A Perspectus on the Narrowing Scope of Psychoanalysis ©
The Perspectus of the Academy gives an accounting of the philosophical, historical and theoretical context within which the Academy emerged.
Table of Contents
- Vision, Project. and Conceptual Foundations of the Academy
Industrialization of the Health Care Professions
- The Industrial Age of the Modern Era: An Historical Context and Tradition
- Psychoanalysis as a Health Care Profession
- The Decade of the Brain
- Redefinition of Professional Standards and "The Narrowing Scope of Psychoanalysis
- Psychoanalytic Practitioner: From Professional to Craftsperson
- Psychoanalysis: A Profession and Practice at Risk
- Psychoanalytic Attitude and Responsibilities
- Essential Questions Posed
- The Information Age of the Postmodern Era
The Academy for the Study of the Psychoanalytic Arts (CD): "The Decade of the Mind"
The Academy for the Study of the Psychoanalytic Arts
Vision, Project, and Conceptual Foundations of the Academy:
Since its beginnings in the early '80's, the Michigan Society for Psychoanalytic Psychology (MSPP), the Michigan chapter of Division 39, has provided a philosophical and professional home for those in Michigan interested in psychoanalytic psychology. In the mid '90's, the MSPP has provided the opportunity through the formation of a new section to begin to develop an alternate conceptual and philosophical home for psychoanalysis and psychoanalytic psychotherapy, one suggested in the observation made in 1927 that "Psychoanalysis falls under the head of psychology; not of medical psychology in the old sense, nor of psychology of morbid processes, but simply of psychology." (italics added) (Freud, 1927).
The Academy for the Study of the Psychoanalytic Arts was founded as a section of the Michigan Society for Psychoanalytic Psychology (MSPP) in January of 1995. A group of five members of the MSPP formed this new section in response to the industrialization and commercialization of the health care professions. The Academy 's organizing interest and defining project is to be found in the reconsideration, reexamination, and rethinking of the philosophical-theoretical underpinnings of psychoanalysis within a contextual metaphor other than that of health care and from within a psychological understanding of the human condition more closely allied with philosophy, the humanities, and the arts than with biology and medicine. The project of the Academy is to extend the understanding of psychoanalysis beyond existing conceptual boundaries. Thus, this new section was formed within MSPP to represent this particular interest in psychoanalysis, to provide a place and space for the like-minded in their pursuit of this scholarly project of rethinking psychoanalysis, and to collectively and vigorously advance this understanding of psychoanalysis in the marketplace of ideas in the professional, lay and academic communities, an activity the Academy considers to be central and foundational. The Academy is dedicated to the spirit of psychoanalysis and the tradition of psychoanalytic inquiry as is suggested in Freud's observation of 1927.
The Academy retained legal counsel to advise and assist in the development of its by-laws. The attorney was well versed in law as it pertained to novelists, musicians, poets, and thespians; and, law as it impacted and defined the mental health professions. From January until April the founding members met to develop the by-laws of the academy. Working closely with the academy's legal counsel, by-laws were developed that incorporated the vision, the project, the philosophy, and the purpose of the Academy. The following has been excerpted from the Preamble of the Academy's by-laws and speaks to:
... the vision, conceptual foundations, purpose, and project of the academy
"This Section of the MSPP is committed to the study of the psychoanalytic arts. Within the thematic context of "The Decade of the Mind," the section has been formed to undertake the long term project of a "rethinking of psychoanalysis": to develop further understandings of psychoanalysis as theory, practice, research, and education from within a psychological framework that is allied with philosophy, the arts, and the anthropic sciences; to present to the academic, professional, and lay communities this expanded definition and further elaboration of a philosophical-psychical way of understanding and working with people; and, to develop programs for the study of the many modern and postmodern versions and visions of psychoanalysis that proceed from contextualized metaphors other than health care... e.g., narrative story, semiotics, amsufism, and psychic theatre."
and, from the Definitional Section of the by-laws, the understanding of the academy of...
"The meanings of such terms as "psychology," "psychological," and "practice" as used in these by-laws are intended to be as defined from within the framework of the anthropic sciences. While aware that others have used these terms to refer to specific meanings that derive from the biological sciences and/or a medicalized contextual metaphor, it is not the intent of the Academy to subsume the meaning of such terms as "psychology," "psychological," and "practice" as they are defined under current laws, legislation, and licensing acts as written for and as applicable to health care professionals.
The Academy subscribes to the definition of psychology as the study and understanding of the human psyche within the anthropic context. Practice of the psychoanalytic arts is defined as the means by which such study occurs and through which such understanding and knowing is achieved. Further, the practice of the psychoanalytic arts is for the express purpose of such understanding and knowing. Psychoanalysis is synonymous with psychology as thus defined."
Whereas the formation of the academy had been brought about by a reactive response to the industrialization and commercialization of the health care professions, the project of the academy was to proceed by proactive design and through the presentation of its project of rethinking psychoanalysis in the marketplace of ideas. In February of 1995, "The Narrowing Scope of Psychoanalysis" announced the formation of the Academy within the MSPP, articulated this foundational philosophy, purpose, vision, and project of the academy, and extended an invitation to colleagues to join with like-minded others in its project and effort. (MSPP News , Feb., 1995) This same article was to be later published in the Psychologist-Psychoanalyst,(Nov-Dec. 1995 vol.5, no. 1). The interest expressed from like-minded colleagues within Michigan and throughout the country has been quite steady and impressive.
The Industrial Age of the Modern Era:
An Historical Context and Tradition
In the history of people and of ideas, it is possible to discern at least three "Ages" in which civilization was organized in a manner characteristic of each Age. In the first Age, the Agricultural Age, civilization was organized around the requirements and tempos of agriculture with the rhythyms of the earth and other quasi-mystical explanations inherent in religion, magic, superstition, and folk wisdom coming to constitute the body of knowledge for that Age. In the second Age, the Modern Age, civilization was organized around the Enlightenment; and, in the accompanying emergence from the Middle Ages emphasis was placed upon rationality and Newtonian based science, method, and explanation. Within this schema of historification, the Industrial Age of the Modern Era is believed to have had its beginnings sometime in the early 1700's with civilization organized around the characteristic and inexorable trend toward the industrialization of the westernized cultures. Within the past quarter of a century, a third Age has made its rather unexpected appearance: The Postmodern Age. A new era has been emerging in which a conceptual revolution has been taking place within the westernized cultures as profound and as far reaching as that which took place between the Agricultural Age and the Industrial Age of the Modern Era. The Information Age of the Postmodern Era has made its disturbing and disquieting presence known. Its discourse speaks loudly to a questioning and unrelenting interrogation of the unquestioned and presumed realities of the so called Truth of the Modern Era. The current upheaval in the episteme of the westernized cultures signals the emergence of a new cultural epoch and provides an overarching historical and cultural context for considering the Narrowing Scope of Psychoanalysis.
The interweave between the epistemological field and the cultural ideology of the Agricultural Age had provided certain fixed, foundational, and enduring "rules" for the political, social, and institutional structures of the Agrarian cultures and had come to be the reality and the "natural order" of things, e.g. the "What Is" during that period of time. These rules had provided for the Agrarian cultures the discursive rationality for that which had come to constitute "knowledge", "perception", "goodness", "beauty", and "truth" during that particular cultural epoch. These rules could be understood to be the fundamental codes of the culture, the instrumentalities of the culture that provided sanctioned and authorized ways of perceiving, thinking, and knowing. It was these very "rules", -these fundamental codes of the culture-, these ways of perceiving, thinking, and knowing, that were being requestioned, reconsidered, and reconceptualized by such marginalized, radicalized, and, indeed, heretical of thinkers as, for example, Darwin in biology, Newton in science and physics, and Freud in the psychological analysis of mental life. Such conceptual revolutionaries were questioning the then traditional ways of knowing, perceiving and thinking that had gradually developed over a 750 year period of time and had come to constitute science and art during the Agricultural Age. It was to be the relentless pursuit of, perhaps, that most dangerous of all questions, the "Why?" of the "What is?" that was to lead to a continuous questioning and challenging of the then well-established and authoritative sources, forms, and bodies of knowledge and of the then unquestioned "truth" of the times: the church, divine revelation, and dogma.
