the Spring/Summer 2014 AMERICAN Volume 48, No . 2 PSYCHOANALYST Quarterly Magazine of The American Psychoanalytic Association

Maintaining a Psychodynamic INSIDE TAP… Perspective in Psychiatry Annual Meeting Jack D. Barchas in Chicago . . . . . 8 –12 As a neurobiologist who was never for- in biological areas and he encouraged that mally associated with psychoanalysis, I have approach as well. It was a perfect evening. Learning Objectives. . . . 14 always had great respect for those who write, After completing Pomona College in three teach, and practice or utilize the discipline. years, I spent a year at UCLA working as a Honorary Members From the start of my interest in psychiatry to research assistant for James Olds, a social Shine...... 16 –19 the present day, I have been encouraged, psychologist who, in a remarkable burst of mentored, and influenced by psychoanalysts creative experimentation, discovered the Downcoding at a personal level and such facilitation has neurobiological reward system of the brain in Psychotherapy. . . . . 20 continued in my research and administrative the early 1950s. His work is now recognized roles, as well as in friendships. as one of the great discoveries in neuro- biology of the past half century. EARLY ATTRACTION TO PSYCHIATRY As one of his earliest assistants, I AND RESEARCH implanted electrodes into the brains of When I was about 16 and told my parents animals that would receive small doses I was interested in psychiatry, my father, a liti- of electricity in a Skinner box setup. By gator whose avocation was the history of sci- applying such stimuli to areas of the ence and ideas, arranged for me to meet one brain, he delineated the reward system. of his friends, a psychoanalyst who practiced Animals would press the bar hundreds in Los Angeles. That gentleman took me to a or thousands of times throughout the lovely small French restaurant in Beverly 24-hour cycle for the reward, which Hills—my first experience with both psychia- took precedence over essentially all try and such a restaurant. Quite dramatic on functions. My first publication was an both counts. He described his palpable enjoy- abstract on the 24-hour cycle. His work ment and satisfaction being in the profession. is now known to be relevant for many Even then I knew my personal interests were forms of normal behavior as well as aspects of mental illness and substance abuse. Had Olds not died at an early Jack D. Barchas, M.D., is Barklie McKee age, he might well have received the Henry Professor and chairman of the Nobel Prize. He realized the implica- Department of Psychiatry at Weill Cornell tions of his work for psychodynamic Medical College and psychiatrist-in-chief concepts and would talk about his ideas of Weill Cornell Medical Center of New as he paced about his small laboratory York-Presbyterian Hospital, including while I implanted the electrodes in a the Payne Whitney Clinic in Manhattan room in the UCLA animal facility. and Westchester. Continued on page 16

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 1 CONTENTS: Spring/Summer 2014 THE AMERICAN PSYCHOANALYTIC ASSOCIATION President: Robert L. Pyles Can We Thrive? Bob Pyles President-Elect: Mark Smaller 3 Secretary: Ralph E. Fishkin Treasurer: William A. Myerson 5 R eclaiming Certification as a Valued Developmental Executive Director: Dean K. Stein Educational Process Harvey Schwartz

Consolidating Psychoanalytic Identity Jamie Cromer THE AMERICAN PSYCHOANALYST 5 Magazine of the American Psychoanalytic Association 8 Highlights of the 2014 Annual Meeting in Chicago: Editor June 6–8 Kimberlyn Leary Janis Chester Film Editor 10 Chicago: History, Architecture, Arts, Food, Sports Bruce H. Sklarew …You May Want to Stay an Extra Week Neal Spira Special Section Editor Michael Slevin Editorial Board 12 National Child and Adolescent Congress Charles E. Parks Brenda Bauer, Vera J. Camden, Leslie Cummins, Phillip S. Freeman, Maxine Fenton Gann, Noreen Honeycutt, 13 COPE: Study Group in Child and Adolescent Analysis 2014 Sheri Butler Hunt, Laura Jensen, Paula G. Atkeson and Anita G. Schmukler Navah Kaplan, Nadine Levinson, A. Michele Morgan, Julie Jaffee Nagel, Marie Rudden, Hinda Simon, Vaia Tsolas, 14 Deepening Our Understanding of Psychoanalytic Dean K. Stein, ex officio Educational Objectives Tessa Cochran; Michael Slevin, Editor Senior Correspondent Jane Walvoord Honorary Members Photographer 16 Mervin Stewart Manuscript and Production Editors 18 Mm Mm Good Frank M. Lachmann Michael and Helene Wolff, Technology Management Communications Honor ary Members: A Phenomenological-Contextualist 18 The American Psychoanalyst is published quar- Psychoanalytic Perspective Robert D. Stolorow terly. Subscriptions are provided automatically to members of The American Psychoanalytic Asso- ciation. For non-members, domestic and Cana- Stopping the Cycle of Abuse Estela Welldon dian subscription rates are $36 for individuals and 19 $80 for institutions. Outside the U.S. and Canada, rates are $56 for individuals and $100 for institu-  Politics and Public Policy: CPT Codes: tions. To subscribe to The American Psychoanalyst, 20 visit http://www.apsa.org/TAPSUB, or write TAP Psychotherapy’s Death Knell? Margo P. Goldman Subscriptions, The American Psychoanalytic Association, 309 East 49th Street, New York, New York 10017; call 212-752-0450 x18 or 21  Poetry: From the Unconscious Sheri Butler e-mail [email protected]. Copyright © 2014 The American Psychoanalytic Moz art and Freud Visit Ann Arbor, Michigan Julie Jaffee Nagel Association. All rights reserved. No part of this 22 publication may be reproduced, stored in a retrieval system, or transmitted in any form or by Art and Analysis at Florence International Symposium any means without the written permission of The 23 American Psychoanalytic Association, 309 East Vera J. Camden 49th Street, New York, New York 10017.

24 Film: As It Is in Heaven Allan Gold and Bruce Sklarew ISSN 1052-7958 The American Psychoanalytic Association does Ps ychotherapy in Psychoanalytic Organizations Alan Pollack not hold itself responsible for statements made in 26 The American Psychoanalyst by contributors or advertisers. Unless otherwise stated, material in The American Psychoanalyst does not reflect the endorsement, official attitude, or position of The Correspondence and letters to the editor should be sent to TAP editor, American Psychoanalytic Association or The Janis Chester, at [email protected]. American Psychoanalyst.

2 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 FROM THE PRESIDENT

with unparalleled power and authority within Can We Thrive? our Association. For many years, the Execu- Bob Pyles tive Council was no more than an appendage of minimal importance. In fact the Executive “Can We Sur- challenges demands thoughtfulness and sup- Council was assigned the title of a Board of vive?” That is the pleness of adaptation, not a blind attachment Directors only because BOPS could not question posed to past policies and practices. A rigid adher- legally serve as its own Board of Directors. by the BOPS ence to institutional habits may offer solace leadership in and the illusion of safety, but it will cripple our THE RIGHTFUL ROLE OF COUNCIL their previous capacity to adapt to the world we live in now. Over the last 25 years, our Association has TAP column [TAP been undergoing a difficult but necessary 48/1, page 5]. A VERTICAL SPLIT transition, as the Executive Council slowly has It is indeed a One enduring feature of our Association assumed its proper role as a Board of Direc- critical question. has been an artificial separation between tors, responsible first and foremost to the Bob Pyles A hostile media, education and membership. This separation is members it represents. In recent years, this a tight economy, the cost-cutting policies of a legacy of the original psychoanalytic insti- chief responsibility has brought the Executive the insurance industry, and new governmen- tute in Berlin, in which all authority and Council into painful conflict with the Board tal sponsored health plans are all squeezing power were vested in those named to be on Professional Standards. the life out of practices and our profession. training analysts. This organizational design To address the question posed by the The Committee on Institutes has estimated was institutionalized when our first four leadership of BOPS, “Can We Survive?”, my that at least 13 of our institutes are in trouble institutes (New York, Chicago, Baltimore answer is that it will be very difficult for our and may very well go out of existence in the Washington and Boston) were established in Association to survive, if BOPS continues to near future. this country. operate in the manner it has for the last 60 When I ran for president the first time in Our structure as a national Association years. The evidence is clear. Our recruitment 1995, I had the specific intent of mobilizing was formed in the context of an early and is dwindling. Our membership is declining. our Association to address these environ- very intense conflict between the American Our members are divided. And more than a mental challenges with the same vigor and Psychoanalytic Association and the Interna- third of our institutes are on a course to fail. focus that have long characterized our tional Psychoanalytical Association (IPA) In my view, a core factor in the genesis of emphasis on education and science. Now, over the training of non-physicians. The reso- our internal problems is the training analyst more than a decade later, we are engaged in lution of this conflict, which occurred in (TA) system. When, as a candidate, I first the most extensive and energetic programs 1938, included the establishment of our became familiar with the training analyst sys- of public information and advocacy in our Association as a “regional association” within tem, it seemed contrary to every principle I organizational history. We can and must per- the IPA. According to this agreement was being taught. It seemed profoundly anti- sist in these efforts to ensure our survival. between APsaA and the IPA, the IPA granted analytic and anti-educational and very close However, these efforts are not enough. us an “exclusive franchise” over the develop- to being unethical. When I ran for a second term as president ment and regulation of psychoanalysis in the In addition to analytic and educational con- four years ago, I was once again concerned United States. We were authorized to siderations, the TA system and the general about our survival, not because the external accredit our own institutes, regulate our own conservatism and “splendid isolation” that it environment was tougher—though it was— training programs, and control access to breeds, has made it increasingly difficult to but because I felt that our organization had membership in the IPA, all subject, of course, recruit candidates. It is an undeniable fact that become too rigidly fixed in its ways to adapt to our adherence to the minimum IPA train- the independent analytic groups with stan- successfully to the changing world in which ing standards. dards comparable to ours, but no TA system, we live. To be clear: Our Association has been We are now suffering from the conse- do far better in recruitment than most of our plagued by internal organizational problems quences of the ideas and attitudes that pre- institutes, many of which are seen as hope- since our bylaws were written in 1949. vailed among our members at that time. lessly conservative. These problems are nothing new. What is Training was privileged above all other pro- In 1985 I wrote a paper on the TA system, different today is not our organization, it is the fessional functions, and the position of the which I distributed privately among col- environment. An environment of mounting training analyst was exalted above all other leagues at the Psychoanalytic Institute of organizational posts and functions. Accord- New England (PINE). In it, I questioned the ingly, the Board on Professional Standards TA system and predicted that we at PINE Bob Pyles, M.D., is president of the (BOPS) was formed as the preeminent would find it hard to survive as an institute, American Psychoanalytic Association. administrative body of organizational elites, Continued on page 4

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 3 FROM THE PRESIDENT

Can We Thrive? BOPS side and indicated if we wanted things To justify such a separation, some have Continued from page 3 to be different we should change our imagined a kind of nightmare scenario, with bylaws. Accordingly, Mark Smaller and I took some groups (including the officers) pushing if the TA system remained in place. If this two actions. Working with the newly formed to eliminate any standards at all, and moving were true of other institutes, as I imagined it Litigation Committee (consisting of the to become a psychotherapy organization. must be, the entire edifice of our Association nationally elected officers), we filed an Happily, these all seem to be scare tactics that was surely in a state of long-term progressive appeal. Secondly, we formed a Bylaws Task have never been suggested by anyone, as far jeopardy. Unfortunately, events have proven Force to do exactly what Judge Schlesinger as I know. that both predictions were accurate. had suggested. The news of the appeal was Whatever the fate of the PPP Proposal, met with indignation by the original filers of we have the opportunity and responsibility PPP PROPOSAL the suit, which once again seemed odd to to create a very different kind of organization, It was with these concerns in mind that me, for while they had felt free to file the one that deals with education, with the needs Rick Perlman, Warren Procci, and I intro- suit, they were angered by our decision to of our members, with the environment—and duced the PPP Proposal in September 2011, appeal. Currently, we await the results of the is not thwarted and constrained by an orga- calling for a reconsideration of the training Court decision. nizational elite that values rules over reason analyst system. We were joined by Mark However, certain things are clear. This and privilege over progress. Smaller. We had intended that the proposal organization will never be the same, regard- We have a critical and historic opportunity would be a starting point for discussion. less of the outcome of the lawsuit. The genie to form a different kind of Board on Profes- We had expected that BOPS would estab- has been let out of the bottle and can never sional Standards. I hope we can do it without lish a task force to consider and discuss the be put back in. any groups splitting off. However if some TA system, with input from the Board of To return once more to the question choose to go their own way, we wish them Directors and membership, to decide upon a posed by the BOPS leadership, can we sur- well. Either way, we will have the opportunity course of action that would remedy the vive? It will be difficult, perhaps impossible, to create a BOPS that embodies a modern problems that the current system entails. unless our organizational structure is altered educational philosophy, adapting to the needs To our astonishment, none of this hap- to match our educational and membership of the students and adapting to the conditions pened. I will not burden the reader with an missions. The crux of the problem is not, as we encounter now and will in the future. I accounting of the many attempts we made BOPS leaders proclaim, that there has not visualize an educational body that embraces to engage the leadership of BOPS, both indi- been enough separation between member- innovation, inclusiveness, and openness and an vidually and through committees. Suffice it to ship and education. It is that there has been organization that would welcome new mem- say that all were unsuccessful. The sole too much. bers and new groups with respect, interest, opportunity that was given to consider the In reviewing the BOPS minutes over the and open arms. substance of the PPP Proposal was limited to past several years, I was struck by the fact It is embarrassing that after BOPS and the 15 minutes at the June 2012 meeting. that BOPS in many ways seems to have gone Executive Council agreed to invite the Wil- The resulting sense of frustration led the out of the education business and into the liam Alanson White to join our Associa- Executive Council the next day to enact an rules business. We have heard there are tion, it took nearly a year to extend a formal interim resolution calling on BOPS to develop some institutes planning to split off from invitation to this important and vibrant “objective and verifiable” criteria for the APsaA in order to form their own associa- psychoanalytic community. There are other selection of training analysts. tion. This, of course, is completely unneces- independent groups we could immediately In January 2013, seven members of BOPS sary, since any institute can continue to do invite into our Association. When I was pres- responded to the enactment of the objec- exactly as it has been doing, even if the PPP ident previously, Don Rosenblitt was chair of tive and verifiable proposal by filing a lawsuit Proposal were adopted. BOPS. We estimated that we could bring in against our Association—without warning An alternative some have suggested 1100 new members to our group. We failed and without discussion. The reasons for filing would involve the externalization of BOPS to bring in any. But now we have a new and the lawsuit were never clear to me. I was and the credentialing function. To me, an golden opportunity. told by one of the petitioners that the BOPS externalized BOPS would be the worst pos- group felt they had exhausted all other sible solution, since it would enshrine perma- AN INTERNATIONAL VIEW means of redress. However, from my point nently the maladaptive methods of the last In considering change, we have been ham- of view, they hadn’t tried any other means, 60 years. It would also enable BOPS to con- pered by the deep belief among some that and the filing of the lawsuit seemed arbitrary tinue as is, only now permanently without the training analyst system is synonymous and unnecessary. “checks and balances,” and without having to with the survival of psychoanalysis, and that To the surprise of many, Judge Schlesinger be responsible to the membership and the the TA system represents a higher standard. (who ruled in the lawsuit) found for the Board of Directors. Continued on page 7

4 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 FROM THE BOARD ON PROFESSIONAL STANDARDS

Pre-Graduation Certification The chair and secretary of the Board on Professional Standards are devoting their column to a review of the Pre-Graduation Certification Program authored by Harvey Schwartz, chair of the Certification Examination Committee (CEC), and a first-hand account of the experience by a recent participant, Jamie Cromer.

All they have before them is the clinical work Reclaiming Certification as a Valued of the candidate analyst. The Board on Professional Standards is Developmental Educational Process encouraging all our institutes to promote Harvey Schwartz the pre-graduation pathway to certification because it is so consistent with our shared The Pre-Graduation Certification Program can be taken, goals for psychoanalytic education and the has been very well received by candidates. which includes development of a psychoanalytic identity, Its introduction parallels that of other pro- writing up a ter- confidence and commitment. The pre-grad- fessions that are increasingly beginning their minated case. uation pathway also emphasizes the educa- certification evaluations during the training The write-ups tional value of this process, rather than its period. Part I consists of writing up two ana- are studied by value being solely limited to that of a link to lytic cases of patients in middle-phase, who the certification training analyst appointment. can be of the same gender. It also entails pre- committee I can say a great deal more about this senting process notes from those cases to composed of program of which I am very proud. Better two interviewers. After graduation, Part II analysts from though to leave that to the candidates who Harvey Schwartz around the coun- are taking it. Below is a piece written by try who are entirely blind to the identity of Jamie Cromer who took the Part I Pre- Harvey Schwartz, M.D., is chair of the the applicant. Unlike local faculty, the entire Graduation Exam, passed it and then Certification Examination Committee, training committee functions free from the inevitable returned this past January to sit for Part II. and supervising analyst at the Psychoanalytic influences of personal familiarity. They do not She wrote about her experience in the most Center of Philadelphia, and clinical professor know the applicant’s name; they do not know recent Candidate Connection newsletter, and of psychiatry at Jefferson Medical College, the applicant’s institute; they do not know with permission we reproduce it in TAP for Thomas Jefferson University. the applicant’s professional degree. Nothing. all our members.

Maybe things had changed, I thought, so I Consolidating Psychoanalytic Identity decided to pursue certification. I viewed the Jamie Cromer CEC as wanting us to succeed in this demand- ing and worthwhile pursuit, and I valued the Certainly none of us entered analytic Psychotherapy Program. I wanted to deepen opportunity for some national review of my training for the easy road. I decided to my understanding of my patients and myself. work. NOBPC agreed to participate in the become a psychoanalyst after 15 years in pri- Entering training and becoming a psycho- Pre-Graduation Certification Program, and vate practice and five years after complet- analyst has been part of my journey, not its since I had passed Mid-Phase Colloquium, I ing New Orleans–Birmingham Psychoanalytic end, and the same holds true in pursuing immediately applied. Center’s (NOBPC) two-year Psychoanalytic certification. The climate of certification darkened in During the Candidates’ Council meeting the years following my first meeting, and at my first APsaA meeting, I heard Paul Hol- strong public opinions often described certi- Jamie Cromer, LCSW, ACSW, a graduate linger speak about certification. He described fication as an unfair, unnecessary and flawed of New Orleans Birmingham Psychoanalytic, it as an extension of the learning process, a review of an analyst’s abilities. I realize now passed the final certification process in January. milestone, and presented the Certification that there had been a traumatic legacy, and She is a fully certified psychoanalyst in full-time Examination Committee as a supportive ally, these narratives were not new. For many, the private practice and finishing her second term a dramatic contrast to the fearsome group certification process had delivered a blow, as treasurer of Candidates’ Council. so many cautionary tales had introduced. Continued on page 6

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 5 FROM THE BOARD ON PROFESSIONAL STANDARDS

Psychoanalytic Identity and consulting, I discovered and rediscov- Harvey Schwartz, CEC chair, greeted me in Continued from page 5 ered important elements of the analyses. I the hall outside the interview room with a was finally able to tell the story of the analy- warm smile, a firm handshake, and a word of leaving unhealed wounds. Despite all this, I sis, the story of me as an analyst and of my encouragement. The interview hour passed wanted the opportunity to consolidate my patients’ analytic journeys. I re-applied for quickly. The quick break in the middle gave own thinking, face my fears, and access a blind the first phase of pre-graduation certifica- me time to reflect, but overall I thought it was national review of my work, especially tion and sent in my reports to be reviewed going well. The two interviewers felt like col- because I was one of only two candidates in by the CEC. leagues, respectful and curious. I answered a small psychoanalytic center. I wanted as I accepted the offer to speak to a mentor the questions the CEC as a whole had pre- close to impartial evaluation as I could get. who formerly served on the CEC. I wasn’t pared from their review of my write-ups. I I met with one of our senior analysts, a sure how I would make use of her as a presented process notes, and we discussed former CEC member. I arrived confident resource, but my fear was growing as the my impressions and considered other per- about my analytic work and skills. I struggled interview date approached, and I needed all spectives. We did not seem to need to agree to be concise. He cut me off mid-sentence the help I could get. I chose to participate in on everything. many times, redirecting my disjointed the optional first phase interview for expe- I received a call two days later on the attempts to tell a cohesive story of the anal- rience since the second phase requires it. I Tuesday night of the 2013 New York meet- ysis. This interaction definitely fanned fears had learned from CEC workshops at the ing as I prepared to walk into the Finance of any certification interview ahead, but he national meetings that the optional interview Committee meeting as Candidates’ Council agreed to be a reader for my certification offers the reviewers opportunity for clarifi- treasurer. I was informed that I had passed. reports. I spent countless hours over many cation, and without it, they might otherwise Dean Stein was the first person I told as we weeks editing and submitted the final draft request resubmission. walked into the meeting. He announced my to him. He left a voice mail conveying my I spoke to my mentor only once. I told her good news, and all warmly congratulated me. efforts had missed the mark, having focused I felt confident about my writing and my ana- I felt joy, relief and pride. I graduated from too much on the patient rather than on my lytic work, but felt increasing worry about the NOBPC in May 2013 and applied for the role as analyst. My disappointment after so interview. She asked me, “What’s the worst final phase of certification. My reports on my much hard work interrupted my progress in thing that could happen?” I said, “I won’t pass.” terminated case were submitted, and my the certification process. She said, “Well, you’ll try again. I didn’t pass interview was scheduled for January 2014. In my fifth year of training, I took an elec- the first time, and I made it.” These words I hoped I could make it through the second tive writing class on the mechanics of writ- helped reassure me. I requested additional interview as well as the first. I hoped for a ing up a case, an adjunct to the case write-up consultation as I prepared the materials for similar call on my way into this year’s Finance workshops I had attended at several APsaA the interview. By the time I interviewed in Committee meeting. But if not, I was deter- meetings. As I prepared my reports, review- New York, I was as prepared as I could be. mined to try again. ing the work as a whole and writing, editing, Staying calm was my primary hurdle. This certification process has been my most challenging professional endeavor and has been essential in consolidating my psy- choanalytic understanding and my psycho- Contacting the National Office analytic identity. I suppose if I did not need National Office certification to eventually pursue becoming a TA, I might have been tempted to avoid the Voice Mail Extensions whole process, but I would have missed out Chris Broughton x19 on the professional and personal rewards. Brian Canty x17 No matter our profession, we have all been Sherkima Edwards x15 graded, awarded degrees, received honors, Tina Faison x23 and earned licenses, all of which required Carolyn Gatto x20 somebody to evaluate us subjectively. Certi- Rosemary Johnson x28 fication has been a part of my becoming a Geralyn Lederman x29 psychoanalyst, as important as my classes, Yorlenys Lora x18 my supervision, and my personal analysis. Nerissa Steele-Browne x16 My certification experience is a valuable and Dean K. Stein x30 essential part of my psychoanalytic journey. Debbie Steinke Wardell x26 I hope my experience has encouraged you to participate.

6 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014

Can We Thrive? between membership and education. All edu- also learn from our own mistakes. We can Continued from page 4 cational functions are subsets of committees transform our Association into a living, breath- of the society, which is the main organizational ing organization again, eager to innovate, At the very least, we should be capable of a body. It is also worthy of note that among emboldened to experiment, and equipped thorough and serious reevaluation of what the three recognized educational models to adapt intelligently. If we can seize the one of our Association leaders in the ’50s, approved by the International Psychoanalytical future by combining a capacity for flexible called “the central pathogen” of psychoana- Association, two of the three do not feature responsiveness to the needs of students and lytic education. any training analyst system at all. members with our ever-more vigorous efforts It is interesting to note that elsewhere in the I believe it is time for us to take a lesson at public information and advocacy, we can world of psychoanalysis, there is no separation from the rest of the analytic world. We can not only survive—we can thrive.

Significant Discount on Financial Management Fees Now Available for APsaA Members and Training Centers! Did that headline catch your attention? It should because this information could be valuable to you—monetarily valuable. APsaA, through its financial advisors, is offering Association institutes, societies and members the opportunity to have their invested assets managed by Steinberg Global Asset Management, Ltd. at a reduced fee.

INTRODUCTION APsaA’s invested assets are now managed by Steinberg Global, a highly respected money management firm. John Schott, M.D., a director of Steinberg Global and chairman of their Investment Committee, is a psychoanalyst, a longtime APsaA member, and a member of APsaA’s Investment Committee. John made it possible for APsaA to secure the services of his firm at a great low rate. Part of our negotiations included making the same rate available for APsaA members and affiliated organizations.

DETAILS OF THE ARRANGEMENT For any APsaA institute, society, or individual member with assets of $1 million or more to invest, Steinberg Global will offer their complete asset management services for the following fees: .75% for equities and .30% for fixed income and cash. The overall fee would be determined by blending the fee schedule with your asset allocation. For interested centers, institutes, societies, and members with less than $1 million to invest, Steinberg Global is offering their SG Select service for an all-inclusive fee of 1.35%. SG Select offers a selection of investment strategies in a less actively managed portfolio that still provides a measure of service greater than a typical mutual fund company. The decision to trust your investments to an asset management company is an important one. John Schott will be happy to answer your questions and discuss Steinberg Global’s services with you. You can reach John at 561-750-0800 or [email protected]. You may also reach their chief operations officer, Ken Pritzker, at the same phone number or [email protected]. For more information about Steinberg Global, visit their website www.steinbergglobal.com.

