending on the geographical region. Furthermore, what is also significant is how these differences in areas of theoretical interest were linked to those authors who had developed their work in the same geographical region as the candidates. These differences are shown to be connected to the candidates' sense of regional belonging. Data are also presented about which authors have the greatest impact in a given region, along with the influence values of the authors in relation to each one of the regions. Finally, the candidates' interest in each of the authors is specified in terms of a general mean rank and a regional mean rank, thus showing which authors candidates find most interesting in each of the regions. The study concludes by arguing that the results of the investigation enable us to question how psychoanalytic theory is transmitted, and, more specifically, how it is transmitted within institutions at a regional level. It is also suggested that the means be found to uncover the inconsistencies linked to cultural ties. It is proposed that further research be conducted to look more deeply into how cultural differences play a part in the different theoretical languages in the training of psychoanalysts.     

: 2

In a national questionnaire survey of clinical psychology internship sites, the status of family therapy training was investigated. With a 65 per cent response rate (182 sites), the study found that 11 per cent of all psychology Ph.D.'s, 9 per cent of all M.S.W.'s and 2 per cent of all M.D.'s on internship faculties considered themselves to be primarily family therapy oriented. Nationwide, 39 per cent of 177 internships indicated that some family therapy training was a requirement of the program; for the remaining 61 per cent, family therapy training was either optional or unavailable entirely. Of the five areas of adult, child, group, and family therapy, and psychodiagnostics, interns were viewed by most programs as being least prepared at the start of the internship to do family therapy. In terms of internship training philosophy, family therapy was rated fourth in overall importance as an essential component of an intern's experience. The family training importance rating was found to be correlated positively with the number of family courses and seminars offered, family supervision received, and family clinical work performed.     

The design and evaluation of a worksharing system for experimental group living

Failure to share household chores equitably may be a major cause of the high failure rate of experimental group-living arrangements. A behavioral approach to worksharing based on a point system was implemented in one experimental group and its most important components experimentally evaluated. Experiment I showed that awarding credits produced more work than not awarding credits. Experiment II showed that making credits contingent on the outcome of a detailed inspection produced more work than awarding credits noncontingently. Experiment III demonstrated that awarding rent reductions contingent on credit earnings produced more work than awarding rent reductions noncontingently. Other evaluative data suggest that the resulting living arrangement is cheaper, more effective, and more satisfactory to the residents when compared to the most popular alternative living arrangements.     

Psychoanalysis in the university: A full‐time vision1

Psychoanalysis may be unique among scholarly disciplines and professions in having grown as an educational enterprise in a private part‐time setting, outside the university. Freud would have liked it to be otherwise, but in Central Europe, when it was created, university placement was not possible. In America, after World War II, the concept of the medical school department of psychiatry psychoanalytic institute was established in some psychoanalytic training centers but it could only partly overcome the educational and research inadequacies of traditional psychoanalytic training. The possibilities for a true university‐based full‐time training structure are explored.     

Individual Accountability in Cooperative Learning Groups at the College Level: Differential Effects on High,Average, and Low Exam Performers

Over a three-semester period in a large undergraduate human development course, students were assigned to 5–7 member groups to work together in preparing for an exam in one of the five content units in the course. Their exam performance was tracked over three units: a baseline unit in which students worked only individually, a unit in which they worked in cooperative teams, and a follow-up unit in which the formal cooperative team structure was removed. Three different bonus-credit contingencies were used in the cooperative learning unit across the three semesters: (a) awarding full bonus credit to each individual in the group if the group as a whole improved its exam performance by the specified amount, (b) awarding partial bonus credit to each individual in the group if the group as a whole improved it exam performance by the specified amount and full bonus credit to each individual who also improved by the specified amount, and (c) awarding full bonus credit to an individual in the group if both the group and the individual improved exam performance by the specified amount. The three contingencies produced somewhat similar patterns of change for low and average performers, but the high performers fared better under the last two contingencies than under the group-only contingency.     

Seeking an Analytic Identity

Abstract

Rothstein has stimulated all analysts to rethink how we can better commit ourselves to our analytic work. In this paper I focus on factors in analysts' personalities and experiences in their training and practice that contribute to or distract from establishing an analytic identity.