It would be misleading, however, to isolate and to narrowly locate this conceptual revolution of the Industrial Age to Newton , Darwin , and Freud. The breadth and scope of this re-questioning and the subsequent re-conceptualizations extended far beyond the natural and biological sciences. This was to prove to be the emergence of the Industrial Age of the Modern Era: the Age of science and technology; the Age of quantification and objectivization. This was to become the Age of mass production, mass distribution, and mass consumption. It was to be the Age in which the assembly line of the factory and the component parts of complex machinery were to serve as the mental model for the ordering and thinking about people and events. And, the Age in which "the producer" and "the consumer" were to become the hyphenated basic unit of society. The Industrial Age was to witness the introduction of revolutionary and radicalized changes at every level and strata of society with new, different, and special institutions to be developed for mass communications and mass education as the land based society of the agrarian cultures underwent mythic transformations into the urban based society of the 20th century.
As the obsolete structures and encrusted institutions of the Agricultural Age gave way to these new, different, and specialized institutions of the Industrial Age, certain descriptive and defining principles were to come to define the formation, framework, and function of these Newtonian based institutions of the Industrial Age. A. Toffler describes a set of six interrelated and organizing principles that were to permeate the institutional structures of the Industrial Age and that were to eventually impact the everyday life of each individual in the westernized cultures. (The Third Wave, 1990). These principles were to provide for the organizational structure and framework of institutions and were to prescribe their specific functions: (1) the assembly line of the factory was to become the basic model to be adopted and implemented by organizations; this model for factory line assembly proceeded from the understanding that the whole is the sum of its parts; (2) standardization of methods and procedures involved in production were to be developed and applied to the end-product; standardization was to be measured by some set of objective standards; conformity and compliance with these standards were to ensure uniformity and quality in the finished product; (3) synchronization wherein which activities and productivity were to become organized around linearized clock time and measured by such factors as cost efficiency, objectively defined activities, and predictability and uniformity of outcome; unquestioned philosophic underpinnings of linearized time and space were to provide for these quantifiable and objectivized standards; (4) uniformity of policies and procedures in the assembly line production of the product were to be developed and implemented; (5) centralization of information and authority/power in the overall system of decision-making pertaining to the design and production of the finished product. This centralization of information, authority, and decision-making power was to be located within hierarchically organized, vertically arranged Newtonian based institutions. These interrelated principles/characteristics came together in the establishment of a bureaucracy. This set of institutional and organizational characteristics were to determine and standardize the mass production of everything from automobiles and the preparation of fast food to the preparation and mass production of graduates from educational institutions.
The episteme of the Industrial Age proceeded from within a philosophic tradition of objectivism in which reality was dichotomized into an outer reality and inner experiences with outer reality considered to be the center of this conceptually created universe. "Outer reality" consisted of an objectively existing and mind-independent world with the basic "units of reality" being located in solid objects. Objective reality was self-evident and was to be found in solid matter with each object occupying its own sharply demarcated place in space and time. This "world" was understood to be a world that had an essential state. In its essence, it was both objective and it was knowable. The "world" of the Industrial Age, however, was more than just "objective and knowable". This world was a Cartesian-Newtonian world, a world based upon a particular way of thinking about institutions, people, and life.
The Cartesian view of the world was that of a complex machine made up of separate and interlocking parts. From self-evident solid objects of matter that comprised "reality" and from certain self-evident principles regarding the nature of the world, one could proceed to search for the universal laws by which this complex machine functioned. A unification of all knowledge regarding the universe and people was not only possible, it was to be the goal of science. A Cartesian certainty of knowledge about the world was possible only through science and through the application of the scientific method. It was this view of "reality", the "world", and of people as complex machines that was to be developed during the 17th, 18th, and 19th centuries. This Cartesian-Newtonian based view of the world was to conceptually fragment people and their needs which was to be both the "cause" and the further "effect" of industrialization. This conceptual fragmentation gave rise to the sixth of Toffler's characteristics: (6) various specializations and the professionalizations of esoteric bodies of knowledge to meet the needs of people in the Industrial Age, e.g. medicine, law, science, engineering, and psychology. Within each profession, further specialization was to further fragment the understanding of people and was to foster further the illusion and belief that the whole could be understood from the sum of its parts.
In the history of people and of ideas, psychoanalysis had its earliest of beginnings within this socio-cultural context of the Industrial Age of the Modern Era. Psychoanalysis has been a child of the Westernized cultures; psychoanalytic education has been a product of its times. As a child of the Westernized cultures, psychoanalysis was born out of the then emergent and revolutionary epistemological field of the culture of the Industrial Age. As a child of its times, the classical version of psychoanalytic theory and technique was born from the objectivist philosophical presuppositions of the Industrial Age and this Cartesian- Newtonian based view of the world, of people, of life, and of science. As a product of its times, psychoanalytic education was to adopt the institutional structure, to embody the educational philosophy, and was to proceed from that view of people and of the world which was to most characterize the world view of the Industrial Age. This Cartesian-Newtonian way of thinking was to provide the epistemological assumptions, premise, core values, and context for the development of classical psychoanalysis as theory, as practice, and as education. Psychoanalysis was to become a specialized body of knowledge and, some would maintain, a profession unto itself.
Indeed, the conceptual revolution taking place in the latter part of the 19th century was to extend far beyond the individual contributions of Newton , Darwin , and Freud. There was to be a fundamental "change in the rules" in the very epistemological field of the westernized cultures. This change was to signal the entry of the westernized cultures into the Industrial Age of the Modern Era. A new set of "rules" were emerging which were to provide a radically different discursive rationality for that which was to constitute "reality", "perception", "goodness", "beauty", and "truth" during the then emergent Industrial Age of the Modern Era. The "What is" of the Modern Era was being discovered, the "Why" of that "What Is" was being developed and established from within the Western Rationalistic Tradition and guided by new systems of values, beliefs, and logic: the Age of Enlightenment/The Age of Reason.
It is from within this socio-philosophical context and westernized-historical tradition of industrialization that the current "Industrialization of the Health Care Professions" takes on very specific meanings for the psychologist-psychoanalyst and quite far reaching significance for psychoanalysis as theory, as practice, and as education.
Psychoanalysis As A Health Care Profession
The history of the conceptual development, the education and training, and the practice of psychoanalysis in this country has been closely interwoven with medical concepts and practices and has been entwined with the history of the development of the health care professions. Over the years this close identification of psychology and psychoanalysis with the health care professions has led to the rather wholesale adoption and transposition of certain medical concepts and ways of thinking, values, and attitudes towards issues and processes which are uniquely and distinctly psychological. In this country, the prevalent contextualizing metaphor in psychoanalytic theory and practice has been that of mental health, diagnostic classification, and mental disease. Mental phenomenon and process has been conceptualized, understood, and taught from within the largely unexamined conceptual framework of symptomatology-etiology-pathology. Differences between people have become medicalized, pathologized, and biologized. Proceeding from the largely unquestioned premise that psychoanalysis is a health care profession or specialty thereof, recent debates in the psychoanalytic community have centered for the most part upon what constitutes treatment, cure, and curative factors from the perspective of each of the various psychologies of psychoanalysis of the modern era, i.e., Drive, Ego, Object, and Self. Largely unquestioned medicalized conceptual models and unexamined ways of thinking have had a profound impact on the development of psychoanalyis as theory, as practice, and as education...... and, upon its identity as being a health care profession or a specialty thereof.