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 7 Annual Meeting in Chicago Highlights of the 2014 Annual Meeting in Chicago June 6–8 Kimberlyn Leary

Analysts are AN INNOVATIVE FORMAT “After the Storm: Living and Dying in Psycho- a passionate We are very pleased to introduce a pro- analysis,” explores the arc of an analysis and breed, caring gram of short talks modeled after the wildly the patient’s return years later. Nancy Kulish deeply about popular TED Talks. We call our program will chair this plenary session, which unlike their craft and Psychoanalysis Here and Now. Six psycho- other plenaries will include Shelley Orgel and practices. So, it analysts will each speak passionately about Warren Poland as discussants. is not surprising psychoanalysis for 12-15 minutes to foster The University Forum, for the first time, that we do not learning, provide inspiration and provoke engages the topic of “climate change” and always agree conversation. Our first Psychoanalysis Here severe weather, bringing together the work about how best and Now speakers will be Aisha Abbasi, of climate scientists, Rob Nixon and Chris Kimberlyn Leary to do things. Andrew Gerber, Peter Goldberg, Julie Nagel, Rapley, and a psychoanalyst, Sally Weintrobe. The 103rd Annual Meeting has been no Sally Weintrobe, and Joan Wheelis. Hans Stuart Twemlow chairs this session, which will exception. Some colleagues felt strongly that Agrawal will moderate. Following the pro- focus on findings from the Intergovernmental APsaA should have only one meeting a year. gram, all attendees are invited to a reception Panel on Climate Change and psychoanalytic Others felt that the nature of our work is with a cash bar and music. perspectives on the disputes about weather such that psychoanalysts may need more Alfred Margulies will give our inaugural changes that persist in some scientific circles contact with one another than other profes- Clinical Plenary, offering a sustained reflec- and in public conversation. sionals and thus should meet twice per year. tion on his work as a clinical analyst. His talk, Continued on page 9 After much discussion (including several task forces), a resolution was reached to continue the Annual Meeting in June but to schedule Ernst and Gertrude Ticho Memorial Lecture the scientific program over two days and over a weekend to minimize disruption to clinical practice. This spring, we will convene Organizational Trauma: in Chicago, from June 6-8, at the Palmer House Hilton, a venue that attendees favor Narcissism, Scapegoating, Mourning because of its proximity to Chicago’s many and the Problem of Succession attractions (including the Art Institute and Magnificent Mile) and because the hotel Christine C. Kieffer, Ph.D. offers many spots for old and new friends to gather for informal conversation. Friday, June 6 at 5:15pm The Program Committee, which I have been delighted to chair these last four years, opted not only to change the schedule of the The speaker will highlight the role of unconscious meeting but also to introduce new formats, large group dynamics in establishing entrenched in addition to traditional sessions that mem- bers appreciate and enjoy. organizational problems such as stagnation and decline due to failure to promote succession in leadership. The power of the group upon the individual will be illustrated through the use of brief excerpts Kimberlyn Leary, Ph.D., M.P.A., is the chair of the APsaA Program Committee, from opera choruses and movies. chief psychologist at the Cambridge Health Alliance, and an associate professor at Harvard Medical School.

8 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 Annual Meeting in Chicago

Leadership consultant and psychoanalytic referrals and orient potential patients to psy- Blum, chair); Fredric Busch and Larry Sand- candidate Stefan Reich joins us from Peru for choanalytic treatment. berg (Alan Pollack, chair); Robert Michels and this June’s Innovations session, where he will Practice-Building Workshop #2 features Gavin Mullen (Richard Zimmer, chair); Jack share his work engaging “adaptive change” in Stefan Reich offering an interactive immersion Novick and Norka Malberg (Christine Kieffer, contexts ranging from finance to educational in the concepts of “Adaptive Leadership and chair). We also have an additional new Two- non-profits. the Challenges of Exercising Real Leadership” Day Clinical Workshop on Psychoanalytic and his way of using these tools to consult Psychotherapy with Elizabeth Feldman and MEET-THE-AUTHOR with organizations and senior leaders. Allison Smith (Ann Dart, chair). Members let the Program Committee Practice-Building Workshop #3 is aimed Each cohort of the APsaA Fellows’ groups know they would welcome hearing from at “Developing a Footprint as a Public Intel- has conceived the program for the Clinical more psychoanalytic authors. We listened lectual: Using Tools from Old and New Conference’s Residents, Psychology and and have expanded the Meet-the-Author Media.” Also hands-on, in this workshop, Social Work Trainees, and Students. Fellows session to include three “One-Hour Engage- Prudence Gourguechon and Jeffrey Leib, for- present clinical material to faculty discussants, ments.” This June join R. Dennis Shelby to merly of the Denver Post, will help attendees which this year include Jane Kite, Charles discuss 13 Ways of Looking at a Man with master the nuts-and-bolts of using Twitter Amrhein, and Elizabeth Simpson. The con- author, Donald Moss, Elizabeth Rottenberg and social media to comment psychoanalyti- tent of these sessions (e.g., “This Couch Has to consider Forgiveness in Intimate Relation- cally on issues of broad interest to communi- Bedbugs!” and “Coercion in Psychotherapy”) ships: A Psychoanalytic Perspective with author, ties and the public at large. The workshop take up public sector psychiatry and the role Shahrzad Siassi, and Dorothy E. Holmes who will also provide guidance and coaching on of courts—everyday contexts for psychiatry will engage Miriam F. Tasini on her memoir of writing op-eds and magazine articles. residents and psychology and social work her family’s traumatic displacement and dislo- The Program Committee is also pleased trainees. While these clinical conference pro- cation, Where Are We Going? to announce an additional new format, Clini- grams are designed for students, all attendees Christine Kieffer will be honored, giving cal Field Studies in Community Psychoanal- are welcome to join. If you do, you will have the Ernst and Gertrude Ticho Memorial ysis, a two-session workshop, focused on a chance to observe first-hand the next Lecture. Her talk on “Organizational Trauma: developing a psychoanalytically sensitive pro- generation of clinical talent and the work of Narcissism, Scapegoating, Mourning, and the gram of community engagement and inter- young clinicians who may become psycho- Problem of Succession” will be followed by a vention to address bullying in schools. Stuart analytic candidates down the line. reception, open to all attendees, and spon- Twemlow chairs this new program. Frank This Annual Meeting also includes perennial sored by the Ernst and Gertrude Ticho Char- Sacco and Mark Smaller will present innova- favorites such as the Film Workshop (“The itable Foundation. tions from several countries that have Gambler”) where Kerry Kelly Novick and Members have consistently requested that reduced school bullying. Marie Rudden will Bruce Sklarew will explore the psychodynam- the Association devote more of its resources discuss their work. Attendees will also focus ics of addiction and the role of omnipotence. to helping members build their clinical prac- on the method of developing a study plan to Two Symposia offerings also bring innova- tices and sustain them, especially as the health include such work in one’s analytic portfolio. tive clinical models to APsaA members. Sandy care environment in the United States shifts G. Ansari, Nancy Blieden, and Gilbert W. Kli- with the introduction of the Affordable Care CLINICAL FOCUS CONTINUES man, will include video to show the utility of Act. Our June conference features three Our meetings would not be complete “Reflective Network Therapy” and Neil Alt- practice-building workshops; each will be without our Discussion Groups. The 103rd man, Ann Marie Sacramone, and Molly Romer repeated twice over the course of the meet- Annual Meeting includes 32 Discussion Witten will present a way of working within ing to maximize the possibility for colleagues Groups, with programs organized by the integrative, systemic psychoanalysis. APsaA to participate in workshops and attend other groups’ chairs and with content ranging committees will also present a full slate of sessions of interest. from “Deepening the Treatment” to “Inter- Committee Sponsored Workshops. Practice-Building Workshop #1 is focused subjectivity in the Work of Saul Bellow.” In Spring revitalizes all of us. The Program on “Using Technology in Developing Clinical addition to attending favorite groups, the Committee invites you to spend a weekend Practice.” William Braun and Geralyn Leder- Program Committee urges you to explore of your spring in Chicago. Join us. Reinvigo- man, APsaA’s director of public affairs, will particular interests, whether that includes rate your practice, be a part of the future of focus on helping attendees use websites like “Field Theory,” “Shame Dynamics,” or psychoanalysis, and share your passion for the APsaA’s “Find-an-Analyst” and Psychology “Women and Leadership.” career we all share. There is more that unites Today’s “Find-A-Therapist” productively. For The June meeting also spotlights our ever- us than divides us. Come to Chicago, meet at example, in this hands-on workshop, attend- popular Two-Day Clinical Workshops, which the center of our nation, honor our history, ees will write (or revise) a description of feature Rogelio Sosnik and Navah Kaplan and redraw the map of what it means to be themselves and their practices to generate (Irene Cairo, chair); Arnold Goldberg (Sharon a psychoanalyst.

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 9 Annual Meeting in Chicago Chicago: History, Architecture, Arts, Food, Sports …You May Want to Stay an Extra Week Neal Spira

One hundred years ago poet Carl Sand- If you like to Swedish-American flavored Midsommarfest burg wrote “Come and show me another laugh, the Chi- in Andersonville on the north side, the Bel- city with lifted head singing so proud to be cago Theater is mont-Sheffield Music Festival in Chicago’s alive…” Come to APsaA’s annual meeting in bringing in Eng- Lakeview Neighborhood (local bands, pro- Chicago this June and you can sing along. land’s Eddie ceed at your own risk) and a tentatively Chicago has something to suit every taste. Izzard, who will scheduled Turkish Festival at Pioneer Court, Here are some personal recommendations. be performing where Chicago’s founding father Jean Baptiste that weekend. Point duSable used to live. Note also that MUSIC, THEATER, COMEDY But who needs while Chicago may no longer be “Hog butcher AND DANCE imports? For for the world,” we do have the Ribfest Chi- Neal Spira If you like classical music there’s the Chi- homegrown tal- cago festival, where you can have your fill of cago Symphony, which will be performing the ent, there’s Chicago’s Second City, where gen- great barbecue from Friday to Sunday up in Shostakovich Fifth. If you like jazz, check out erations of SNL performers developed their Chicago’s Lincoln Square neighborhood. the Jazz Showcase in the south Loop, where improv chops. Or on the wilder side Ravi Coltrane (son of John and Alice) will be of improv, check out the Neo-Futur- playing. Another great jazz venue is the Green ists at the Neo-Futurarium on the Mill, where Al Capone used to hang out in north side, where they attempt to the good old days. If you like blues, pay a visit perform 30 plays in 60 minutes in their to Buddy Guy’s (south Loop), Rosa’s Lounge long running Too Much Light Makes the or Kingston Mines (further north). Baby Go Blind. If you like modern dance, check out Hub- bard Street Dance Company’s performance at VEGETARIANS REPENT the Harris Theater in Millen- Speaking of food we do have a few restau- nium Park. It is a great vibrant rants. If your tastes run to fine dining, get your reservations for Alinea or the Girl & the Goat. Or for something more If you like theater, Chicago Shakespeare pedestrian, wait in line Theater will be performing Henry V. There with the other pedes- will be productions at the Goodman down- trians for a hot dog at town and by Chicago’s famed Steppenwolf Hot Doug’s. If you are Company. Another good bet is Chicago’s a meat eater, indulge Court Theater, in Hyde Park, where M. But- yourself with a great terfly will be in the last few days of its run. steak at Dave Burke’s And you cannot go wrong with Million Dollar Primehouse, Quartet, at the Apollo, which puts you in the Bavette’s, Mor- recording studio with Elvis, Carl Perkins, ton’s, Michael Johnny Cash and Jerry Lee Lewis on the night company in a great venue. In June, Chicago’s Jordan’s, Gib- they played together in Nashville. neighborhoods come alive with weekend son’s, Capital festivals. Check out the Printers Row Liter- Grille, Gene & Neal Spira, M.D., is associate dean of the ary Festival, which is considered the largest Georgetti’s , the Chicago Institute for Psychoanalysis and free outdoor literary event in the Midwest, list goes on and on. (If you are not a meat immediate past president of the Chicago drawing more than 150,000 book lovers eater, become one, at least for a day). Psychoanalytic Society. to the two-day showcase. There’s also the Continued on page 11

10 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 Annual Meeting in Chicago

But Chica- is Manny’s Deli for a great corned go’s real culi- beef sandwich. I must also make spe- nary strength cial mention of our local specialty, lies in its eth- Chicago pizza, which is the best in nic restau- the world. Try Lou Malnati’s, Gino’s, rants, which or Pizzeria Uno where deep dish reflect Chi- pizza was invented. cago’s ethnic and cultural FOR THE ATHLETICALLY diversity. Of INCLINED course, there For those who like to be more is Chicago’s active—especially after all this eating—grab a And finally, let me conclude my picks by Divvy bike (rented by the hour) and take recommending an outdoor experience that a trip down the Lake Shore bicycle path. should not be missed, especially if we get Take an architectural walking tour. Or some sun and the temperature climbs above oldest restaurant, rent a kayak at Urban Kayak and take 60. If you have not seen Wrigley Field, it is a the German Berg- your own tour down the Chicago River, little bit of heaven in the city. Did I forget to hoff, right down- where you can have a unique experience mention that they play baseball there, too? town. It is worth a of the buildings that flank our waterways. The Cubs face off against the Marlins, and trip just to sit at the bar, grab a beer, and Then it is time to relax at one of our riverside while I do not think this is going to be our people watch. Italian, Mexican, Greek, Chi- outdoor dining establishments with a cool year, for those who like betting on long shots, nese, Japanese, Thai, Vietnamese, Ethiopian, beverage and watch the river flow (Cyrano’s it just does not get any better than this. Spanish, French, Russian…it’s all here. There is a good spot). You may want to stay an extra week.

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 11 Annual Meeting in Chicago National Child and Adolescent Congress Charles E. Parks A congress follow-up meeting More than 95 participants attended the to training standards that balances flexibil- has been scheduled in National Child and Adolescent Congress ity with consistency is most likely to foster conjunction with the annual held in New York on January 13-14, 2014. such an attitude in our candidates. meeting of the American This congress, sponsored by the American Other participants spoke to the anxieties Psychoanalytic Association in Psychoanalytic Association’s Committee on associated with child analysis, including the Chicago on Tuesday, June 3, Child and Adolescent Analysis (COCAA), anxiety generated by the low prestige from 1:30 p.m. to 5:00 p.m. was convened in response to concerns about accorded to professional work with children the future of child and adolescent psychoana- in our society; by the exposure to raw and lytic training and practice in this country. A intense affects; and by the stimulation of Others suggested developing work groups special feature of the congress was the inclu- regressive experiences in the analyst and to focus intensively on specific topics (e.g., sion of child training directors, child supervi- patient. In addition, there continue to be training standards, public relations, Internet sors, child faculty, child candidates, adult ways adult analysts marginalize child analysts presence) before reporting on that work at faculty, and adult candidates from around the and training programs. a future meeting. country. The impressive nationwide institute Large group discussions of the issues of Efforts supporting institutes in working representation and the varied child experi- supervision of child and adolescent analysis together to develop shared educational ence encouraged a wide-ranging discussion. and the potential value of an integrated child, efforts and clinical case seminars, finding In my opening remarks as chair of the adolescent and adult curriculum were impor- additional avenues of financial support for Congress Organizing Committee, I noted tant topics. Small group work sessions were child analytic training, helping child analysts that child and adolescent analysts face sub- held to enable more focused attention to learn about and build relationships with stantial challenges at every stage in their several areas, including community outreach professionals in other modalities (e.g., occu- training and career development. The task of as a part of building a child practice, teaching pational therapy, special education and psy- the congress was to further elucidate and and learning about parent work, the “widen- chopharmacology), and exploring ways of define these challenges and begin to develop ing scope” of child and adolescent analysis, collaborating with other child analytic organi- a plan for responding to them. distance learning, child psychoanalytic clinics zations, such as the Academy of Child Psy- in local institutes, and the child analyst’s role chiatry, were all considered. One important IDENTITY, STANDARDS in consultation, evaluation and case develop- proposal involved creating a National In- AND CHALLENGES ment. In an additional venue, participants Residence Analytic Program in Child Psycho- The topic of developing an identity as a met with others at similar points in their ana- analysis associated with a setting (the Lucy child analyst was central to the general dis- lytic careers (i.e., child and adult candidates; Daniels Center in North Carolina, for exam- cussion that followed. In this regard, the group adult analysts and faculty; child faculty; child ple) that would be uniquely situated to considered the sources of passion that child supervisors; and child and adolescent train- provide an intensive child analytic training and adolescent analysts have for their work. ing program directors) to discuss areas of program for early career child candidates. Child analytic training provides multiple mutual concern. A congress follow-up meeting has been opportunities to work closely with children, scheduled in conjunction with the annual adolescents and their parents in ways that NEXT STEPS meeting of the American Psychoanalytic meaningfully improve their lives. The nature In the final plenary session, there was gen- Association in Chicago on Tuesday, June 3, of the analytic work and training with chil- eral agreement the congress had played an from 1:30 p.m. to 5:00 p.m. The purpose of dren and adolescents also enhances one’s important, vitalizing function by providing this meeting will be to further develop plans flexibility in clinical work and teaching. Open- the opportunity for analysts from different to build on the momentum from the January ness and curiosity are important aspects of backgrounds and locales to discuss their congress. This will be an open-ended meeting the analytic attitude. A thoughtful approach work in ways that led to a shared sense of and all interested analysts and candidates intellectual stimulation and mutual support. are welcome. Charles E. Parks, Ph.D., is chair of APsaA’s This led to the recommendation for devel- Committee on Child and Adolescent Analysis oping a listserv for child analysts to connect (COCAA). He serves as child and adolescent and continue to discuss issues of mutual Reprinted with permission supervisor as well as adult training and interest about children and their treatment. from the Association for Child supervising analyst at the Baltimore Meetings to build on the momentum devel- Psychoanalysis Newsletter Washington Center for Psychoanalysis. oped at the congress were also suggested.

12 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014

COPE Study Group in Child and Adolescent Analysis 2014 Paula G. Atkeson Anita G. Schmukler Paula G. Atkeson and Anita G. Schmukler

Our COPE Study Group on Supervision in unfolding of the analysis. Third are the com- in child and adolescent supervision, which Child and Adolescent Analysis has been meet- plex issues of confidentiality, secrecy and pri- include supervising the widening scope of ing regularly for several years at the National vacy that arise as the candidate works with children and adolescents who seek help. and Annual Meetings of the American Psycho- family members, teachers and pediatricians. analytic Association. Our COPE group mem- As our discussions developed, we found that A WIDENING SCOPE bership is representative of institutes from many perplexing issues arose around ethical We supervisors tend to supervise our can- various parts of the country; this diversity dilemmas encountered by the nature of didates the way we were supervised as can- enriches the sharing of our experiences. child/adolescent analysis. We wanted to didates using the supervisory approach we Our discussions of theoretical questions share our thinking with supervisors beyond experienced without considering what alterna- and clinical material are rich and lively as we our study group. To achieve this, we pub- tive approaches might also be useful. In the talk over the particular issues that confront the lished a book in 2011, Ethical Practice in Child supervision of child and adolescent cases we supervisor of the candidate who is learning and Adolescent Analysis and Psychotherapy: find there are many dilemmas that confront how to conduct child and adolescent analysis. Protecting Safety in a Therapeutic Environment. the supervisor. The children and adolescents As we realized that the principles of super- who enter analysis today are often more chal- TASKS SPECIFIC TO CHILD AND vision and the education of supervisors are lenging than in the past when candidates ADOLESCENT TREATMENT not formally taught in many institutes, we tended to treat children and adolescents with Special tasks for the child and adolescent thought it would be helpful to develop a book neurotic conflicts. Today, the children and ado- supervisor that are not present in the super- directed toward the teaching of supervision lescents who come for treatment present with vision of candidates in adult training require that might serve as a starting point for the more severe difficulties, including organic and particular attention. First, there is the devel- study of supervision within institutes. To this developmental issues, such as autism and phys- opment of multiple transferences and coun- end we have a second book in press titled The ical delays, requiring speech, hearing and occu- tertransferences, not only to the child but Supervision of Child and Adolescent Analysis: pational therapies. They often have problems also to his or her parents and others in the Enriching the Candidate’s Clinical Experience. with executive function and self-regulation. child’s life. Second is the impact of the child/ The chapters in this book are directed These children are often receiving help with adolescent’s developmental process on the toward helping new and experienced supervi- multiple problems. Parents also present with sors develop their capacities to supervise can- severe difficulties in parenting and in their lives. didates in their work with child and adolescent These cases confront the supervisor and Paula G Atkeson, Ph.D., is training and patients. The chapters in this book include candidate with the task of considering a “wid- supervising analyst, supervisor in child supervision of assessment, of transferences and ening scope” of techniques that encompass analysis at the Baltimore Washington countertransferences, of work with parents, of the particular needs of that child or adoles- Institute for Psychoanalysis, co-chair, COPE ethical issues, of working with play, fantasies cent. It is important that the supervisor help Workshop/Study Group on Supervision and dreams, and the challenges of termination. the candidate not only on the practical level in Child Analysis, co-editor of Teaching The intent of the new book is to help of how to intervene and interpret but also to Effective Supervision in Child and supervisors develop their own approach to conceptualize why an interpretation or inter- Adolescent Analysis (in press). and style of supervision. It is also intended to vention is chosen at any particular moment Anita G. Schmukler, D.O., is a training call attention to the multiple unconscious in the treatment. This learning includes main- and supervising analyst and supervisor in processes that can potentially interfere with a taining an analytic frame while meeting the child analysis at the Philadelphia Center for supervisor’s recognition of issues in clinical treatment needs of the child and adolescent. Psychoanalysis; president of the Association material and the invaluable benefit of study Supervisors and supervisees can learn for Child Psychoanalysis and a co-editor groups and consultations for supervisors. together in this challenging task of child and of Teaching Effective Supervision in Thus, we included chapters on several mod- adolescent analytic work. Child and Adolescent Analysis. els of supervision and the special challenges Continued on page 31

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 13 LEARNING OBJECTIVES

Deepening Our Understanding of Psychoanalytic Educational Objectives

Tessa Cochran Michael Slevin, Editor

By now, many of you will have experienced Formerly serving as my society’s continuing the American Psychoanalytic Association’s education (CE) program coordinator, I was phenomenon: learning objectives. To be an responsible for requesting written objectives accredited educational organization at the from instructors and presenters. There was a national level, APsaA must comply with the fair degree of confusion and uncertainty requirement to use specific learning goals in about translating course material into specific planning and appraising course efficacy. In objectives. Some analytic educators found our institutes and societies, analysts who plan it difficult to formulate course content in courses for psychotherapy or psychoanalytic this new way, especially when speaking of Tessa Cochran Michael Slevin training programs must delineate goals of advanced clinical skills. Other colleagues were the educational experience. This requirement unsure how many objectives were needed to the work and the idiosyncratic nature of the is true for continuing education programs as summarize a course. These reactions are not therapist’s development. well. Whether having to write them for edu- all that surprising. Often, what we do as ana- It is time to deepen our understanding of cational programs or having to complete lysts and analytic teachers cannot be easily the task before us of basing curricula on course evaluation forms based on them, they translated into specific goals. objectives. The reactions of colleagues that I have become part of our lives. Recently, Deborah Cabaniss, the Columbia encountered as CE coordinator are a natural The move toward greater clarity and spec- Task Force on Progression and Graduation, outcome of the nature and complexity of ificity of purpose follows a period of intense and the Multi-center Assessment Project, our field. To speak to this, in this article, I offer reexamination of psychoanalytic education. designed to assess the effectiveness of super- a historical perspective on the learning objec- The use of pedagogical principles and, in vision, have endeavored to demystify and tive movement, outline criticisms and con- particular, written learning objectives is one systematize psychoanalytic education. These troversies of the movement in the field of of many efforts to improve psychoanalytic efforts evolved from recognition that there education, and introduce two newer taxo- training. Guidelines that are available for was significant room for improvement in can- nomic systems useful in describing goals that establishing objectives emphasize formulating didate training—a conviction Cabaniss and may help all of us approaching the task of outcomes that are observable by the pre- colleagues have contributed to with articles formulating objectives. senter and/or the learner. For example, “the and institute workshops. learner will be able to state the developmen- Recognition of the complexity of psycho- HISTORICAL BACKGROUND: ORIGIN tal tasks of latency” is more satisfactory than analytic praxis has long been a part of the OF TAXONOMIES OF LEARNING “the learner will know or understand them.” structure of analytic training programs as well While defining preparatory tasks has inter- as a criterion in the selection of candidates. ested educators for centuries, an effort to do The combined requirements of coursework, this in a comprehensive, research-based way Tessa Cochran, Ph.D., served as teaching training analysis, and supervision all contrib- began in the 1940s. At that time, a group of analyst at the Baltimore Washington Center ute to a candidate’s growing knowledge. We eminent scholars, among them Ralph Tyler, and clinical supervisor at GWU, before might say, though, that despite our best teach- Benjamin Bloom, and David R. Krathwohl moving recently to Orleans, Cape Cod. ing efforts, an analyst’s development is a pro- formed a committee to create a common lan- A new member of BPSI, she will open an cess that progresses at an uneven pace for guage for educators to use in curriculum plan- analytic and psychotherapy practice in 2014. the trainee. Identification with one’s analyst, ning. They concluded the task could best be Michael Slevin, M.A., M.S.W., a former supervisors, and teachers, the desire for their accomplished by defining outcomes that were TAP editor, graduated as academic associate approval, the anxiety to feel that one knows behaviorally observable and thereby measur- from the Baltimore Washington Institute for something given the clinical responsibility we able psychometrically. The committee’s original Psychoanalysis, where he completed the Adult are taking on all shape the learning process. plan was for not one but three taxonomies, Psychotherapy Training Program. He works Even psychotherapy programs, whose goals representing the basic domains of learning: at Jewish Community Services of Baltimore can be more tightly focused, are subject to cognitive, affective, and psychomotor. and has a private practice. the limitations imposed by the complexity of Continued on page 15

14 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 LEARNING OBJECTIVES

After several years, the committee pro- Some scholars raise arguments that not In a 1995 Psychoanalytic Quarterly article, duced the first publication, Taxonomy of all important learning outcomes can be Jacob Arlow describes this cognitive shift as Educational Objectives: the Classification of made explicit or operational. Learning developing a “working concept of the nature Educational Goals: Handbook I: Cognitive experiences that involve implicit under- of the psychoanalytic situation.” He adds, Domain. This publication came to be known standing cannot easily be described. In our “There is a considerable divergence between by the first editor’s name, as Bloom’s Taxon- field, for instance, abstract concepts such the articulated understanding of the nature of omy. The other two, affective capabilities and as transference, the unconscious, alpha and the psychoanalytic situation and free associa- psychomotor skills, were each dealt with beta elements, or the analytic third can be tion, and an unacknowledged, guiding concept separately in later publications: Krathwohl’s, difficult to grasp. Take, as an example, inter- that emerges during the actual management Taxonomy of Educational Objectives: the Clas- nalizing the concept of transference mani- of the clinical data.” He expresses this as an sification of Educational Goals: Handbook II: festations. Learning this concept involves important caveat to be addressed in teaching The Affective Domain (1964) and E. J. Simp- repeated exposure to clinical material, and supervising candidates. son’s The Classification of Educational Objec- accompanied by supervisors or teachers Further, critics of objective-based curri- tives: Psychomotor Domain (1966). pointing out the resemblance between cula argue that some learning activities are It is important to note several features of that material and information about the idiosyncratic and intended to change stu- the committee’s original intentions. First, they patients’ early relationships. These help but dents in ways defined by the individual emphasized that all three domains were to be comprehension also involves a cognitive alone. Since each of us possesses a unique considered in planning curricula to cover the shift from ordinary ways of considering combination of capabilities, not all learning full array of requisite knowledge and abilities. discourse. outcomes can be spelled out. We can spec- Second, their efforts were to ulate that the many new be considered a work in prog- perspectives and innovations ress, one that should be revised in psychoanalytic technique over time. Third, as Bloom later have emerged due in part to clarifies: Each major field the unique talents candi- should have its own taxonomy dates and analysts bring to of objectives in its own lan- bear on the field. Creative guage—more detailed, closer responses to patient encoun- to the special language and ters develop as a result of thinking of its experts.” As psy- both what we are taught and choanalytic educators, we take what our distinctive combina- that recommendation into tion of our abilities, opinions, consideration as we approach and values gives rise to. the task of generating our own Other critics take issue set of objectives. with the emphasis on perfor- mance outcome rather than CONTROVERSIES ON the pleasurable and creative APPLYING LEARNING aspects of the learning expe- OBJECTIVES rience itself. These are exem- Although a half-century of plified in programs that research findings demonstrate emphasize the autonomy and the usefulness of this approach self-directed intentions of in educational endeavors, the students to seek what they learning objectives movement need. Applying these view- has its critics. Even enthusiasts points to psychoanalytic edu- for using them were forthright cation, we might consider about their limitations. In this further implications of the section, I mention some of the fact that candidates come to arguments made in the field our programs with advanced of education as a whole to degrees and therefore bring raise questions as to whether with them a measure of they apply to curriculum plan- sophistication as learners. ning in our field. Continued on page 28

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 15 HONORARY MEMBERS

Psychodynamic Perspective Freedman liked my ideas, including the goal thorough knowledge of Freud’s writing. He Continued from page 1 of using newly developed biochemical assays concluded by saying: “If Freud were alive, he instead of the less reliable and variable bioas- would spend his days with me working on Leaving Olds says, such as clam hearts, for the neurotrans- topics such as brain serotonin and LSD and to attend Yale mitters, serotonin and norepinephrine. We his evenings talking with his patients and writ- Medical School, I knew we could only measure the concentra- ing ideas in psychoanalysis.” had an idea that tions of the substances and that the changes It was clear that the “wars in psychiatry” formed the core could be small but important, thus the need were heated. Nevertheless, during the clinical of my future for more sensitive assays. The Department of years on the Yale psychiatry service, I con- work and my life Psychiatry at Yale, later to become a great stantly saw the excellence of the analytic in research: If power in neurobiology, did not have a pH perspective as evidenced, for example, by behavior is im- meter and could not afford to purchase one. watching a clinician quietly listening to a per- portant in sub- We tried without proper equipment to set son with schizophrenia and establishing real Jack D. Barchas sequent mental up the assays. contact with that individual. life—a viewpoint central to psychodynamic I was sent to try to convince the Depart- (I had seen some aspects of the “wars” in approaches and all the multiple ideas of ment of Biochemistry to lend us such an my first psychiatry course at Yale, with a treatment that have evolved from psychody- instrument—quite beautiful in their maple young instructor who was to become a namics—then behavior must change neuro- boxes. Biochemistry had a closet full of such major power in American psychiatry, Thomas chemistry and neurotransmitters. That instruments. The department chair refused Detre. When I asked if there could be any behavior can influence brain chemistry to lend us a pH meter. He said in effect, biological aspects to the severe psychiatric ill- mechanisms that in turn can change subse- “Nothing will happen in neurochemistry for nesses, he stated absolutely not. Years later quent behavior now seems obvious; 50 years 100 years, if you want to study biochemistry, he completely changed his mind and basically ago it had not been directly demonstrated. study the liver.” More discouraging was his took the position that we should all be neu- I resolved to study that process at Yale. response to what I wanted to do with the rologists. I disagreed with him the first time and disagreed with him the second time.) After the difficulty trying to move the proj- Had Olds not died at an early age, he might well have ect ahead and seeing the problems that Freed- received the Nobel Prize. man was having, I elected to take a year out of medical school and work with Aaron Lerner, the discoverer of melatonin. Through that and While other students were involved in instrument: “Biochemistry is strong, bio- subsequent work, I provided evidence that orientation the first week of medical school, chemistry is the locomotive, behavior is weak, melatonin is a hormone and impacts sleep. I met with almost every person at Yale who like the wind. The wind does not change the Later, with Freedman, I returned to stress worked in what we now call neuroscience. locomotive.” We tried our best using Euro- research. I even picked an internship at the In the great psychiatry department there, pean pH paper; it did not work. University of Chicago where I could (with dif- then headed by Fritz Redlich, there was only Then another event occurred that was ficulty) continue the stress studies, sending the one person doing biological research, Dan- both exhilarating and discouraging. Using a brains to him from a then small O’Hare airport iel X. Freedman, a young instructor trying clam heart assay for serotonin, Freedman had late at night on dry ice for chemical assays. to do research but without a laboratory; he the first evidence that a hallucinogen, LSD, We were ultimately to find that indeed borrowed some of the facilities of a phar- could change brain serotonin. It was a finding stress does differentially impact neurotrans- macology professor for bioassays of neu- with implications for psychosis. He was mitters, changing serotonin and norepi- rotransmitters. Freedman was destined to scheduled to give his first lecture to the nephrine in opposite ways—the first such become one of the great figures as a men- Department of Psychiatry. The room was demonstration proving that the wind does tor and administrator of the last half of the packed. People were standing or sitting on impact the locomotive! Today that and similar 20th century in psychiatry. Freedman, a psy- the floor. His presentation, dramatic and findings with other neuroregulators is a fac- choanalyst who had been analyzed twice clearly important, was to lead to major work toid of neurobiology, confirmed and extended and was deeply committed to clinical prac- and hundreds of papers in the decades to by hundreds of papers rarely referring to our tice, was an outstanding educator, gifted edi- follow. The first question was from a power- first demonstration, but still highly satisfying. tor of the Archives of General Psychiatry, and ful leader in the department, Professor Theo- In later years, my research group at Stanford author with Redlich of a superb one-volume dore Lidtz, who asked in a hostile tone: provided the first demonstration of changes text of psychiatry. He was also a warm and “Where is this work justified in the work of in endorphins in the brain in rats with stress loving mentor. Freud?” Freedman answered strongly with a Continued on page 17

16 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 HONORARY MEMBERS and changes in the blood of runners, and David encouraged my interaction and When she developed severe headaches in worked out many fundamental mechanisms training experiences with serious psycho- her early forties, she saw many physicians. The of stress responses. analysts, such as William Weber, formerly two neurologists she saw were convinced her From my perspective, much of my work and of New York, Norman Graff, and Maurice symptoms must be psychological and that she that of my colleagues, even our work demon- Grossman—all of whom I came to revere. should see a psychiatrist or psychoanalyst. She strating for the first time genetic controls on Grossman was so serious that some resi- decided on Norm Graff, a Menninger-trained the formation of key neurotransmitters, was dents were afraid to have him as a supervi- psychoanalyst of broad intelligence, wide inter- quietly inspired out of a belief that it tied into sor. I found him demanding and incredibly ests, good humor, and marvelous sense. He theories of psychodynamics and the interplay interesting. He would often stop our super- decided she was one of the healthiest individ- of mind and brain—that perspective seemed vision sessions about 10 minutes early to uals he had ever encountered, said she had a to me to also be the way Freedman saw our discuss one or another question. He would physical problem (which turned out to be a work. Freedman sometimes said his work on ask me, for example, to summarize what we large brain astrocytoma) and followed her LSD, our work on stress, and his work on knew about serotonin. episodically for the next 15 years of her life autism were his major scientific contributions. While some of my friends in what we when there were transitions or surgeries. now call neurobiology have complained Despite the difficulties, he noted that through PSYCHIATRY TRAINING AT STANFORD— about how they were treated decades ago the course of her illness she never became PSYCHOANALYSTS’ IMPACT during the wars of psychiatry, I have always depressed. I was proud of my profession and After two years working on peptides and had the opposite feeling—welcomed, appreciative of wise psychoanalysts. enzymology in a superb National Heart Insti- helped, aided, and encouraged. Those three tute biochemistry laboratory, I started to psychoanalysts made a profound impact. MY GOAL AT WEILL CORNELL: search for a residency in psychiatry. There Interestingly, Fritz Redlich, who had moved TO HELP PSYCHIATRY AND THE were few persons who we would now call from the chairmanship of psychiatry to ANALYTIC COMMUNITY neurobiologists interested in psychiatry, and become the dean at Yale, visited the Stan- Although I had been at Stanford for 25 few places interested in their training. Alfred ford department and noted that it was years, I rarely looked at other positions even Stanton at Harvard was one. Another was remarkable as a place that had the full range when approached. The nature of my wife’s ill- Milton Rosenbaum at Einstein. Highly encour- of intellectual areas but enjoyed the various ness meant that an offer to become dean for aging, he graciously offered me a position but approaches without conflicts so common neuroscience at UCLA would be interesting advised me to go someplace where my inter- elsewhere. That was the culture David Ham- and give me far more time to be with her ests would be understood. burg and a true representation of his values. than other positions. All roads led to David Hamburg at Stan- Later, Hamburg led a group of leading psy- As I tracked what was happening in Ameri- ford, my other great mentor and the person chiatrists, most from the analytic tradition, in can psychiatry, I had become concerned that who has had the most impact on me profes- a landmark study for the National Research there was a new form of the wars in psychia- sionally for 50 years, along with Betty Ham- Council, Psychiatry as a Behavioral Science. It try. Now psychoanalytic approaches were burg, in her own right, a great figure in called for broad inclusion of areas of knowl- the ones largely being ignored and marginal- American psychiatry. David was trained as a edge into psychiatry. ized, just the opposite of what had happened psychiatrist and psychoanalyst but has Another aspect of my connection to psy- decades before. crossed more disciplines with understanding choanalysts came with the illness of my late Then came the request from Cornell to and more situations with powerful impacts wife, Patricia, now viewed as a founder of consider their position. Bob Michels, the than any person I have ever known. He and what is today called social neuroscience, great chair of the department who brought Betty were pioneers in the study of human whom I had met and fallen in love with the it to its modern form, had become dean. I coping mechanisms. He also facilitated work first hour of the first day I was at Pomona fantasized that the Cornell community had in anthropology and primatology and was College. She put me through medical school made a list of neuroscientists and tried to involved in studies of aggression, including his and I put her through a doctorate in sociol- decide who on the list would be sympathetic current work on genocide, in which he is ogy that led to her being a faculty member to what had been developed at Cornell, acknowledged as the world leader in the in sociology and psychiatry at Stanford. She which included psychoanalytic approaches study of its prevention. It is a project he had extensive interaction with psychoana- and much more. My wife, Pat, was bedrid- worked on for over 10 years in the faculty lysts through the Yale child psychiatry pro- den and headed toward what would be a office closest to mine at Weill Cornell after gram as she became the senior teacher at long state of altered consciousness, but retiring from the presidency of the Carnegie the Ribicoff Center for profoundly ill chil- she wanted me to look at the position and Corporation. What started as a mentorship dren. Most of the supervision was by Yale to accept it if offered. She loved New York became an emotional hybrid equivalent to psychoanalysts, and she read a great deal of and she liked the idea of the department. the closest of friends-family. literature in that field. Continued on page 30

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 17 HONORARY MEMBERS

similar idea many years later and from an Mm Mm Good entirely different source. He discovered a Frank M. Lachmann series of notes in music from different coun- tries around the globe that resembled the I attended my first meeting of the Ameri- would gain me “mm” sound. He also related it to the sound can Psychoanalytic Association about 55 admission, the a baby can make and not lose any milk. Bern- years ago, when, as a psychologist, I would fact it was writ- stein even added that the word “mother” in only be admitted to meetings with a letter ten by my ana- many languages begins with this sound. He from a member supporting my interest in lyst would be also found another series of notes that attending. Fortunately my analyst was a seen as counter- resembled an “ech” sound, which Bernstein Frank M. Lachmann member and he wrote such a letter for me. transference act- suggested was “spitting out the bad milk.” But, I had to swear I would not reveal my ing out and would have gotten him kicked out. I think Bernstein succeeded thereby in bring- analyst wrote the letter. Although the letter I attended the meeting and I remember a ing together Ralph Greenson and Melanie paper I heard then. It was Ralph Greenson’s Klein. All this is of particular interest today, paper, “On the meaning of the sound ‘mm’ as since Beatrice Beebe and I are being made Frank M. Lachmann, Ph.D., is a member in the Campbell soup ad ‘Mm, mm good.’ ” Honorary Members for our work on the rel- of the founding faculty of the Institute for The meaning is that this is the only sound a evance of infant research for adult treatment. the Psychoanalytic Study of Subjectivity baby can make and keep in all the milk. Inter- It seems Ralph Greenson had a similar idea and in private practice in Manhattan. estingly Leonard Bernstein came up with a 55 years ago.

Honorary Members A Phenomenological-Contextualist Psychoanalytic Perspective Robert D. Stolorow

Intersubjective-systems theory, the name of meaning-structures) that unconsciously orga- system. Psycho- the post-Cartesian psychoanalytic perspec- nize subsequent emotional and relational analysis is a dia- tive that my collaborators and I have devel- experiences. Such organizing principles are logical method oped over the course of some four decades, unconscious, not in the sense of being for bringing this is a phenomenological contextualism. repressed but in being prereflective; they prereflective It is phenomenological in that it investi- ordinarily do not enter the domain of reflec- organizing activ- gates and illuminates worlds of emotional tive self-awareness. ity into reflective experience and the structures that organize These intersubjectively derived, prereflec- self-awareness. Robert D. Stolorow them. It is contextual in that it holds that such tive organizing principles are the basic building Such organiz- structures take form, both developmentally blocks of personality development, and their ing principles include, importantly, those that and in the psychoanalytic situation, in consti- totality constitutes one’s character. They show dictate what emotional experiences must tutive intersubjective contexts. Developmen- up in the psychoanalytic situation in the form be prevented from coming into full being— tally, recurring patterns of intersubjective of transference, which intersubjective-systems that is, those that must be dynamically transaction within the developmental system theory conceptualizes as unconscious orga- repressed—because they are prohibited or give rise to principles (thematic patterns, nizing activity. The patient’s transference too dangerous. Intersubjective-systems theory experience is co-constituted by the patient’s emphasizes that all such forms of uncon- prereflective organizing principles and what- sciousness are constituted in relational con- Robert D. Stolorow, Ph.D., is a founding ever is coming from the analyst that is lending texts. Indeed, from an intersubjective-systems faculty member at the Institute of itself to being organized by them. perspective, all of the clinical phenomena Contemporary Psychoanalysis, Los Angeles. A parallel statement can be made about with which psychoanalysis has been tradition- He received his Ph.D. in clinical psychology the analyst’s transference. The psychological ally concerned are seen as taking form within from Harvard (1970) and his Ph.D. in field formed by the interplay of the patient’s systems of interacting, differently organized, philosophy from the University of California transference and the analyst’s transference is mutually influencing emotional worlds. at Riverside (2007). an example of what we call an intersubjective Continued on page 19

18 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 HONORARY MEMBERS

Therefore I began my quest in listening Stopping the Cycle of Abuse to these women’s voices of despair and des- Estela Welldon olation, and from then on my aim was for these women to have not only a voice but Although I have lived and worked in Great difficult nature also an ear. This led me to the question: Britain for most of my professional life, my of my work What if we start seeing these women them- heart comes from the Americas, both from because of the selves as victims? South America, where I was born and “negative coun- So, the task was to look at the damaged- attended medical school, and first learned tertransference damaging mother as the product of at least the rigors of psychoanalytical technique from evoked by these three generations. If we are able to apply this my earliest mentor Horacio Etchegoyen, but abusive women.” mental construct, we are then able to apply also from North America, where immedi- I learned of our understanding, compassion and empathy ately afterwards I undertook my psychiatric this extreme needed to stop the cycle of abuse. residency with Karl Menninger whose links to predicament We have to challenge our strong tendency Estela Welldon this organization will be well known to you all. through my own and assumptions to idealize motherhood to Menninger, in particular, had a huge impact personal pain and emotional distress. You the extent of denying any perverse motiva- on my work in the field of forensic psycho- see, we almost always automatically identify tions on becoming a mother or in taking care therapy and psychoanalysis. Dr. Karl was the with the victim—and almost never with the of babies. first in helping me to learn about the cruel, aggressor-perpetrator. This was all covered in my first book unconscious hostility we project onto crimi- But working for 30 years in the United Mother, Madonna, Whore, published in 1988. nals, and how a more humane society can Kingdom at the Tavistock Portman Clinic Initially the book was greeted with some con- treat even offenders with greater compas- NHS Trust with male perpetrators, I discov- troversy, but eventually the concepts were sion. Thus, my debt to American psychoanal- ered that their early lives were filled with at widely accepted and acknowledged, and since ysis is immense. best neglect, or at worst with emotional, then a number of resources have been cre- In the letter bearing official news of this physical and sexual abuse, not infrequently ated to deal with abuse by mothers. honor, your president paid tribute to the caused by their mothers. The fact that this first book has never been As a clinician I observed that the main dif- out of print does not worry me, because in a Estela Welldon, M.D., D.Sc. (Hon), ference between a male and female perverse way it is an indication that even though these F.R.C.Psych.BPC, is a member of the action lies in the aim: Whereas in men the act terrible malfunctions have not yet disap- British Psychotherapy Foundation, founder is aimed at an outside part-object; in women peared, at least they are now being acknowl- and lifelong president of the International it is usually against themselves, either against edged and discussed. Association for Forensic Psychotherapy, their own bodies or against objects they see In 1991, with the aim of changing per- author of Mother, Madonna, Whore, and as their own creations, their babies. In both ceptions and creating an understanding, I consultant forensic psychiatrist, Tavistock cases, bodies and babies are treated as founded the International Association for & Portman NHS Foundation Trust. part-objects. Forensic Psychotherapy, which built a plat- form and a forum for professionals working around the world in this field to gather once Honorary Members components of a unitary therapeutic pro- a year to discuss in a frank and honest envi- Continued from page 18 cess that establishes the possibility of alter- ronment our own difficulties encountered in native principles for organizing experience, our daily work dealing with abuse and abus- Phenomenology led us inexorably to whereby the patient’s emotional horizons ers. With respect to mothers as abusers, contextualism. can become widened, enriched, more flexi- Mother, Madonna, Whore was the first to Intersubjective-systems theory gives an ble, and more complex. As the tight grip of acknowledge this painful and awkward, even account of therapeutic action in which insight old organizing principles becomes loosened, “politically incorrect” insight. through interpretation and the affective bond as emotional experiencing thereby expands Let me be clear, the effects of abuse are with the analyst are seen to form an irre- and becomes increasingly nameable within terrible and can be long lasting, but con- ducible unity. Interpretive expansion of the a context of human understanding, and as demnation and abhorrence will not change patient’s capacity for reflective awareness of what one feels becomes seamlessly woven behavior or provide the help those victims old, repetitive organizing principles occurs into the fabric of whom one essentially is, need. concomitantly with the affective impact and there is an enhancement of one’s very sense Our therapeutic work is hard but it is the meanings of ongoing relational experiences of being. That, to my mind, is the essence of only solution. I pay tribute to you all for your with the analyst, and both are indissoluble therapeutic change. precious work.

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 19

POLITICS and PUBLIC POLICY CPT Codes: Psychotherapy’s Death Knell? Margo P. Goldman

As a psychia- For example, the documentation tem- trist and psycho- plate suggested by the American Psychi- therapist who atric Association includes such sections accepts some on Chief Complaint, History of Present The associated documentation guidelines insurance, I am Illness, Mental Status Exam, each consist- potentially distract us from attending to concerned about ing of “data elements” (i.e., severity, trig- patients’ thoughts, feelings, and reactions, as the impact of gers and associated symptoms) that are well as our own, because of the necessity to current mental added together to determine complex- elicit required data. Transference and coun- health proce- ity and coding. tertransference, core psychodynamic princi- dural terminol- 5. Psychiatrists and nurse practitioners can ples, are pushed to the periphery in this new Margo P. Goldman ogy (CPT) codes bill for just E&M. Time can be used to health care model that detracts from sponta- on psychotherapy—especially their effect on choose the procedure code for E&M neity and quality. quality of care, payment, access, and privacy. without psychotherapy, if more than half the time is spent in counseling and/or PAYMENT AND ACCESS CODING CHANGES coordinating care. Though total insurance fees for therapy The January 2013 coding changes are as 6. There is a new code for crisis psycho- with E&M have increased, the allowable reim- follows: therapy and a new add-on code for bursement for the therapy component has 1. Most prior mental health evaluation and interactive complexity, in lieu of a prior decreased for psychiatrists and advanced therapy codes were eliminated. “interactive therapy” billing code. Inter- practice nurses. Because E&M is more lucra- 2. Individual therapy, when concurrent active complexity is defined by having tive, psychiatrists and nurses may prefer to with evaluation and management (E&M) to use more complex communication code sessions as time-based E&M, provided is not billed as the primary service. techniques, i.e., an interpreter, third- the work consists of “counseling/coordina- Treatment is billed with an E&M code party informant or manipulatives such as tion of care.” Billing records could spuriously plus an add-on psychotherapy code. play therapy. underrepresent integrated psychotherapy 3. New individual psychotherapy codes, and can be expected to endanger insurance with and without E&M, cover a range of EFFECT ON CARE coverage for psychotherapy by psychiatrists time instead of a specific time. For These codes devalue psychotherapy, mak- and advanced practice nurses. example, a 45-minute session is coded ing therapy an add-on procedure, if it takes Most insurers, without prior authorization, for 37–52 minutes, determined by the place with E&M. Billing integrated treatment disallow 60-minute sessions; some pay the “CPT time rule.” (therapy with E&M) as two services falsely same amount for 45- and 60-minute sessions, 4. The E&M codes, with add-on therapy, dichotomizes what would be otherwise making longer sessions less economically desir- are based on complexity, not time. We seamless, concurrent treatment. Comparably able. Furthermore, because “average times” are required to use data points based low fees for individual therapy without E&M, determine fees, payment will not accurately on a medical model to document care. crisis psychotherapy and therapy with inter- reflect the actual time spent. The requirement active complexity emphasize psychotherapy’s that psychotherapists document the type of Margo P. Goldman, M.D., a psychiatrist in second-class status in this new reimburse- psychotherapy may herald decreased reim- Andover, Massachusetts, is an advocate for ment scheme. bursement or reduced insurance coverage for patient confidentiality. She is a Distinguished The coding changes will no doubt impact long-term psychoanalytic psychotherapy, in Life Fellow of the American Psychiatric therapeutic process. The new psychotherapy favor of short-term, “cost-effective” treatment Association, Psychotherapist Associate time frames distort the notion of the tradi- modalities. This could endanger the future of Member of APsaA, and an active member tional 50- or 60-minute session, and fit poorly psychodynamic psychotherapy. of the Psychotherapist Associates Committee. with how we actually practice. Continued on page 31

20 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014

From the Unconscious Sheri Butler poetry Michael Harty is a training and supervising analyst at the Greater Kansas City Psychoanalytic Institute. He has practiced for the last 30 years in Prairie Village, Kansas. Do Invisible People Still Have to Breathe? With a long-standing interest in psychoanalysis and poetry, he has been expanding That’s affirmative, no question. I knew his writing horizons through the publication of his work and through taking the a woman invisible for thirty-eight years New Directions Program of the Washington Psychoanalytic Center. In February he if you count her time growing up appeared as the featured poet on the International Psychoanalysis website. He has plus most of her marriage. She took been published in the Texas Poetry Calendar and Still Crazy, an over-50 magazine. many breaths during that time Harty trained at the Topeka Institute for Psychoanalysis. He was part of the although very quietly. development of psychoanalysis in his area from the study group stage all the way through to the development of the Greater Kansas City-Topeka Psychoanalytic Center. She learned early to time her breathing The center contains the Greater Kansas City Psychoanalytic Institute, where he is a TA. to coincide with others so she He currently serves as president of the center. would not be audible. This matched The three poems that follow are gripping realities placed within language so her skill at dressing to blend well suited to each that they are very striking. There is internal drama to each piece with the background and finding and like a good book leaves you wanting to know more. a shadow to stand in.