First, I explore analysts' background and motivation. In admissions to psychoanalytic institutes we look for candidates who can see psychoanalysis as an intellectual puzzle to be solved and an emotional involvement to be experienced. We look for earlv conflicts that the candidate can sublimate in the service of analytic functioning. We assume that the capacity to sublimate is only partial and that analysts in their development continue to recognize conflicts in transference—countertransference reactions.

Second, I give some examples of experiences from analysts' training that stimulate the formation of their analytic identities. These include transient identifications and counter-identifications with the training analyst, supervisor, seminar leader, and favorite analytic authors.

Third, I discuss more external factors that influence the development of analytic identity. These include the climate in training and continuing education at the institute. How much does the institute support its members in immersion in psychoanalysis? Economic factors continue to he an important factor in determining individual choice in this immersion.

Finally, I review studies on the effectiveness of psychoanalysis. Dedicated analysts with considerable experience believe that analysis works despite some limitations. Part of high motivation to continue analytic work includes understanding how analytic results differ from the simpler solutions achieved by nonanalytic therapies.     

Understanding Hope. Persons in the Process of Dying

Changes both within the profession of psychoanalysis and in society as a whole have affected our psychoanalytic training programs and presented new ethical challenges. Whereas in earlier decades training programs needed to be concerned primarily about the inviolability of the training analysis and the choice of appropriate analytic candidates, today there is little support for psychoanalysis as a treatment modality. Institutes are experiencing greater competition in attracting quality candidates and in providing them with adequate training experiences. This strain encourages institutes to operate in unethical ways to attract candidates. On the other hand, within the profession itself we are experiencing much theoretical ferment and the increasing feminization of the profession. These changes are affecting our training institutes and our ethical values in both positive and negative ways.     

Training analysis in the dutch society for psychoanalytic psychotherapy: A survey of attitudes and feasibility

SUMMARY

As is the case in many training courses in psychoanalytic psychotherapy, one of the training requirements of the Dutch Society for Psychoanalytical Psychotherapy (NVPP) is a training analysis, currently a minimum duration of 700 hours. During the last few years, this requirement has become somewhat controversial. Because the NVPP does not have information about the current interest in NVPP membership, the Board of the NVPP decided to do a survey. Of 995 psychiatrists, clinical psychologists and psychotherapists, who had recently completed their training, or were still in training, 623 filled in a questionnaire. Of those who are interested in the NVPP training, 39 per cent judged the training analysis as not feasible in terms of time, and 61 per cent in terms of money. Forms of personal treatment thought desirable for anyone who wishes to become a psychoanalytic psychotherapist at a specialist level are, in descending order, psychoanalytic psychotherapy (63%), psychoanalysis (39%), psychoanalytic group psychotherapy (25%), and psychoanalytic marital or family therapy (6%). Respondents who judge personal analysis as not feasible, also tend to judge psychoanalysis to be equivalent to other forms of psychoanalytic psychotherapy, whereas those who judge personal analysis as feasible, tend to think that personal analysis is essential for a psychoanalytic psychotherapist at the specialist level.     

Candidates’ Responses to Sexual Boundary Violations

This paper addresses the subtle and not-so-subtle power that sexual boundary violations have on the candidates within psychoanalytic institutes. The unspoken leaves things shrouded in secrecy, generating powerful feelings in candidates. Multiple psychological responses, including splitting, envy, and paranoia, along with reactions that range from the sanctimonious to the apathetic, are explored. I address how elusive boundary violations can be and the multiple forms they can take (physical/sexual and nonsexual). I examine some of the reasons for a resulting generalized passivity in both faculty and candidates, including the evocation of early conflicts centered on primal scene and oedipal anxieties and reflect on the ongoing difficulties of finding a personal voice as a candidate.     

Themen der Ausbildungsforschung in der Psychotherapie

This review is based upon an appraisal of training research in psychotherapy showing that many questions are still unanswered. By means of a schema for the organization of research results that differentiates input, process and output variables, unselected results are summarized relating to issues such as the choice of the psychotherapeutic profession, pre-experiences of candidates, the selection of an orientation, personality factors, characteristics of training institutes, quality standards, as well as the organisation and structure of training programs. Process oriented studies mainly focus on the operationalisation and development of skills, the significance, the effects of and the satisfaction with training components. Finally, the output category comprises results related to graduation, to professional development during and following training and to the development of competence and its prediction.