In many ways, the medicalized conceptual model of symptomatology-etiology-pathology has become the strongest conceptual weakness of contemporary psychoanalysis. This conceptual model of symptomatology-etiology-pathology has provided for the psychoanalytic educator and practitioner alike an explanatory model consisting of an hierarchical relationship between the elements. If one can know the three elements of the model, one can understand fully the multiple departures from the norm of the physical processes involved in any disease entity. This model has come to constitute a theoretical ideal of the diagnostic process. This model for the diagnosis and treatment for physical disease and illness has become the largely unquestioned model for the diagnosis and treatment of so called mental disease and illness. Symptoms in this model are conceptualized to be the result of some pathological process going on within the person, on the basis of which conceptualization, further examination is conducted to determine the nature of the pathology. As pathology is conceived to be causal to symptomatology, so too is etiology causal to pathology. This conceptual model for the diagnosis and treatment of physical disease has come to serve as the conceptual model for mental life. Idealized normative standards of development and of society have become embedded within the psychological theories of psychoanalysis of the modern era, e.g., Drive, Ego, Object, and Self. Departures from these idealized normative standards of development and society have come to be understood as disorders and disease entities, the consequence of failures in empathic attunement which have resulted in developmental anomalies, arrest, and structural defect. Symptoms are produced by some (psycho) pathological condition which, in turn, is itself the product of an etiological disease entity. Psychoanalysis of the modern era has come to be understood as the means by which members of a health care profession working within this disease model of symptomatology-etiology-pathology seek to repair these structural defects. The theoretically anticipated goals, objectives, and outcomes of psychoanalysis have been organized around these idealized versions of the developmental "ought to be's" of the individual.
Until relatively recently, the relationship between psychoanalysis and health care has been largely unquestioned by either organized psychology or organized psychoanalysis. Psychoanalysis had been vigorously advanced and represented by organized psychoanalysis as a health care profession or a specialty thereof. More specifically, the talking therapies of psychoanalysis and psychoanalytic psychotherapy had come to be defined and generally thought of as a health care profession. And, psychoanalytic psychology had come to be understood and functionally defined, de facto, as a medical psychology. Clinical psychology had become a psychology concerned with the further specification and elaboration of causative and/or correlative factors involved in human behavior through scientific research, the findings of which were understood and evaluated from within this medicalized conceptual framework of symptomatology-etiology-pathology and the medicalized contextual metaphor of disease-treatment-cure. It had long been customary for many psychoanalytic educators and practitioners alike to maintain the position that the traditional medicalized contextual metaphor of "disease-illness-cure" was to be understood as simply being a convenient, pre-structured and sometimes helpful way of thinking about the human condition. This historical relationship between psychoanalysis and healthcare, however, has become for many educators and practitioners an increasingly uneasy one and has resulted in a rather strained attitudinal posture. Something quite profound has happened.
The changing socio-political-economic times of this current cultural epoch as embodied in the health care reformation has reified this traditional and prominent contextualizing metaphor of "health" and "disease". For many legislators, professionals, regulatory and accrediting groups the reification of this contextual metaphor for psychoanalysis and psychoanalytic psychotherapy has made psychoanalysis subject to the maze of regulations reshaping and redefining the health care professions. Most importantly, perhaps, it has been the largely unquestioned conceptual model of symptomatology-etiology-pathology that has been presumptively foundational in the development of health care policies and in the design of health care delivery systems by the various governmental-legislative-regulatory bodies. As a health care profession, psychoanalysis has been subject to the ongoing Industrialization of the Health Care Professions and its systematic redefinition of professional standards.
Industrialization of the Health Care Professional
"The Decade of the Brain"
During the 1980's, the basic metaphysical position regarding the nature of people that guided research and clinical practice considered the ultimate nature of the human condition to be understood through biology, chemistry, and brain behavior relationships. During the decade of the '80's, the human condition became increasingly biologized, chemicalized, pathologized, and medicalized. In July of 1989, President Bush signed legislation, supported by the American Psychological Association (APA), declaring the 1990's to be "The Decade of the Brain". With a stroke of the presidential pen, behaviors considered to be abnormal were to be understood from within the medicalized conceptual framework of symptomatology-etiology-pathology. In July of 1990, the National Institute of Mental Health (NIMH) co-sponsored a two day symposium, the topic of which was "Frontiers in Neuroscience and Brain Research". At this symposium, the neurosciences were proclaimed to be the basic sciences of "mental illness" with the then current as well as the yet-to-be-discovered neuropharmaceuticals of the '90's declared to be the treatment of choice for these "disorders and diseases" of the brain. Behaviors were being conceptually (re)defined as "medical disease conditions" awaiting the "appropriate and necessary" medicine/treatments to be discovered and prescribed. The stage was being set for what was to become the juggernaut of the healthcare reformation of the '90s: The Industrialization of the Health Care Professions.
The Decade of the 90's has witnessed the emergence and rapid development of three identifiable and, for many psychoanalytic practitioners, disconcerting trends which have quite directly impinged upon psychoanalysis and psychoanalytic psychotherapy: (1) a bio-reductionistic-medicalized way of conceptualizing human behavior serving as the conceptual premise in the formulation of health care policy and in the design of health care delivery systems, (2) the adoption of the Managed Care Model for the delivery of such health care services, and (3) the ongoing industrialization and commercialization of the health care professions. Considered in combination, these trends have had a profound and, all too often, under-recognized impact on the professional status of psychologist-psychoanalysts; and, an underappreciated yet defining influence on psychoanalysis as theory, as practice, and as education. Considered in combination, these trends constitute unprecedented challenges to the professionalism and professional autonomy of the psychologist-psychoanalyst, irrespective of theoretical persuasion, e.g. Drive , Ego, Object, Self, area of interest and specialization, e.g. education, practice, and research, or the setting within which one practices, e.g. hospital, university, public sector, or private practice. Amongst other of the consequences of the health care reformation, there is the ongoing redefinition of various defining "standards of the profession" e.g. standards of care, standards of practice, ethical standards, and educational and training standards. The developing definitions of these new "standards" derive from the prominent underlying conceptualizations guiding the health care reformation and are being articulated and established through the maze of rules, regulations, and procedures being bureaucratically generated and encoded in various health care regulations, standards, and state Mental Health Codes that have already impacted quite directly upon each psychoanalytic practitioner. The standards of the health care model have been applied to psychoanalysis as theory, as practice, and as education.
The current industrialization and commercialization of psychology-psychoanalysis as a health care profession proceeds within the historical context and industrialized tradition of the westernized cultures. The Redefinition of Professional Standards, the regulatory schema to be found on the next page, provides a graphic illustration of institutional structures and processes already in place that are dramatically redefining these standards of the profession as more clearly being the standards of a health care profession. These standards include the standards of care and of practice, the standards for education and training, and the ethical standards of the profession. The establishment of institutional structures such as URAC, NCQA, the NCPP, and the BPA Task Force and its recently issued templates serves to centralize, standardize, and qualitize psychoanalysis as theory, practice, and education. Further, these institutional structures and processes are remarkably consistent with the characteristics and principles of industrialization as developed during the Industrial Age of the Modern Era. To further elaborate:
Centralization of Information, Authority, Decision Making Power:
The centralization of information, authority, and decision making power has located psychoanalysis within the matrix of the health care professions. And, this centralization is to be found most immediately within the overlapping structures of organized psychology and organized psychoanalysis, and in the proliferation of standard setting and bearing national committees.
The Practitioner Update published by the APA Practice Directorate, December, 1993 reported that the Directorate was actively endorsing and supporting the Health Security Act and was actively engaged in having clinical psychologists written into the act. In February, 1995, the Practitioner Focus reported that the strategic objective of the APA Practice Directorate was to maintain psychology's stake in American health care. And, as reported in the February, 1996 issue of the Practice Directorate's Practitioner Focus, the Practice Directorate's organizational focus during 1995 had been to address "...the need for better balance between cost containment and efforts to ensure quality services in the health care delivery system." Two of the APA's priority policy objective for the '90s reflective of this strategic objective, progress in obtaining prescription and hospital privileges, continue to be regularly updated for the practitioner. For example, the February, 1996 of the Practitioner Focus reports on the key victory for psychology in which Congress had extended the Psychopharmacology Demonstration Project (PDP) until 6/30/97 at which time Congress will consider making it permanent; and, at the state level, the March, 1996 News Bulletin of the Michigan Psychological Association (MPA) updates the MPA membership on the introduction of a Hospital Practice Bill in the Senate and the House.
This centralization of information, authority, and decision making power is to be found as well within the proliferation of a number of national committees/task forces, such as those reported in the December, 1993 issue of the Practitioner Update. These committees and task forces, e.g. URAC, NCQA, the NCPP, and the BPA Task Force, had been formed and charged with the responsibility of setting standards for the profession and practice of the psychologist-psychoanalyst. The establishment of these and other such structures proceeds from the largely unquestioned premise that the profession and the practice of psychology-psychoanalysis is a craft, that psychology-psychoanalysis is a health care profession, that psychologist-psychoanalysts comprise a "cottage industry" of loosely organized and minimally regulated craftspeople; and, that the next evolutionary step for the profession is to adapt to the health care systems being devised and to practice from within these systems.
And, another layering of this centralization of authority, and decision making power is to be found in the State Psychological Associations (SPAs): With the defeat of the Health Security Act of 1994 and the failure to accomplish health care reform through the passage of national legislation, the primary forum for the shaping of health care plans has moved to the state legislatures. Currently, health care reform is to be found in state legislative initiatives and state psychological associations have become major players in the shaping of these initiatives. Organized psychology and psychoanalysis have sought to establish or influence through their state psychological associations and local chapters, mental health parity bills, i.e. mental health benefits "in parity with" i.e. on the same basis as coverage for physical conditions, Patient Protection Acts, Points of Service, and Any Willing Provider Laws, and Hospital Privileges/Practice legislation for psychologists (-psychoanalysts). However, the framework of healthcare that presumes an integral relationship between healthcare and psychoanalysis remains unquestioned and unchallenged as health care policies are formulated, standards of practice are redefined, and revisions to state Mental Health Codes take place. The focus and effort of organized psychoanalysis has been to deal with "the managed care threat" through the education and lobbying of legislators, the providing of information to consumers, and the organization of various coalitions in the service of influencing and shaping these health care policies, plans, and delivery systems (Eagle, M., Psychologist-Psychoanalyst, Winter, 1966. vol.XVI, no. 1)
Specialization and Professionalization:
As reported in "A Legal Update on Provider Credentialing" (The Psychologists' Legal Update, June, 1995, no.7), provider-specific credentials are becoming the standard by which competency in specific areas of ability are measured: "Since 'quality' in health care has proven so difficult to advertise based on outcomes of care, those who assemble networks (of MCO'S, PPOS, and HMOs) usually resort to asserting quality based on the inputs i.e. the providers' credentials. (p.3) (italics added) This emerging trend of proficiency credentialing in designated areas of competence is taking place throughout the health care professions.
The following speaks to this increased emphasis on specialization, standards, and proficiency credentialing in organized psychology and organized psychoanalysis. In 1993, the Practitioner Update reported that the National College of Professional Psychology (NCPP) had been proposed as a new structure within the APA to provide guidelines for the education and credentialing of psychologists in "designated proficiency areas". In the February, 1996 issue of the Practitioner Focus, the NCPP announced the availability of its first certification: The Certificate of Proficiency in the Treatment of Alcohol and Other Psychoactive Substance Use Disorders. The increased specialization and credentialing in designated proficiency areas within the profession of psychology-psychoanalysis has kept pace with this larger industrializing trend in the health care professions. For example: The announcement of the rendering of diplomats status by the American Board of Psychoanalysis in Psychology (ABPsaP) in "ABPsaP and ABPP Begin to Diplomate Psychologists-Psychoanalysts" (Lane, R., Psychologist-Psychoanalyst, Spring, 1995); Division 39's Committee on Specialization and Accreditation of Psychoanalysis which has been working to achieve recognition for psychoanalysis as one of the first postdoctoral specialties in professional psychology; (Kaley, H., Psychoanalytic-Psychologist, Fall, 1995, vol.XV, no. 4) or, in the efforts of the Psychoanalytic Consortium which represents Division 39 on matters of national accreditation, state-level licensing and certification. The Psychoanalytic Consortium, representing itself as the collective and responsible voice for psychoanalysts, advances psychoanalysis as a function and specialty of health care professionals. In response to the Vermont State Legislature passing a psychoanalyst certification law, Division 39's representative called for the Psychoanalytic Consortium to be the militant standard bearer for well trained psychoanalysts with "well trained" being defined as trained and licensed as mental health professionals; and, being a mental health professional i.e. attainment of a professional degree in a field of mental health service, as being criteria to be included as training standards for defining a " national psychoanalytic association". (Calligor, L., The Psychoanalytic Consortium, The Psychologist-Psychoanalyst, Summer, 1995; Winter, 1996)
This increased emphasis on specialization and credentialing for the psychologist-psychoanalyst follows in the footsteps of the medicalized model of specialization, contributes to the further conceptual fragmentation of people, serves as both the "effect" and the further "cause" of industrialization......... and, as reported in the Legal Update, the expectation is that these credentialing requirements will increase. Credentialing in designated proficiency areas carries with it far reaching consequences for psychoanalytic practice and education. (see below)
Uniform Policies and Procedures, Synchronization, and Quality of Therapeutic Product:
Another report in the Practitioner Update of 1993, indicated the establishment of The Board of Professional Affairs Task Force (BPA) on Psychological Intervention Guidelines. The report states that this Task Force had been established as a reaction to federal and state government attempts to develop their own specific practice and treatment guidelines for designated conditions so that certain diagnostic categories would receive specific treatments. The BPA Task Force was charged with the responsibility of developing a template for the practitioner which were to meet certain "internal validity criteria", derived from clinical experience and based on research data. "External validity criteria" were to be based on cost factors, feasibility of treatment, and ease with which the practitioner can be trained in its application. The Task Force has recently published the "Template for Developing Guidelines: Interventions for Mental Disorders and Psychosocial Aspects of Physical Disorders" (1995). Effective psychotherapeutic techniques are specified for a specific diagnostic condition. These guidelines were approved by the APA Council of Representatives in February of 1995. These "suggested" guidelines carry far reaching consequences for psychoanalytic practice and education, the restrictive implications of which increasingly are being recognized and considered by members of the psychoanalytic community (Walls, G.B. & Scholom, A.H., Psychologist-Psychoanalyst, Winter, 1996; vol. XV], No. 1).
Uniform Policies and Procedures, Synchronization, and Quality of Educational Product:
As reported in the 1993 issue of the Practitioner Update, the guidelines developed by the BPA Task Force were intended to also serve as a template for graduate school programs of study in psychology: (1) training in evaluating appropriate procedures to be used, and (2) training in their application. Outcome based education, more standardized psychological education, and standardizing the competencies of new practitioners have been adopted by the APA as priority objectives. (APA Monitor, March, 1995; APA Education Directorate News, Summer, 1995) Outcome based psychotherapy, not surprisingly, has lead to outcome based education, psychoanalytic and otherwise. The Industrialization of the Health Care Professions has lead to the early stages of the Industrialization of Education........... as a part of the wave of the present. Such industrializing efforts in psychoanalytic practice and education tacitly advances and endorses the principle and practice of "Economic Credentialing" in which efforts are made to include only those who meet certain levels of "efficiency" in managing the costs of treatment.
Uniformity of Policy and Treatment Procedures and Methods:
The Register Report of 1993 describes the establishment of the Utilization Review and Accreditation Commission (URAC). URAC originated because of the rapid growth of managed care; was charged with the responsibility of developing uniform standards and ensuring quality in utilization review organizations and procedures; was to address problems of inappropriate and inefficient health procedures; was medically oriented and, as reported in the Register Report, was controlled by the American Medical Association (AMA). Medically appropriate and necessary utilization of services was to be established and determined from the conceptual framework of symptomatology, etiology, and pathology. URAC accreditation is currently being substituted for state certification in various states.
Synchronization and Quality Assurance of Therapeutic Product:
The Register Report of 1993 also described the formation of the National Committee for Quality Assurance (NCQA) which was charged with the responsibility of determining a core set of performance measures for greater standards in the Health Care Industry; was medically oriented and was controlled by the American Medical Association; and, which espoused the position that mental health could be evaluated adequately by NCQA standards even though the then current standards were not necessarily focused on mental health. The NCQA is currently operational and has become one of the recognized standard setting, bearing, and accrediting organizations for quality assurance in the Health Care Industry.
The Medicare Program had been already well established as a national health care system. It has established policies, procedures, practice guidelines, "audit flags" for deviation from regulations, and the principle that the guidelines cover all "medicare eligible" individuals, regardless of whether or not they are enrolled in the program. The program reserves to itself the determination of whether a procedure is medically "necessary and appropriate". With the recent deregulation of federal programs and the more active role being played by state psychological associations in designing health care plans, Medicare can serve as a model for the development of such health care plans and delivery systems; or, perhaps, an integrated health care delivery system for health care needs as is currently being designed by the APA Practice Directorate in conjunction with the Department of Defense to be implemented in the military health care system could provide such a model. (Practitoner Focus, APA Practice Directorate, Feb., 1996, vol.9, no.1)
In either case, the policies, procedures, practice and treatment guidelines currently being defined and implemented by these various national committees and state regulatory agencies are: (1) shaping and defining the ethical standards of the profession and the standards of practice and care for the psychologist-psychoanalyst in the near term, and (2) are setting the "standards of care" and the "standards of practice" which determine the health care professional's legal exposure and liability and form the legal basis for malpractice actions in the intermediate term. The Psychologist's Legal Update, December 1993, provides the following information: In a tort case the law compares the professional's conduct: (1) to the standards of the profession in general; and (2) especially to that of practitioners who are similarly trained and situated. Accuracy in diagnostic assessment and proficiency in the application of the appropriate treatment methods for the specified condition have become crucial factors in recent malpractice actions. The most common types of malpractice claims and those most likely to produce litigation are: Misdiagnosis; Practicing outside of one's area of competence; (italics added) Failure to obtain informed consent for treatment; Negligent or improper treatment; Physical contact or sexual relations with patients; Failure to prevent patients from harming themselves or others; Improper release of hospitalized patients; Failure to consult another practitioner or to refer a patient; Failure to supervise students or assistants; Abandonment of patients. The current trends in liability are: sexual involvement with patients continues to cause, directly or indirectly, the largest number of claims. The next largest category of recent cases are those challenging the propriety of a therapist's diagnosis and treatment methods. Negligent or improper diagnosis is a deviation from accepted standards of practice and standards of care.(italics added)
Considered in combination, the trends shaping the health care reformation of the '90s are setting the standards of care, of practice, of ethics, and of education and training. Large numbers of psychologist-psychoanalysts and a large percentage of psychoanalytic-psychological services continue to be incorporated into this highly bureaucratized system of service delivery in both the public and private sector. "Suggested" practice guidelines and current quality assurance measures eventually will become applicable to all practitioners as they are currently setting the recognized standards of the profession in general. As considered in the January, 1995 issue of the Register Report, projections as to that which is expected to constitute "quality", "integrity", "reliability", and "value" as the healthcare professions become more industrialized are based upon and derive from the definitions and standards as are currently being established. It will be these industrialized and industrializing standards that determine the psychologist-psychoanalyst's legal exposure and liability in future malpractice actions.
There are certain pragmatic consequences for the psychoanalytic practitioner and for the recipient of psychoanalytic-psychological services which derive from these current trends. Namely, limits are imposed upon the autonomy of the psychoanalytic practitioner and of the recipient to choose not to participate in the prevailing systems of health care delivery being developed. More importantly, limits are imposed upon the autonomy of the psychoanalytic practitioner and the recipient of psychoanalytic-psychological services to choose to not participate in the prevalent conceptual framework of symptomatology-etiology-pathology that prescribes the particular treatment plans that have been determined to be medically "appropriate and necessary" as prescribed by and reflected in various practice and treatment guidelines.
Narrowing Scope of Psychoanalysis
The industrialization of the health care professions currently has enveloped the psychologist-psychoanalyst and has come to define for the practitioner how to conceptualize and practice. In effect, the psychoanalytic practitioner has been enveloped and confined within a conceptual prison the bars of which are being constructed by these ongoing redefinitions of the standards of ethics, practice, and education. In this current cultural time and context of "Managed Economy", "Managed Trade", "Managed Competition", "Managed Quality", and "Managed Education", "Managed Health Care" has taken its place as one of the industries of the times. The managed care model of health care delivery has quickly led to the emergence of the Managed Behavioral Care Industry, as it is now known, with its stated objectives of "industrializing" the health care professions. Certain characteristics of industry and industrialization obtain, then, for the mental health professions functioning within such an industrialized milieu. Succinctly stated: standardized production methods are being developed wherein which patient-consumers are assigned to diagnostic categories based upon certain clusters of traits as determined by bureaucratically sanctioned and empirically generated evaluative procedures. Authorized and uniform treatment methods are to be applied according to empirically developed and prescribed practice and treatment guidelines. The overall objectives of the Managed Behavioral Care Industry are that of any other industry: to mass produce a competitive product at the lowest economic cost without compromising "quality". The industrialized and prescribed objectives for the psychologist-psychoanalyst: to see more individuals, less frequently, for shorter periods of time with the least allocation and expenditure of resources, i.e. time , money, and effort.
Colleagues have spoken to the incompatibility of the fundamental assumptions of managed care and psychodynamic psychotherapy (Barron, J., Psychologist-Psychoanalyst, Spring, 1994, vol.XIV, no.2), the subversion of psychoanalysis as a way of thinking by adapting to the managed care mentality, (Shore, K., Psychologist-Psychoanalyst, Spring, 1994, vol. XIV, no. 2), and have warned of the trends in managed care that threaten the legitimacy of long term psychotherapies (Shulman, M., Psychologist-Psychoanalyst, Spring, 1994, vol. XIV, no.2). Nonetheless, various governmental, professional, regulatory and other bureaucratic entities have continued to either create or participate in the illusion that they are possessed of the necessary knowledge, commitment, dedication, and skills to competently manage the otherwise unmanageable: people and the human condition. In the participation in this illusion lies the perpetuation of the belief. Many coalitions of individual professionals, consumers, and professional organizations have been formed and have worked in concert: to develop more enlightened and humane policies within the managed care system through the cultivation of influence of friendly state legislators, to refine managed care corporate policies through the chronicling of managed care horror stories, or to increase the number of sessions to be allotted per diagnostic condition through the appeal of empirical outcome studies presented to legislative-regulatory groups. Indeed, considerable time, money, and lobbying effort has been expended to preserve the values of psychology and psychoanalysis within this industrialized, standardized, and qualitized system of providing psychoanalytic-psychological services.
The position advanced by the Academy, however, is that managed care is not the issue. The industrialization and commercialization of the health care professions speaks to more than a particular system or model of health care delivery. Industrialization speaks to a Cartesian-Newtonian based way of thinking about people and life and proceeds from the episteme of the Industrial Age. Industrialization of health care speaks to a way of conceptualizing differences between people as being symptoms which, it is believed, have specific linearized developmental phase specific causes rooted in pathology; diagnostic procedures, appropriate treatment methods, and proficiency credentialing; medical reviews of what is "necessary and appropriate" treatment for the specified diagnostic condition; and, uniform procedures in education and treatment to ensure quality of the finished educational and therapeutic product. In representing itself as a health care profession, psychoanalysis is............... treated like a health care profession.
The Narrowing Scope of Psychoanalysis, the regulatory schema presented on the next page, provides a graphic illustration of the conceptual prison as is currently constructed for and by the psychologist-psychoanalyst as a health care professional. The psychologist-psychoanalyst has been captured and imprisoned in the image of themselves as health care professionals. He/she remains captive in the prison of their contextualizing and defining metaphors. Through the centralizations of information, authority, and decision making power, uniformity of policies that define quality in practice and education, templates that indicate appropriate treatments for specific diagnostic categories....... the scope of psychoanalysis narrows and psychoanalysis becomes a psychoanalysis of conformity and compliance: conforming to the health care standards that contextualize psychoanalytic practice and education and encourages people who seek consultation to conform to these standardized and expected outcomes.
The Academy staunchly maintains and vigorously advances the position that: psychoanalysis is not a health care profession or a specialty thereof; the "threat of managed care" is not the defining issue; the development of more enlightened or compassionate alternatives within the current health care delivery systems does not constitute "progress"; and, patient choice of provider and health plan is not the solution. While proceeding from the premise of disease and health might be quite appropriate for understanding and treating the physical diseases, the conceptual framework of symptomatology-etiology-pathology is quite inappropriate for understanding people, psychic functioning, and psychic reality. Succinctly stated in the affirmative: The Academy advances the position that psychoanalysis is a way of thinking, knowing, and presencing in the understanding of the human psyche within the context of the anthropic sciences. As such, psychoanalysis is understood to be a unique psychological discourse. Psychoanalysis as derived from philosophy and the arts is considered to be a poetic work of art in that it registers, monumentalizes, and attempts to speak to the subject's passage of time.
Psychoanalytic practitioners who would prefer to believe that as licensed health care professionals they can continue to conceptualize alternative understandings of mental phenomenon and proceed to theorize, practice, and teach according to these conceptualizations outside of the standards of this industrialized health care system appear to have not realized the full impact of the health care reformation. As health care providers, the psychologist-psychoanalyst has become subject to and subsumed by the proliferation of rules and regulations that are strangulating the profession and the practice of psychoanalysis and has profoundly impacted the practitioner's psychoanalytic attitude and therapeutic responsibilities.
Profession, Practice, and Psychoanalytic Attitude
The Psychologist-Psychoanalyst: From Professional to Craftsperson
This "Industrialization of the Profession" has had a profound and underappreciated impact on the professional status of each psychoanalytic practitioner. One of the most far reaching of the challenges posed to the psychologist-psychoanalyst’s professional status and autonomy by these trends is the functional redefinition of the profession of psychology-psychoanalysis as a craft in which therapists become interchangeable and diagnosis determines the prescribed treatment plan. Irrespective of one's area of specialization, theoretical allegiance, or the setting within which one practices, such policy formulations constitute a threat to professionalism, professional autonomy, and professional integrity.
Psychology-Psychoanalysis: A Profession At Risk
There is a major distinction to be made between a profession and a craft. A profession is a vocation in which some body of valid and reliable scientific knowledge, anthropic or otherwise, is developed and utilized in the service of discharging the functions of the profession. Historically, there has been a social contract entered into between members of a profession on the one hand and members of society on the other: the profession, for its part, holds itself accountable to the highest of ethical and professional standards. In return for its devotion to the values to hiwch it subscribes, society grants to the profession certain essential and defining rights and privileges including the right of self regulation, autonomy of function in pursuit of professional objectives, the right of discretionary judgement in the performance of professional activities, and the right of privacy in the best interests of those whom the profession serves. Entry into the profession of psychology-psychoanalysis brings with it certain well-defined expectations and responsibilities attendant to professional life as are embodies and as are to be found in the APA Ethics Code. Irrespective of the psychologist-psychoanalyst’s area of interest and specialization, theoretical school, or the setting within which one practices, federal and state policy formulations based upon industrialization, bioreductionism and a managed care model of service delivery constitute for the Administrator, Academician, and Practitioner, alike, a threat to professionalism, professional autonomy, and professional integrity.
As healthcare becomes more industrialized, professionals are no longer named as such, considered to be, or treated as "professionals". Most importantly, health care professionals are viewed as craftspersons rather than professionals. As stated earlier, this current trend towards the industrialization of the professions proceeds from the largely unquestioned premise that the profession and the practice of psychology-psychoanalysis is a craft; that psychologist-psychoanalysts comprise a "cottage industry" of loosely organized and minimally regulated craftspeople; and, the next evolutionary step for the profession is to adapt to the health care systems being devised and to practice from within these systems. With the increased industrialization of the profession and practice of psychology-psychoanalysis, there is a corresponding increase in bureaucratic regulation, development of practice and treatment guidelines for certain diagnostic classifications, and an intolerance within this bureaucratized milieu for the exercise of professional discretionary judgement by the psychologist-psychoanalyst. It is this discretionary judgment which is one of the central and defining characteristics of the profession of psychology-psychoanalysis and one of its greatest strengths. Bureaucratization in the form of regulation of professional activities, formularized treatment plans, and the implementation of the formulary becomes the institutionalized adversary of discretionary judgement. Thus, one of the most far reaching of the challenges posed to the psychologist-psychoanalyst's professional status and autonomy by these trends is the functional redefinition of the profession of psychology-psychoanalysis as a craft in which psychoanalytic practitioners become interchangeable and diagnosis determines the prescribed treatment plan.
Psychology-Psychoanalysis: A Practice At Risk:
There are certain pragmatic consequences for the practitioner and for the recipient of psychological services which also derive from these current trends. Namely, limits are imposed upon the autonomy of the practitioner and of the recipient to choose not to participate in either (1) the prevailing system of health care delivery; or, perhaps, more importantly (2) in the prevalent conceptual model of symptomatology, pathology, and etiology with its suggested treatment plans as pre-authorized, pre-sanctioned, and pre-scribed via practice and treatment guidelines. The type, frequency, duration, objectives of treatment and every other aspect of service as well as the fee arrangements for the psychological services are currently in various stages of being prescribed and regulated for both the practitioner (the producer) and the recipient (the consumer). With the practitioner viewed as craftsperson, certain far-reaching implications for clinical practice follow: (1) the practitioner is considered to be interchangeable with any other craftsperson who is equally well trained and has a demonstrated competency with particular treatment applications for certain diagnostic conditions, i.e. proficiency credentialing in designated areas; (2) the clinical relationship is neither recognized nor appreciated as a unique ingredient in the delivery of psychological services as uniform policies and procedures, practice and treatment guidelines, and outcome based evaluations take precedence; and, lastly, (3) within such a bureaucratized system, confidentiality is necessarily eroded and compromised as utilization reviews and quality assurance evaluations based on outcome measures necessitate the collection and centralization of information in the service of reviewing medical appropriateness and medical necessity and revising, refining, and fine tuning policies and procedures.
With the development of health care service delivery systems based upon cost management factors and the evaluation of such systems based upon cost effectiveness factors, the increasing industrialization of the profession has placed the psychologist-psychoanalyst squarely within a bureaucratic maze of procedure and regulation. Professional judgement is being replaced with the rather mechanical application of prescribed treatment plans based upon diagnostic classification. Thus, psychologist-psychoanalysts are expected to be laborers on the factory floor of the health care industry without independent judgement, concern for recipients, or freedom to function independently and in privacy. Increasingly, the psychologist-psychoanalyst is being required to participate in a health care system in which professional judgement and mutual decision making is removed from the provider and the recipient. In effect, the practitioner is being required to participate in the demise of the profession.
Psychoanalytic Attitude and Therapeutic Responsibilities
Certain characteristics of the psychologist-psychoanalyst as a craftsperson serves to institutionalize psychoanalytic attitude and industrialize therapeutic responsibilities. With the formal adoption of the structural deficit-disease model, the psychologist-psychoanalyst has moved ever closer to taking on the role in their mind of becoming an agent of society as contrasted with being agents of the individual and of the psychoanalysis. As a craftsperson and agent of society, the psychoanalytic practitioner takes on a number of therapeutic responsibilities having to do with their patients' actions, behaviors, and thinking. Standards of care and practice are assigned to the role of the psychologist-psychoanalyst as a health care provider and are prescribed as an integral part of the responsibilities applicable to all individuals who might seek consultation. They are particularly apparent in those instances where the individual is identified as "more regressed" or as "chronically mentally ill". These therapeutic responsibilities are organized around the idea that the therapist is first and foremost a representative of society in the psychoanalytic treatment and that the person, by virtue of seeking consultation and being identified as a patient, is not capable of making certain decisions for themselves. As such, one of the therapist's primary responsibilities is to organize the goals of treatment around the expectations of society as to what constitutes "normal" and "acceptable" behavior and thinking. The practitioner is there to monitor and to seek the patient's compliance and conformity with the requirements and standards that society holds out as being appropriate and acceptable in terms of how one thinks, feels, and behaves. Within this larger social milieu and industrialized context, the psychoanalytic practitioner is increasingly being held responsible to protect the patient and society from the patient's actions and behaviors. We currently see these responsibilities of the psychologist-psychoanalyst defined in the proliferation of legislatively enacted duties to warn, duties to inform, duties to report, and duties to protect. These various duties are being incorporated and encoded in the profession’s code of ethics.
From this bio-medicalized metaphysical position, one’s therapeutic responsibility also includes seeking the patient’s compliance and conformity in thinking with society’s standards of that which constitutes "normal thinking". Psychoanalysis and psychoanalytic psychotherapy then have as one of their primary objectives to achieve just such compliance with medication regimens and conformity with treatment objectives. Those very characteristics with which most individuals present when seeking treatment are characteristics which are philosophically unacceptable to society at large. This is particularly true with individuals for whom expressions of noncompliance and nonconformity in thought, action, and deed have become pathologized. The metaphor of the "disease" of social non-compliance has undergone a process of reification which has literalized the metaphor into a physical disease which now, it is believed, can be treated best and most cost-effectively with chemicals. To the list of the various "duties" which spring from this deficit-disease biochemical position, one can anticipate the "duty to hospitalize on an involuntary basis" and the "duty to medicate" emerging on the horizon in the not to distant future to join the other duties and responsibilities of the psychologist/psychoanalyst if the individual is not thinking or acting "normally".
With the adoption of this metaphysical position, the profession has gone far beyond being concerned with the functioning of the individual as an individual, and moves to the question: How well does that individual function and adapt to the acceptable standards of thought and action in society? From this metaphysical position, treatment then has as its purpose the perhaps gentle and tactful but nonetheless coercive and insistent attempt to engender the compliance of the individual with the standards and expectations of society. It attempts to promote: (1) a reliance upon and conformity with the norms of society, (2) a dependency upon the collective, and (3) an acceptance of one's proper place in society, which has been determined in advance by one's diagnosis and set forth in a treatment plan organized around the presumed behavioral and developmental "ought to be's" known in advance by the practitioner (producer) and to be acquired by the recipient (consumer).
Essential Questions To Be Addressed:
When the current trends, in effect, mandate that the treatment formulary to be implemented derives from a bio-reductionistic way of conceptualizing and treating human behavior, then there are several essential questions to be confronted by each psychologist-psychoanalyst: At what cost do we limit our collective response to that of adaptation to the redefinitions of our profession and practice by policymakers and legislative actions?; and, Is this the benefit or, the price of 'progress' in the Industrial Age of the modern era?
The Academy has answered these questions in the following way: Ultimately, it would be at great cost to the profession, to the practice, and to the recipients of psychoanalytic-psychological services to forgo a psychological way of understanding and working with people. Further, to limit our individual and collective effort(s) to a reflexive adaptation to policy and legislative redefinitions of the profession of psychology-psychoanalysis is to participate in the gradual dilution of professional functioning and responsibility, the erosion of a psychological-psychoanalytic way of understanding and working with people, and in the eventual demise of the profession of psychology-psychoanalysis...... The flame has been flickering.....
There is another essential question to be addressed: How come? Psychoanalysis is the quintessential immersion and involvement in the Psychical understanding of the individual. Yet, paradoxically, psychoanalysts are in the forefront of standardizing psychoanalytic education, theory, and practice; and, in so doing are defining and advancing psychoanalysis as a psychoanalysis of conformity and compliance. Advancing psychoanalysis as a health care profession has resulted in organized psychoanalysis actively participating in the industrialization of the profession while paradoxically decrying the deprofessionalization of the profession being brought about by the "Industrialization of the Health Care Professions". The question remains: How come?
Certainly, uncertainty is a major factor to be considered in addressing the question of "How come?". Inherent in the psychoanalytic endeavor is the certainty of uncertainty and the importance of the practitioner becoming comfortable with this uncomfortableness. Certainly the stresses and uncertainty in the psychoanalytic endeavor could contribute to the recent increased emphasis by organized psychoanalysis upon training standards, outcome measures, and credentialing in designated proficiency areas. However, there would appear to be other and more significant sources contributing to the uncertainty within organized psychology and organized psychoanalysis. In recent years, there has been a profound kind of uncertainty arising from within both psychoanalysis itself and from within the very cultural fabric and context of the westernized cultures.
Something has been happening within psychoanalysis.....the monolithic view of psychoanalysis of the Modern Era has been disappearing, if not disintegrating, as a plurality of heterogeneous theories have been making their appearance in the creative ferment of contemporary psychoanalytic thinking as has been captured in "The Widening Scope of Psychoanalysis". This theoretical pluralism, at least for the time being, has been accommodated, if not appropriated, through innovations within the traditional institutional structures and educational curriculum. The monolithic view of psychoanalytic education of the Modern Era has become corroded and encrusted as a plurality of epistemological premises have been making their postmodern appearances. And, something has been happening within the cultural fabric of the westernized cultures...... The epistemological-philosophical tradition of the Industrial Age which had provided a seemingly eternal and unquestioned justification for psychoanalysis in the Newtonian-Cartesian tradition and psychoanalytic education fashioned in the image of the Berlin Model has been disappearing and evaporating beneath our feet. The episteme of the Modern Era, having its origins in the 17th century, is becoming as obsolete and non-functional for the emerging Postmodern Era as the episteme of the Agricultural Era was for the Modern Era. The seemingly "natural" and "common sensical" organic bond between psychoanalysis and its largely unquestioned and unexamined medical practices, concepts, and attitudes; and, psychoanalytic education and its institutional(ized) structure, educational philosophy, and educational model, methods and objectives of the Modern Era is decaying. The Master discourse of the Modern Era is dying.
The Information Age of The Postmodern Era
The Industrial Age of the Modern Era which had its beginnings in the early 1700's has ended after @ 300 years. The westernized cultures are currently immersed in a turbulent transition from the Industrial Age of the Modern Era to the Information Age of the Postmodern Era. The fundamental and foundational codes as to that which have constituted, authorized, and sanctioned "appropriateness" in perceiving, thinking, and knowing during the Modern Era have been changing dramatically and radically, in leaps and lurches... Rather abrupt and ruptured breaks with traditional ways of thinking about things,--- as opposed to continuous evolutionary developments, --- have resulted in radicalized differences and departures from the more traditional ways of understanding and conceptualizing people, ideas, life, and the world. These revolutionary changes have not been limited to the natural sciences and the humanities. There have been dramatic and global changes in economic, political, and social structures. The westernized cultures have been travelling the Information Superhighways at warp speed and have entered the Information Age of the Postmodern Era: the Cyberworld and cyberspace of the Internet and Virtual Reality; the Quantum Age of physics and science.--- These changes have been most disturbing in their sudden onset, disruptive in their continued encroachment and impact in everyday life, and disorienting and disorganizing for institutional structures and individuals alike in their aftermath. This entry of the westernized cultures into the Postmodern Era carries equally consequential and far-reaching implications ---- and, a profound sense of uncertainty ---- for the future of psychoanalysis as theory, as practice, and for education.
This entry into the Information Age of the Postmodern Era has come to represent for many an alarming unraveling of the traditional, well-recognized, and comfortable familiar ways of knowing, perceiving, and thinking as had been woven within the cultural fabric of the Modern Era. Uncertainty has been spreading as the unquestioned fundamental assumptions, traditional epistemological premises, and presumed realities of the Industrial Age elusively evaporate and transform into something quite unexpectedly different. There has been a spreading stain of desperation in the cultural fabric that no amount of cleansing, cognitive or otherwise, seems to be able to remove. The postmodern world has presented the psychoanalytic community with a profound sense of uncertainty as to what the future might hold for the psychoanalytic practitioner and educator, alike. Comfortably fixed and traditional ways of thinking and knowing about psychoanalysis and psychoanalytic education have become more illusory and elusive. The present has become filled with efforts by organized psychology and psychoanalysis to preserve, if not to restore, that which ‘has been’ during the Industrial Age of the Modern Era. The "Industrialization of the Professions" has led to the current "Industrialization of Education" as is reflected by such recent policy objectives of the American Psychological Association (APA) as "outcome-based education" in graduate schools and the increased educational focus upon common learning experiences that is to lead to mastery of core competencies. The increased emphasis upon the conceptual fragmentation of the world, of people, of life, and of knowledge is further reflected in the recent proliferation of specialty and proficiency credentialing and certification throughout the health care professions. Psychoanalytic education is becoming encrusted within traditional institutional structures and encased, if not entombed, within a traditional educational philosophy, the institutional(ized) tri-partite educational model, and the linearized educational methods and practices of the Industrial Age of the Modern Era. The recent efforts by organized psychology and psychoanalysis to introduce innovations within traditional institutional structures appear to reflect a nostalgic yearning for a future for psychoanalysis and psychoanalytic education that, quite simply put, will never be as it once was. Indeed, one could question that it ever was as it is portrayed to have been.
It is this changing epistemological field of the postmodern Era as a cultural epoch that provides the context for the project of the Academy. It is this emerging epistemological field of the Postmodern Era as a discourse that prompts the re-examination, reconsideration, and reappraisal of psychoanalysis as theory, as practice, and as education.
The Academy for the Study of the Psychoanalytic Arts (CD)
"The Decade of the Mind"
Thus, in January of 1995 the Academy was formed in response to the growing realization that these powerful socio-political-economic institutions and forces had functionally narrowed the definition of psychoanalysis and psychoanalytic psychotherapy to that of a health care profession or a specialty thereof. The health care professions were being industrialized and the practice of psychoanalysis and psychoanalytic psychotherapy was being regulated and strangulated by various regulatory agencies and accrediting bodies at the federal, state, and local levels. Cost driven managed care delivery systems were redefining the professional standards, e.g., standards of care, practice, education and training, and ethical standards. Thus, the project of the Academy to undertake the long term project of rethinking psychoanalysis and to develop alternate understandings of psychoanalysis as theory, practice, research, and education that extend beyond the conceptual boundaries and parameters of the psychologies of the modern era.
The project of the academy involves stepping away from a very comfortable and familiar conceptual framework which has been provided by the contextual metaphor of disease, treatment, and cure and the conceptual framework of symptomatology-etiology-pathology. And, to consider and adopt new and different contextual metaphors which would be closer to and more reflective of psychology's philosophical beginnings. It is certainly recognized that the project of the Academy moves in conceptual directions that lack the authoritative certitude that accompanies the biochemical structural deficit-disease position. It is further recognized that it involves a willingness to exist in a state of not knowing--- a relatively continuous state of uncertainty and tolerance for conceptual diversity. It also involves the willingness to be involved in a continuing process of questioning the cherished beliefs, attitudes, values, and assumptions of one's theoretical reality. The alternative, however, would be to continue to wrap psychology and psychoanalysis in the cloak of medicine and its disease-deficit way of thinking which might provide a longed-for authoritative certitude and might also meet certain social, political-power, and economic objectives for the profession. It would seem, however, this would be at a tremendous cost to the public and thus, ultimately, to the practice of psychoanalysis, itself.
Les Voyageurs Des Seele
Rethinking, Reexamining, and Reconsidering
The Academy's project of rethinking psychoanalysis has taken many different forms, e.g., paper presentations, community film series, and interdisciplinary conferences. These contributions to the study of the psychoanalytic arts have been made in local, national and international forums. Each of these contributions have proceeded from the premise that the essence of psychoanalysis derives from philosophy and the arts in contrast to the perspective that the application of medicalized principles of psychology can be made to non-medical subjects such as the theater, poetry, history, and the arts. And, each of these presentations have conceptualized psychology as the study and understanding of the human psyche in the context of the anthropic sciences.
The Academy fully expects to continue to move in leaps and lurches in all directions at the same time while staying quite narrowly focused on the project of the academy. Longer term projects of the Academy include the planning and development of non-traditional educational programs of study and the planning and development of a community information program that will present to the public an alternative to the current medical model of analysis. Indeed, this presentation to the public of a confidential, collaborative endeavor whose purposes and duration are based upon mutual agreement is one of the primary goals and objectives of the Academy. It deserves to be mentioned that in venturing into this aspect of its project, the Academy holds the following principles to be axiomatic:
....... individuals involved in the psychoanalytic endeavor are assumed to be individuals capable of mutually determining and managing what is the best service and how it is to be delivered and paid for. The sole responsibility for the determination of all aspects of psychoanalytic services lies between the individuals contracting such services. This axiom serves as a defining principle of psychology-psychoanalysis as a profession. Further, the essential foundations for the delivery of psychoanalytic services are to be found in the exercise of professional discretionary judgments and the mutuality of agreement, involvement, and participation by the individuals;
..... those who wish to seek services at their own expense for their own reasons must be free to do so without having to label themselves as "diseased" or "sick". An individual's decision to participate in a psychoanalytic process and discourse for purposes of self discovery and self determination serves as its own justification. Further, it is to be recognized that the preservation and protection of confidentiality is of fundamental importance and extends to the relationship itself;
..... it is essential in our democratic society to preserve and to protect the right of each citizen to enter freely into private contracts for professional services independent of and irrespective of any organized health care system or plan. Further, any health care system devised must explicitly provide for and protect this right of the practitioner and recipient to contract independently and confidentially based upon a mutual determination as to type, frequency, duration, objectives, fee arrangements, and mutual evaluation of treatment effectiveness without regulatory restraint and/or penalty by any governmental-legislative-regulatory entity or health care reimbursement plan;
..... the psychologist-psychoanalyst has the right to practice outside of the health care system being developed and to exercise the professional right to conceptualize mental phenomena outside of the prevalent medicalized way of thinking and conceptualizing upon which this system is being constructed. Thus, it is advanced that both parties, the psychoanalytic practitioner and the individual seeking services, have the right to opt out of a particular model of delivery of health care services; and, perhaps more importantly, to opt out of the particular conceptual model of symptomatology-etiology-pathology with its prescribed treatment plan.
Psychoanalysis has reached a critical juncture in its evolution as a profession as it moves through the '90s toward the millennium. The major issue to be considered by each psychoanalytic practitioner is the viability of metaphysical positions, biomedical or psychological, and the impact of each upon the future course and evolution of the profession and practice of psychoanalysis. The metaphysical position from which one proceeds is the difference between the declaration of the 90's as the "Decade of the Brain" with the focus of inquiry on brain-behavior relationships, future courses in pre- and post-doctoral training programs centered on psychopharmacology and neuropharmaceuticals, and the methods of psychoanalytic treatment being further developed in a medicalized conceptual framework and context--- OR --- the declaration of the 90's as the "Decade of the Mind" with the focus of inquiry upon the intricacies of the person and motivational causalities; future courses and programs of study centered on the study of philosophy, poetry, and psychology; and, the methodologies of understanding being further developed within a psychological conceptual framework. The Academy provides a place and space for the like-minded to reexamine and rethink psychoanalysis and to collectively and vigorously advance psychoanalysis as allied with philosophy, the humanities, and the arts.
Patrick B. Kavanaugh, Ph.D., President,
Academy for the Study of the Psychoanalytic Arts