Her parents would cut four pieces of pie when there were five at the table. Unasked Countertransference Teachers had to think hard I should have read you like a poem, Sometimes when you speak when they saw her name on an essay. should have interrogated the silences I hear my first boss, soft like you, Beggars never asked her for money, around your words, found the invitation stingy with his help. dogs never barked when she passed. you would never speak—to ask about a mother’s romance Or my fourth-grade teacher Throughout that time she was breathing with illness, the hush around her door; who had your hair and wanted though concerned she might be using to ask about your nightmare boys to be like girls. too much air. The trouble started of hotel rooms, why you would run when she grew tired of children to exhaustion in the dark streets Parents, preachers, coaches, cousins: on tricycles ramming her legs, store clerks while your protector drank himself to sleep. I search for your voice distinct ignoring her, gifts always the wrong size. Why no eager schoolmate would know from the chorus of reminders the tender down of your thighs. Why you drove She tried hard to put invisibility to the store for your mother yet after all this time behind her, began to breathe openly like the good daughter you were, if you grab my collar and scream, like everyone else, admitted she had opinions. picked up her prescription I might think you are embracing me. And her husband for the first time then home in your pink bedroom looked straight at her and said, You know, ate a handful, and placed I may tell you a dozen ignorant lies you should learn to hold your breath. yourself beyond all questions. in pursuit of one truth, and all you can do is try to forgive me, and keep talking. —Michael Harty

Sheri Butler, M.D., is an adult training and consulting analyst and a child consulting analyst in the child division at the Seattle Psychoanalytic Society and Institute. A published poet and member of TAP’s editorial board, she welcomes readers’ comments, suggestions, and poetry submissions at [email protected].

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 21 MOZART AND FREUD

Mozart and Freud Visit Ann Arbor, Michigan Julie Jaffee Nagel

In the unconscious, there is no such thing as time, place or dates. This became clearly evident when Sigmund Freud and Wolfgang Amadeus Mozart visited Ann Arbor, Michigan, on October 24 while taking a break from their journey in eter- nity. As you may know, Freud made dis- claimers about music, maintaining he could not appreciate it. Mozart coun- tered that he could express himself only through music. Displaying enough comfort to address each other on a first name basis, the two icons engaged in a lively discussion (with assistance from my original script) about From left, Carol Seigel, Al Fallick, Julie Jaffee Nagel, John Alexander Sakelos and Louis Nagel their feelings regarding music and psy- choanalysis. This topic is explored in my with his mother who, sadly, died during (Freud) and John-Alexander Sakelos book, Melodies of the Mind. their travels. (Mozart), we learned about the devel- Mozart could During their visit to reality, Freud and opment of psychoanalysis and about not understand Mozart were welcomed by Carol Seigel, Mozart’s composing his great piano how Freud, devel- director of the Freud Museum in Lon- Sonata, K. 310 in A minor. As Freud and oping his theory don, at a large gathering at the Ann Mozart departed and continued their of the mind at the Arbor Jewish Community Center. Freud, journey back to eternity, the entire turn of the 20th in particular, felt at home as Seigel sonata was performed by Louis Nagel. century in Vienna, brought objects from the Freud House It has been documented that Freud was not curious to share. With the assistance of actors and Mozart have appeared together in about how music from the University of Michigan’s other venues around the U.S., and it was was a road to the respected Music Theater Department rumored they will visit other locations in unconscious. (Brent Wagner, director), Al Fallick the future. Freud could not understand how music was a pathway to mental life without using words to analyze it. The two men also discussed leaving their mother- land—Freud left Vienna for London to escape the Nazi invasion and Mozart left his home in Salzburg to travel to Paris

Julie Jaffee Nagel, Ph.D., is a graduate of the Juilliard School, University of Michigan, and Michigan Psychoanalytic Institute, where she is also faculty. She is author of Melodies of the Mind and in private practice in Ann Arbor. Website: www.julienagel.net

22 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 FLORENCE INTERNATIONAL SYMPOSIUM

Art and Analysis at Florence International Symposium Vera J. Camden

This spring, in the birthplace of the Renais- and literature is a living tribute to such a vision, Silverman (Van Gogh and Gauguin: The Search sance, Florence, Italy, the city will host another which Freud felt would promise a future for for Sacred Art), to which psychoanalyst and manner of “renaissance” for the intersecting psychoanalysis. As outlined in my 2009 paper theater consultant Phillip Freeman will and interdependent fields of psychoanalysis in the International Journal of Psychoanalysis, the respond with a contemporary critique of vio- and art. Co-chairs Laurie Wilson and Graziella “imbrication [of psychoanalysis] in the full lence in contemporary theater and virtual Magherini will host The Sixth International matrix of cultural knowledge” remains crucial culture. Segueing into the contemporary Symposium on Psychoanalysis and Art to be to the health, endurance and flourishing of scene, and in a testimony to the enduring held on May 15-17, 2014. This conference, both clinical and cultural psychoanalysis. capacity of psychoanalysis to invent and rein- “Art/Object: the Artist, the Object, the vent itself through the arts, my own Patron and the Audience,” brings paper, “Alison’s Autographics,” will dis- together leading scholars on art, litera- cuss cartoonist Alison Bechdel’s invo- ture, music, psychoanalysis and neuro- cation of D.W. Winnicott, as “muse” to science in sessions to be held at a 14th her nascent self. By turning to graphic century cloister, Chiostro del Maglio. narrative as an emerging genre in this There will be two plenary addresses: symposium, we are once again witness The renowned art historian, David to psychoanalysis’s never shying away Freedberg (The Power of Images), will from any aspect of creativity and cul- address “Art, Empathy and Neuro- ture, a claim to which Adele Tutter will science,” which will be discussed by respond with further reflections on Vittorio Gallese, the eminent neuro- “the psychoanalytic muse” as pervasive scientist. Distinguished choral con- in modern culture. Las Meninas—Diego Velázquez ductor and music director, David Museo del Prado Madrid This international symposium pays Rosenmeyer (Oratorio Society of credence to the true power of psycho- New York), will present “Mahler: Death and SCULPTURE, COLLECTIONS, FASHION analysis. The life that psychoanalysis has found Rebirth in Song,” which will be discussed by AND GRAPHIC ARTS and will continue to find in the arts and musicologist Alexandra Amati-Camperi. The symposium will take up the ways psy- humanities contradicts the laments we often From these two plenary addresses, one can choanalysis continues to learn from and con- hear regarding the diminished interest in see the interdisciplinary dialogue that tinues to illuminate art, visual culture and psychoanalysis in our fast-paced world. This informs the vision of this conference. material culture. For example, Jane McAdam symposium suggests an ongoing renaissance Indeed, by bringing together the worlds of Freud, the sculptor and great-granddaughter in the cultural field, placing art where Freud neuroscience, music and art through the lan- of Freud, will present a paper entitled “In the placed it: at the very core of his vision for guage of psychoanalysis, the cultural field is Mould of the Fathers—Objects of Sculpture, both clinical and cultural analysis. For as he expanded to position sciences and art in Subjects of Legacy.” Donald Kuspit (The makes very clear: “the use of analysis for the dynamic discussion, reviving Sigmund Freud’s Death of Art) will address “Collecting: A Nar- treatment of the neuroses is only one of its original vision of the “psychoanalytic academy” cissistic Agony,” to which Mary Kay O’Neil applications; the future will perhaps show enunciated in The Question of Lay Analysis, will respond with her paper, “The Analyst as that it is not the most important one.” where he invokes “the evolution of human Collector.” Gennaro Saragnano, chair of the Freud’s challenging prediction suggests that civilization and its major institutions such as art, International Psychoanalytical Association’s as analysts, artists, critics, patrons, journalists, religion and the social order” as the ultimate Publication Committee, will moderate a educators, and audience, we have powerful forum for the psychoanalytic enterprise. The roundtable discussion on art and psychoan- cultural tools that derive from clinical con- Florence Interdisciplinary symposium on art alytic publications, while other talks will texts in a mutually enriching and creative explore art in relation to broad societal communion of body, mind and spirit. It is our Vera J. Camden, Ph.D., is professor of issues including “Fashion as Fetish,” by art his- hope and expectation that this gathering in English at Kent State University and training torian and fashion writer, Amy Fine Collins. Florence will celebrate such creativity in the and supervising analyst at the Cleveland Other interdisciplinary talks will explore spirit of its founder’s vision for psychoanalysis, Psychoanalytic Center. She is a member of the art in relation to broad societal issues such culture and society. Please join us in Florence. Committee on Research and Special Training as “Belgian Modernism and Imperial Violence For more information visit http://www.florence and co-editor of American Imago. in the 1890s,” by art historian Deborah psychoart2014.com/events.

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 23

F I L M

As It Is in Heaven

Allan Gold Bruce Sklarew, Film Editor

Daniel Dareus, a play on words from the Bible story, (played by Michael Nyqvist) is transformed and transfigured on his journey from world-class conductor to a disguised boy/man in a dangerous return to the dark and cold place of his childhood in northern Sweden. His heart attack triggers past heart- breaks. Daniel’s doctor says, “Your heart is Allan Gold Bruce Sklarew completely worn out.” We see that Daniel was beaten by the Kay Pollak, the successful Swedish director, boys of his town while practicing his violin in How does this happen? This film tells us returned to filmmaking after an absence of an open wheat field. Immediately after, he much about trauma and healing. 20 years in 2002 when he directed As It Is says, “I want to marry you, Mommy,” as the The prolonged and repeated trauma of in Heaven. In the interim he published a face and voice of his mother comfort him being sadistically beaten, rejected, humiliated little book of spiritual wisdom titled No and she promises to take him away to and terrorized many times by the boys, joins Chance Encounter. He the cruelty of fate that strikes down Daniel’s writes, “Everyone I meet mother (and where is the father whom we is my teacher…in every never see?). Daniel’s development freezes on encounter with another the spot with lightning speed. The boy person I have something escapes into music. to learn…just imagine if Pierre Janet described trauma in the mind everyone I meet is sent as a large zone of inflammation, walled off by for a purpose…” Could surrounding layers of scar tissue, around Pollak’s vision be right in which an outer rind might mature, rerouting a very deep sense also? all connections Are there any chance around the fro- encounters? Is life on zen center into a earth…As It Is in Heaven? rigid or chaotic another school. When personality. This she comes to hear cuts off impor- Allan Gold, M.D., practices psychoanalysis him play later as a tant internal and and psychotherapy in Baltimore. He has been young teen, she is external experi- a discussant for many years of films in the cruelly struck down ences that a child Baltimore Washington Institute’s “Close-Ups: by a car that he sees would need to Psychoanalysts Look at Film” series. impassively from a tower window above the develop into a full loving adult. A career in Bruce H. Sklarew, M.D., an associate street. In this film, he becomes a generative music is a wonderful displacement and com- editor and co-founder of the award-winning “Man of Achievement” (Wilfred Bion) promise, but not a substitute for the buried Projections: The Journal for Movies through his love for Lena (played by Frida emotions and energies inside Daniel’s real and Mind, organizes the film programs Hallgren), a local, young, unsophisticated and self. His potential for a full life is encased at meetings of the American Psychoanalytic vivacious beauty in the frozen northern behind a castle of repression and a garrison Association and has co-edited two books Swedish town. We watch as his and the of defensive guards. on psychoanalysis and film. town’s frozen hearts melt and meld together. Continued on page 25

24 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 FILM

THE JOURNEY BACK Daniel regulates his aggression with love as After his heart he stands up for the abused and repressed attack, Daniel returns wives of Connie and Stig, both of whom try to the town, for rea- to murder him in the film for threatening sons he was not con- their tyrannical control of their wives. Res- scious of, to a frozen cued by the town, he reveals his identity and landscape on a snow his childhood trauma as the town rallies buried road. The around him. He achieves mature sexuality unconscious seeks wholeness. His life had reached a pinnacle, yet he feels numb. His return to the frozen town of his youth, in the dark of winter, symbolizes the journey that a traumatized person in therapy makes Daniel on the night of his beating. into the dark areas of the mind. Lena shyly and playfully awakens Daniel encounters Connie, now a man, notes of a buried chord in Daniel that vibrates and love culminating in what is likely his first who was the abusive persecutor of his child- with her sexuality and tenderness. He cannot sexual experience, followed by tender sleep, hood, and Stig, the repressed, tyrannical take his eyes off her beautiful smile, which just a few hours before he will die a com- churchman of the town, who mirror the cru- begins the melting of his heart. Lena’s tender plete and Authentic Man. elty of fate, Daniel’s own murderous rage, his and sexual feelings will combine to reawaken identification with the aggressors, external and harmonize Daniel’s connections back to A LARGER CONTEXT persecutors who embody the internal perse- the mother of his childhood and forward in The film reflects multiple Oedipal triangles. cutors that cut him off from human warmth. time to his becoming an adult sexual partner. However, as Freud also taught, our patients’ Lena helps him recover from both lives take place in larger contexts of meaning, the traumas of violent bullying and history, human culture, art and literature, and the violent loss of his mother by pro- myth. The film in story and imagery portrays viding the mirroring Daniel needs Daniel as Christ-like and as Daniel in the for early reattachment, as we do lion’s den in the Old Testament. Even more central, as in the myth of the hero elaborated by Jung and Joseph Campbell, a broken Daniel leaves the familiar, undergoes a series of trials and perils, and brings wisdom, skill and healing back to his home. Daniel is like He is easily overwhelmed by anxiety, Odysseus in his journey back to Penelope unable to face the intense anger and or Percival in search of the Holy Grail. longings inside or to connect emo- The film also resonates with more recent tionally with understandings in psychoanalysis from infant people outside. research and neuroscience. Like Lars, in the The film articu- American/Canadian film Lars and the Real Girl, lates a “myth of with our patients. Daniel prac- Daniel is hypervigilant and hypersensitive the hero,” a tices new skills and develops (emotionally and tactilely). His schizoid and journey back to tolerance for emotions and avoidant personality struggles against a hyper- connection with anxiety. Lena smiles as he aroused nervous system resulting in his avoid- Daniel’s deeper explores leadership and learns ant and, at times, odd behavior. Daniel learns self and others. friendship with the choir, using through Lena and his encounters at multiple Lena, her face illuminated in the warm light his acquired skills and talent in music to cre- levels with the town to find centers of calm in of the town convenience store, first appears ate community in the choir and a commu- his personality, his music and his nervous sys- as the angel of Christmas. Her smiles and face nity of interconnecting aggressive and loving tem and to allow increasing amounts of contact. recall Daniel’s mother when she comforts emotions within. Continued on page 29

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 25 PSYCHOTHERAPY

ceased to trouble the field. Perhaps these dis- Psychotherapy in cussions fail to resolve the question because they engage it at only a manifest level. A sub- Psychoanalytic Organizations terranean level of great emotional power Alan Pollack remains unaddressed, resisting resolution by intellectual comparison alone. I have come to The nature of informatively, its Workshop for Directors of think of this level as characterized by projec- the relationship Psychotherapy Training Programs. The work- tive identification, in which disavowed but between psy- shop became a vital support group for those inescapable parts of psychoanalytic treatment choanalysis and of us struggling with the complex dynamics were consigned to psychotherapy. psychotherapy of representing the value of psychotherapy Freud described the scope of psychoanaly- has bedeviled training within psychoanalytic institutions. sis, in that same 1918 address, as “to bring to our field, seem- Through our discussions, we discovered that the patient’s knowledge the unconscious, ingly eternally. similar dynamics affected every psychoana- repressed impulses existing in him, and, for While framed at lytic organization that undertook psychother- that purpose, to uncover the resistances that an intellectual apy training—with, of course, local flavorings. oppose this extension of his knowledge about Alan Pollack and clinical level, I would like to share some speculations himself.” Anything other than providing such the issue also has organizational repercus- regarding some sources of these dynamics. insight deviated from “pure” psychoanalysis. sions that powerfully affect many psychoana- By the 1950s, the desire of psychoanalysts for lytic institutions. These forces have been IN THE BEGINNING… purity had produced an austere and impos- particularly challenging in recent decades From its earliest years, psychoanalysis was sible model of treatment. The ideal analyst when so many societies and institutes, concerned with distinguishing itself from would limit himself to systematic interpreta- responding to the crisis in institute recruit- other therapeutic modalities. Freud was par- tion designed to facilitate the development ment, have established psychotherapy train- ticularly eager to distinguish psychoanalysis and then the resolution of a regressive trans- ing programs. The problematic aspects of the from suggestion, the use of authority to influ- ference neurosis, through insight alone. dynamics include these: The analytic institu- ence the patient. The relative value he placed tion responds to the new psychotherapy on the two modalities is captured by his DYNAMICS OF DISAVOWAL program with concerns about standards, famous remark to the Fifth International How far we have come from that original identity, intrusion, cooption and corruption; Psycho-Analytical Congress in 1918: “[T]he ideal is evident in nearly every contemporary those involved in the psychotherapy program large-scale application of our therapy will psychoanalytic presentation. Almost all ana- experience distrust, marginalization and compel us to alloy the pure gold of analysis lysts now conceptualize insight as meaningful devaluation. Sometimes the tensions are with the copper of direct suggestion.” and effective only as part of the relationship pointed and intense, sometimes subtle and Freud’s hopeful vision of a “large-scale between analyst and analysand. And this implicit. Over time, as the worst fears prove application of our therapy” eventually came therapeutic relationship is understood not to be unfounded, tensions diminish, and the to fruition, in the form of psychotherapy. But merely as the catalyst for the development of strained upstairs-downstairs relationship this successful development triggered a crisis insight, but as an active, complex force essen- evolves into a beneficial partnership. of identity, compelling psychoanalysts to tial in its own right to therapeutic action. If we I have been privileged to occupy a ringside define what distinguishes psychoanalysis are correct in this today, how did psychoanal- seat on these developments, both locally and proper from psychoanalytic psychotherapy. ysis deal with this essential force before? I sug- nationally. I served as director of psychother- The struggle begat repeated discussions, gest that it dealt with it largely by disavowal. apy training at the Boston Psychoanalytic debates, panels and reports, all attempting to All along the historical route to our contem- Society and Institute (BPSI) for 24 years. I was clarify the issue, but none successfully putting porary position, psychoanalysis repeatedly also a founding co-chair of APsaA’s Commit- it to rest. (For a history of these matters, see rejected proponents of the interpersonal tee on Psychotherapy Training, and most Robert Wallerstein’s book The Talking Cures.) position, consigning them and their work to Why has so much intellectual effort failed to the realm of not-analysis, that is, to the realm put the question to rest? Why do we repeat of psychotherapy. Alan Pollack, M.D., is a psychotherapist the same debates over and over? But psychoanalysis could not successfully and psychoanalyst practicing in Newton, In these discussions, commonalities and dis- rid itself of this supposedly non-analytic taint. Massachusetts. He is a member of the faculty tinctions between psychoanalysis and psycho- In one form or another, the interpersonal of the Boston Psychoanalytic Society and analytic psychotherapy have been mapped force kept finding voice, and kept having to Institute, where for 24 years he served carefully and usefully. Yet the question of the be rejected. From our current understanding, as director of psychotherapy training. relationship between the two never quite Continued on page 27

26 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 PSYCHOTHERAPY this recurrence was inevitable because of the training program—or that has even discussed We “discovered” two-person psychology, truth and necessity of the rejected view. Thus establishing such a program—come reports intersubjectivity, enactments, self-objects, psychotherapy held a disavowed but essen- of upstairs-downstairs dynamics, of devalua- empathic resonance, countertransference as tial part of psychoanalysis. tion subtle or overt, and of signs of threat- an active force, and so on, all relational I would like to propose a speculative claim. ened identity in the parent psychoanalytic dynamics under new names. It is not essential to my observations on organization. The French psychoanalyst Paul As psychoanalysis has become more rela- institutional dynamics, and I will not try to Israel noted that as Freud’s gold/copper tional, many analysts have come to see substantiate it. My speculation is that Freud’s analogy was repeatedly quoted and para- psychoanalysis and psychoanalytic psycho- conscious and principled disavowal of sug- phrased over the years, the second metal therapy along a spectrum, rather than gestion was part of a broader disavowal, one gradually transmuted from copper to bronze, divided by a gulf. Disavowal and devaluation less conscious, which was a disavowal of the tin and ultimately lead—an alchemy of urgent have diminished, and psychoanalytic institu- importance of relationship; and furthermore, disavowal. tions have increasingly embraced psycho- that the importance of relationship was dis- Identity threat is not the only cost for the therapy training as part of their mission. avowed partly because it fell within the disavowing. Impoverishment, though often Market realities have contributed powerfully realm of the feminine. Freud’s patient H.D. consciously unrecognized, may be the greater to this development. The consulting firm that recalled that Freud confessed to her, “I do cost. What is left for dominant culture if irra- helped guide BPSI’s strategic planning pro- not like to be the mother in transference—it tionality, intuition, creativity, sexuality, softness, cess reported a blunt conclusion from its always surprises and shocks me a little. I feel vulnerability and other such troublesome national research: The institutes around the so very masculine.” (I am indebted to Boston attributes are all to be assigned, variably, to country that remain strong are those with analyst Lora Tessman for this quotation.) blacks, to gays or to women? successful psychotherapy training programs. Insight penetrates, phallicly. Relationship Impoverishment leads to a complex Yet I suspect market forces alone would holds, maternally. response. The affirmed identity, needing ele- have been insufficient to effect change were Whatever the value of this speculation ments of vitality assigned to the disavowed, psychotherapy still so desperately needed as about Freud’s psychology, psychoanalysis dis- repeatedly must reincorporate aspects of the container of projective identification in avowed the importance of relationship. I do the disavowed. The trick is for the affirmed the service of supporting the threatened not intend to consider here the profound identity to frame the reincorporations as identity of psychoanalysis. implications of this disavowal for psychoana- new developments proper to itself, without The pendulum in mental health has begun lytic theory and practice, nor the transforma- acknowledging the source. Yet because each to swing back from its reductionist biological tion of theory and practice that has resulted reincorporation diminishes to some degree position, and trainees are looking to psycho- from the gradual reincorporation of the the distinction between the two identities, analytic institutions to enrich the constricted importance of relationship into psychoanalysis. identity threat increases, and the distinguish- perspectives offered by their primary training That subject has been treated well by many ing line has to be drawn and redrawn, over centers. Psychotherapy training is our pri- writers (for example, by Stephen Mitchell in and over and over. (Think of the develop- mary means of connecting with these train- Hope and Dread in Psychoanalysis). What I ment of popular music in the 20th century. ees. At BPSI, we regularly draw about 30 wish to consider here are some of the organi- To begin to internalize the exciting sexuality students each year for our first-year psycho- zational dynamics of the disavowal process. and rhythmic intensity of black music, white therapy program. The energy and enthusiasm The dynamics of disavowal are familiar culture needed to invent Elvis, whose dazzling are palpable. Things could not have evolved from other forms of group projective identi- glitter kept the blackness of the music out of this way had the old split persisted unabated. fication. On the level of society, one thinks of view. Later could come Motown, black but Internal devaluation and marginalization of race, ethnicity, gender or sexual orientation not too black.) psychotherapy hobbled us. But our field is as fault lines across which such projective The model of pure psychoanalysis became gradually healing the old split in its identity, identifications occur. On one side of the line increasingly impoverished as it excluded unleashing new vitality and vibrant possibili- is the affirmed identity; on the other, the dis- from its official, affirmed self much that is vital ties for growth. avowed. Devaluation is a painful conse- and necessary in the therapeutic process, quence for the disavowed, and identity threat much that analysts knew and practiced but is an ever-present anxiety for the disavowing. could not openly value or even acknowledge. The 1950s model, at the time of the field’s A version of this article FROM COPPER TO LEAD apogee of worldly power and respect, was was presented to the New York Anyone involved in psychotherapy within austere nearly to the point of sterility. