Master Psychotherapists Discuss Their Life and Work
Owen Renik, MD — Plenary Address at the American Psychoanalytic Association Meeting January 24, 2003, New York
Standards and Standardization
Owen Renik
I’m quite sure that every one of us is convinced of the necessity to formulate and maintain psychoanalytic standards; further, I think we all agree that analysts should be required to conform, to the best of their ability, to a standard of excellence in psychoanalytic work. That said, however, we face a monumental problem because—as we well know—there is no consensus among us as to the nature of excellence in psychoanalytic work. What some of us will judge to be an analyst’s creative and useful technical innovation, others of us will consider irresponsible self-indulgence on the analyst’s part; what some of us will regard as an analyst’s advisable caution and restraint, others of us will see as the analyst’s self-protective inhibition; what impresses some of us as sensitive interpretation of the patient’s here-and-now experience, others will see as an avoidance of the transference relationship and an impediment to the unfolding of the patient’s unconscious conflicts; what to some will seem a timely reconstruction, others will perceive as an invitation to intellectualize and ruminate about the past; and so on. It would be comforting to believe that we can formulate a standard of excellence that transcends our individual assumptions, one that can be applied to all psychoanalysts, across our very different operating theories. But, alas, no such standard is possible because our judgments of excellence are inextricably tied to our widely varying, often conflicting conceptions of the psychoanalytic enterprise.
The actual situation in our field is aptly captured, in my opinion, by the well-known anecdote that concerns a meeting of the British Psychoanalytical Society at which Wilfred Bion was the presenter. Bion, as you may know, besides being a renowned psychoanalytic contributor, was a decorated military hero during the First World War.
On the evening in question, Bion, after being introduced, prepared to speak. He straightened his sheaf of papers and placed it on the podium. He removed his wristwatch and placed it on the podium. He produced from his pocket a pistol and placed it on the podium—at which point, an alarmed colleague in the audience shouted out, “Professor Bion! What’s that for?” “Oh, that?” Bion replied; “That’s for the first person who tells me that what I’m doing isn’t psychoanalysis!” (The story may be apocryphal; I don’t know, but it makes the point).
Not only is the idea that a nonpartisan standard of psychoanalytic excellent exists a myth—it is a dangerous myth. A place we have to be especially careful of it is in the functioning of psychoanalytic organizations—local, national, and international. Within the American we have, of course, an agency specifically devoted to dealing with standards; our Board on Professional Standards. During the four-plus years that Marvin Margolis was chair of the Board, I was his number two—secretary of the Board. My main responsibility during those years was to restrain Marvin in his zeal for creating every increasing numbers of committees; and, as those of you who were around at the time will remember, I failed miserably. I think the number of Board committees probably tripled during our tenure. Marvin came perilously close to realizing his dream of turning the American into a giant kibbutz‑‑with everybody communicating with everybody else, all of the time. But while that was happening, I did have the opportunity to observe closely at first hand, and to reflect upon, the workings of the Board.
What seemed clear to me then, and continues to seem clear, is that because our various conceptions of psychoanalytic excellence, deriving as they do from our individual assumptions about psychoanalysis, are often incompatible, much of the formulation and maintenance of psychoanalytic standards is inherently political. Therefore, the gatekeeping functions that psychoanalytic organizations have tended to take upon themselves—admission of candidates for training, control of candidate progression, certification of psychoanalysts, selection of training analysts, etc.—all those judgmental activities that propose to determine who is doing psychoanalysis and who is not, who should be a psychoanalyst and who should not, are in large measure arbitrary and presumptuous; and the analysts who administer gatekeeping functions, despite their best intentions (which I do believe are often very idealistic) are in grave danger of being self-serving. These judges, in effect, vindicate their own individual views about psychoanalysis at the potential expense of the colleagues being judged, and ultimately at the expense of our field in general.
Although I teased Marvin Margolis a moment ago, I want to endorse and underline the importance of his vision of the mission of the Board on Professional Standards. It was always Marvin’s idea that the Board should be an essentially consultative agency, one that promotes investigation and discussion of psychoanalytic standards, rather than a prescriptive agency that dictates and imposes them. Actually, Marvin’s extravagance in the creation of innumerable Board committees was a brilliant guerilla tactic, whether he was explicitly aware of it or not. I think it was his intuition that if we couldn’t immediately eliminate the Board’s power to formulate and enforce arbitrary standards, we could at least diffuse that power—lose it in a maze of complex, inconclusive committee activity. It was a solution that drove me nuts, personally; but I have to admit Marvin’s genius in taking advantage of the general disposition among psychoanalysts toward interminable discussion.
Given the difficulty in formulating and applying psychoanalytic standards, what do I suggest? That we do away with standards? Of course not. That we relax standards? In no way. What I suggest is that we revise our standards: change their content so that they take better account of the fundamental heterogeneity of the psychoanalytic community, and so that they take better account of the actual limits of what one psychoanalyst can validly assess about another’s work.
Many years ago, Maxwell Gitelson pointed out that psychoanalysts become much more effective when they accept the reality of what they can not do, and he urged his colleagues to heed what he called “a counsel of modesty.” Gitelson’s recommendation is still timely; nowhere is a counsel of modesty more needed than in the establishment of standards. With regard to the standards used in gatekeeping by psychoanalytic organizations, for example, I think we need to be significantly less pretentious than we have been about our evaluative powers.
Concerning applicants for training, ours has been a sad history of having turned away or turned off some of the best and brightest. Our policy ought to be to cast a wide net, accepting all interested persons who are not obviously disturbed or dishonest, without an invariable requirement that the applicant have achieved (unlike Anna Freud or Erik Erikson!) an advanced postgraduate degree. Many institutes are now moving in this direction under the press of necessity having found themselves too often without enough candidates to hold classes. I don’t consider that evolution a bad thing.
Similarly, I think that we ought to lay claim to many fewer judgments of quality than we usually do in regulating the progression and graduation of candidates. The basic criterion for advancement should be simply time spent working in courses and supervised analyses, with evaluations by teachers and supervisors understood to be highly subjective impressions, personal opinions, and offered as such to candidates and used authoritatively only to manage rare cases in which there is conspicuous incompetence.
The much discussed certification process, as far as I can tell, is a vestigial remainder from an era when the Board was run by a power elite within the American who believed that they knew better than anyone what psychoanalysis really was. They were a very talented bunch of analysts, and their sense of superiority was in a way understandable. However, I can’t see any present-day rationale for certification; and as many have pointed out, it does enormous damage.
In the same vein, I think that the training analyst system as now constituted is indefensible. The judgments about colleagues on which selection for training analyst status is based are of the ultimately political kind mentioned earlier. Therefore, a fraternity/sorority atmosphere sets in, with in-groups and out-groups; and in every society with which I’m familiar the training analyst system has supported a pyramid scheme that influences the distribution of patient referrals and other forms of patronage.
Many institutes around the world have already, de facto, gotten rid of training analyst status by limiting the requirements for it to include only five years’ postgraduate experience, with no significant further examination needed. That makes a lot of sense to me. It also makes sense to the many potential candidates who do not apply to the American’s institutes because they would be required to interrupt what they know to be successful analyses with non-training analysts. Instead they go to and are accepted by institutes outside our national organization that do not require that a candidate’s personal analytic experience be with a Board-certified training analyst.
I’ve referred to the heterogeneity that exists within our professional community concerning standards. Certainly, myriad individual preferences can be seen to operate. At the same time, a few opposing shared assumptions about fundamental issues divide us deeply into factions concerning standards. For instance, a great many colleagues see psychoanalysis essentially a thing unto itself, and therefore believe that only psychoanalysts are in a good position to determine psychoanalytic standards. Others, myself included, are dissatisfied with this view, concluding that psychoanalysts’ vested interests, conscious and unconscious, operate too powerfully not to be checked and balanced by external judgments in the determination of standards.
We can think of surgeons. Surgeons like to cut; therefore, all things considered, they tend, in good conscience, to believe in the utility of the procedures they devise—which explains why some widely recommended and implemented surgical interventions (like tonsillectomy and radical mastectomy) come, in the fullness of time, to be found much less effective and more potentially harmful than initially thought. Well, psychoanalysts like to psychoanalyze; and we tend to like our procedures, too. Given the ambiguity of our data of observation, we are at least as susceptible as surgeons to the expectable self-aggrandizing bias of the practitioner-observer—a bias that must be taken into account in the maintenance of psychoanalytic standards.
How are we psychoanalysts to instate checks and balances on ourselves? What external sources of evaluation can we usefully employ? Surgeons use systematic empirical research. In principle, we could look to systematic empirical research to help us as well, and I think we all recognize that historically we have given systematic empirical research in psychoanalysis far less support than we should have. But it must also be admitted that the methodological problems entailed in systematic psychoanalytic empirical research are quite formidable, so that it is still at an early stage and can’t yet contribute all that much to the formulation of effective standards. In my judgment, the best way available to us as practicing psychoanalysts to try to control for our inevitable biases is for us to enlist as much help as possible from the only people besides ourselves who are privy to the complex, private details of the psychoanalytic encounter—namely, our patients.
In practice, the role played by psychoanalytic patients in determining psychoanalytic standards devolves upon the goals that are established for clinical psychoanalytic work. In other words, disagreement among psychoanalysts concerning the goals of clinical psychoanalytic work is another aspect of our deep divide with respect to psychoanalytic standards. Colleagues who judge that psychoanalysts are exclusively in a position to determine psychoanalytic standards will also judge that psychoanalysts are in the best position to determine the goals of clinical work and to assess clinical progress, because both conclusions follow from the same fundamental conception of a special psychoanalytic situation (even, according to some, a special psychoanalytic reality) in relation to which the successfully trained psychoanalyst’s singular expertise earns him or her a privileged voice.
My impression is that this view is very common among contemporary analysts, though not always articulated as unambiguously and explicitly as it might be. I therefore particularly appreciate the clarity and forthrightness of some of our British colleagues—Elizabeth Bott Spillius comes to mind as an example—in stating a position in which psychoanalytic goals are distinguished from therapeutic goals. Specifically psychoanalytic goals are necessarily formulated in terms that refer to psychoanalytic theory, which makes them something about which a psychoanalyst knows best, whereas therapeutic goals can pertain to the patient’s own judgments about his or her well-being—something about which the patient knows best. As a matter of fact, analysts who advocate the pursuit of specifically psychoanalytic goals in clinical work caution against giving therapeutic goals (the patient’s area of expertise) too much importance. Therapeutic zeal in the analyst is considered a liability.
On the other side of the divide stand those of us who consider that therapeutic goals—determined by the patient’s own judgments of his or her well-being—should direct clinical analytic work. This conception of goals in psychoanalysis, needless to say, grants the patient a much greater role in the determination of psychoanalytic standards, since judgment of excellence in psychoanalytic work rests on the patient’s self-assessment. According to this view, for example, there is no such thing as an excellent psychoanalytic outcome in which important insight is gained but full therapeutic benefit is not yet discernible because so-called working through is still incomplete. The degree of therapeutic benefit achieved is the criterion by which the validity and completeness of insight gained in analysis is measured. And, for that same reason, “flights into health” are welcome developments until proven otherwise.
Our deep divide concerning the nature of psychoanalytic standards cannot be straddled. It is all very well to claim that structural change (a specifically psychoanalytic goal) and therapeutic benefit (not a specifically psychoanalytic goal) proceed together and so can be pursued at the same time. However, when the rubber meets the road, one of the two must be chosen as the final standard by which analytic work is evaluated. Observation of structural change comes down to the analyst’s inferences, while observation of therapeutic benefit comes down to the patient’s self-report. At the end of the day, either the analyst’s inferences or the patient’s self-report takes precedence. The question of which to prioritize is a crucial controversy in our field.
We need to remember, as well, that our collegial differences do not apply only to the role in determining standards that we give to the patients we see in psychoanalytic treatment; our differing perspectives apply also to the role in determining standards that we give to the very much larger number of patients who, though suffering emotional distress, choose not to seek treatment with psychoanalysts. I for one think we need to listen to the patients who don’t want to see us. From my point of view, it would be a mistake to believe that paying attention to marketplace phenomena concerning psychoanalysis represents commercialism and a compromise of our professional standards. Popular opinion about the efficacy of psychoanalysis gives us the best empirical data related to outcome that we have—the results of a large n clinical study, in effect. And what do those results tell us? That we need better marketing? I don’t think so. If we had a better product, it would sell itself. We must at least consider the possibility that clinical analysis, as generally conducted, has become substandard, in that it does not reliably provide relief from psychological distress to most patients.
Of course, from a point of view of psychoanalytic standards different from mine—the other side of the divide—the ever diminishing popularity of psychoanalysis does not necessarily give us reason to engage in critical self-review and questioning of our clinical methods. According to that view, psychoanalysts are the treatment experts, not patients; and clinical analysis is seen as a highly specialized procedure, suitable for only a fraction of the large number of individuals in the general population who suffer psychological distress. The great majority of sufferers, either because of their participation in a narcissistic culture that urges them toward superficial quick fixes, or because of their intractable resistances, or because they lack the requisite capacities to engage in an arduous voyage of self-discovery, are not patients whom psychoanalysts should expect to be able to help.
From that perspective, in order to maintain our standards we should avoid becoming confused and discrediting a treatment that is well designed for the select few, just because there are so many for whom it is not appropriate. To my mind, the question for our profession then becomes: If psychoanalysis is suitable for only a small minority of individuals—many of them, by the way, people who want to become analysts themselves or who have an intellectual interest in psychoanalysis, stemming from their work in allied disciplines—how do we distinguish psychoanalysis as a treatment modality from psychoanalysis as an esoteric practice? Is the clinical psychoanalyst offering therapy or proselytizing?
In speaking of the possibility that clinical psychoanalysis, as generally practiced, is substandard, I want to emphasize the importance of the qualifier as generally practiced because, of course, there are and have always been analysts who help their patients feel better. What’s more (and this has been noted so often it qualifies as a truism), analysts espousing different, even contradictory, theories have therapeutic successes—including analysts positioned on both sides of the deep divide I have been discussing. One explanation for this observation is that an individual analyst’s personal dispositions, not covered by theory, can be more important in determining therapeutic outcome than directives of theoretical origin. Another explanation is that many therapeutically effective analysts do things that violate their theories, but deny it to themselves—or at least don’t talk about it publicly. Probably both explanations have merit. In any event, looking into the matter brings us to a discussion of standardization, by which I mean the effort to construct a model that can be generally applied—most importantly, in our field, a model for conducting treatment that can be generally applied.
Customarily in psychoanalytic circles we speak reverentially of case-specific factors, of the uniqueness of the clinical moment, and we look with great skepticism upon generalizations that might threaten to efface the complexity of these particulars. “It depends on the individual” might well be a motto emblazoned on the psychoanalytic coat of arms. There are many colleagues for whom technique is in itself a dirty word because it is understood to denote a rigid code of behavior that would make them insensitive to their patients’ individuality.
And yet we realize that responsible clinical practice requires us to think about what we are doing and to develop, if possible, principles that we can apply across cases and across moments to guide ourselves toward optimal patient care. For example, Otto Kernberg and his associates have written a manual that standardizes the psychoanalytic treatment of borderline patients. One may disagree with Kernberg about his diagnostic approach or about the system of therapy he proposes, but there is no question, at least in my mind, that the effort toward standardization that he has undertaken is exemplary. I would say the same of Charles Brenner’s writing, deceptively simple in its clarity, about how to conduct a clinical analysis.
Attempts to standardize treatment go against the grain for many colleagues, but responsible standardization represents an effort to get away from a kind of self-glamorizing vagueness that excuses psychoanalysts from accountability (as when we flatter ourselves that we are pursuing an “impossible profession”). Standardization represents an effort to engage in the formulation of specific hypotheses to be tested—something we need more of in psychoanalysis. It would be helpful if our literature could move beyond a tendency to valorize essays that eloquently state lofty ideas in inspirational terms but do not, in the end contribute to close pragmatic review of the way we work with patients. We see altogether too much of the old wine in new bottles. That kind of thing may seem safe, because it is reassuring; but in the end, it is stultifying. We must be willing to take the risk of translating our clinical impressions into specific, consequential recommendations about how to analyze—and about how to analyze better—recommendations that are shared with colleagues who can test them against their own experiences.
Standardization, in this sense, does not mean rigidity. It goes without saying that any generalization we might propose remains open to revision and review. As a matter of fact, in my opinion, something we very much need to standardize is an experimental approach to psychoanalytic technique. It’s striking how little our principles of technique have evolved since the early days of psychoanalysis. I think that in our efforts to maintain what is called a “psychoanalytic identity,” we have clung too tenaciously to established practices based on received wisdom.
Over the past seventy years, many of Freud’s valuable discoveries have permeated the cultural surround, and as a result contemporary therapists of all orientations are, in fact, psychoanalytically informed to a significant degree. In reaction to this dissemination of psychoanalytic sophistication, psychoanalysts have tended to insist on certain procedures that we believe distinguish us from other therapists, make us special—frequency of visits, use of the couch, a stance of personal anonymity, etc. I think that psychoanalysts have been insufficiently open to the possibility that some of these procedures are not actually useful in many—or even in any—cases. That’s the kind of standardization we don’t need.
So far I have been proposing, on one hand, that we take seriously the need for standards and standardization in psychoanalysis and, on the other hand, that we do so without becoming hypercertain and presumptuously imposing our standards and standardizations on one another. What then, if anything, in the way of specific practices do we have the right and responsibility to demand, not only of ourselves, but of our colleagues? We come now to the difficult topic of ethical standards in psychoanalysis.
I think that ethical standards can be precisely formulated, and that all psychoanalysts should be required to conform to them. The reason it’s possible to make this requirement is that ethical standards are a matter quite separate from psychoanalytic theories, even theories of technique. Therefore, the same ethical standards can be applied to practitioners with widely differing basic assumptions about psychoanalysis. Ethical standards have to do with rigorous maintenance of attention and regard for the patient’s welfare by the analyst, regardless of the theory the analyst uses. Any psychoanalytic theory can be used to rationalize unethical behavior by an analyst. No theory protects against unethical behavior. Equally ethical analysts can disagree completely about the right thing to do in a given clinical situation.
Unfortunately, psychoanalysts tend to conflate ethics and clinical theory. Psychoanalysts regularly make the mistake of treating their preferred conceptions of psychoanalytic technique as if they were ethical standards. All too often I have seen an ethics committee, at the local or national level, judge a colleague to have behaved unethically when he or she has been guilty only of treating a patient in a way that did not conform the clinical views of the committee members. I’m talking about instances in which a tight internal consensus about optimal technique within an ethics committee was mistaken to represent an ethical standard and misapplied to condemn the conduct of an analyst who came before the committee.
I do want to mention, though, a truly unethical behavior which I believe to be quite common in our profession, and about which we have maintained a sort of conspiracy of silence. I refer to the practice of analyzing a patient for years, even decades, in the absence of evidence that analysis is helping the patient—or, if it helped initially, that it continues to be helpful. In these cases, the patient suffers great damage—not only in terms of time and money spent, but in terms of the lost opportunity to seek greater benefit elsewhere. Is there anyone present this evening who has never been guilty of this serious ethical violation? I must tell you, sadly, that I cannot make that claim.
The offense is easily explained away: we can tell ourselves that the patient has deeply entrenched problems that require long, painstaking work during which progress may be imperceptible; we can tell ourselves that the analysis we conduct, even if in the end it proves unproductive, is the patient’s only hope; we can tell ourselves that the apparent lack of improvement over years must be contrasted with the deterioration that would have occurred had the patient not been in analysis; etc. But we shouldn’t let these rationalizations deceive us. Ethical violations by analysts can always be rationalized.
Why, really, do we continue to analyze patients, unhelpfully, much longer than we should? For financial gain (the great majority of victims are able to pay a substantial fee); because we don’t want subsequent caregivers to discover our mistakes; because we don’t want anyone else to succeed where we have failed; because, for whatever particular personal reasons, we can’t stand to admit failure. There are many motivations. My point is that the conduct of overlong, unproductive analyses, for the benefit of the analyst rather than the patient, is a destructive unethical practice endemic in our field. I would estimate that far more harm has been done to patients by analysts in this way than by all the sexual transgressions analysts have committed put together.
As a matter of fact, I wonder if there hasn’t been a tendency among us lately to scapegoat so-called boundary violators. Have we been spotlighting their dramatic, relatively unusual ethical failures in part to keep our own less conspicuous, more commonplace ethical failures in the shade? I ask this not because I think an analyst having sex with a patient should ever be overlooked or excused, but because I’ve noted a recent tendency toward self-righteousness and facile moralism in dealing with these cases. In my experience, there is a wide range of situations that can eventuate in sex between an analyst and a patient. I’ve known analysts and patients who have fallen in love and lived happily ever after; I’ve know generally conscientious analysts who, under highly unusual stressful conditions, succumbed, destructively and self-destructively, to seduction by patients whose psychopathology made them predatory; and I’ve know conscienceless analysts who were themselves predators. These were all instances of irresponsibility on the analyst’s part, and some form of disciplinary action was needed. However, the specifics of the misconduct varied and had different implications with regard to the analyst’s limitations. It’s very hard to judge these differences and to know how to deal with them appropriately, but I’m not convinced that we have always been trying as thoughtfully, compassionately, and carefully as we might.
After all, the issue, ultimately, isn’t sex; it’s taking advantage of and harming a patient. That’s the real slippery slope that we all walk on all the time, like it or not. Let’s not kid ourselves otherwise by finger-pointing.
I want to conclude on an especially personal note, using aspects of my own professional life to illustrate what I’ve been trying to say about standards and standardization. The American Psychoanalytic Association has meant a great deal to me over the years, as I imagine it has to many of you. Professionally, I grew up in the American, and I’ve enjoyed through our psychoanalytic community a sense of affiliation and comradeship without which, as we know all too well, it is very easy for a working analyst to feel isolated and lonely. I have a significant number of dear, close friends whom I would never have met had it not been for the American. I love that it can take half an hour to get across the Waldorf lobby because there are so many people one wants to greet. Probably, many of you feel the same way.
Further, the analytic community has been generous to me. I’ve had some wonderful jobs in which I had a grand time and learned a lot: program chair of the American, secretary of the Board, editor of the Quarterly. In relation to the subject of standards and standardization, what I want to emphasize about my own career is that I was appointed to responsible positions by colleagues who knew full well that my views about psychoanalysis are not always mainstream, and that my presentation of them can be very direct—“provocative” is a word that’s sometimes used. In each of those jobs, I received tremendous support from the analysts with whom I worked. Throughout my ten years as editor, the Quarterly’s editorial board did more than tolerate me, they collaborated with me enthusiastically—even though three-quarters of them disagreed violently with many of my ideas about psychoanalysis. Judy Schachter asked me to be program chair of the American not despite the fact that, as she described it to me at the time, some people on the left and some on the right were uncomfortable about me, but precisely because they were!
I mention all of this to show how much I have personally benefited from the capacity of our psychoanalytic community to contain differences, even when those differences are keenly felt. I think we all benefit from heterogeneity and debate. It is crucial that our standards, and our efforts towards standardization, nourish constructive controversy within psychoanalysis—that we do not suppress it in the service of trying to feel (and to appear) sure of ourselves. That is why I’ve offered my remarks this evening—some of them, I hope, provocative in a useful way—on the assumption that we at least share a professional standard that welcomes a spirit of challenge to the status quo. That is the spirit that characterized psychoanalysis at the beginning, it’s the spirit that drew many of us to psychoanalysis, and it’s the spirit that, if we promote it, will give us our future.
Published on Psychotherapy.net with permission of the author, February, 2008.
About Owen Renik: Owen Renik, MD, is currently a Training and Supervising Analyst at the San Francisco Psychoanalytic Society. He was Editor in Chief of the Psychoanalytic Quarterly for ten years, Program Chair of the American Psychoanalytic Association for two terms, and served as Director of Training and Associate Chief of the Department of Psychiatry at Mount Zion Hospital, San Francisco. He maintains a private practice in San Francisco. In his book, Practical Psychoanalysis for Therapist and Patients (2006), Renik makes use of clinical anecdotes to describe how to begin psychotherapy and psychoanalysis, how to end it, and how to deal with the in-betweens in an engaging, practical, and down-to-earth style.
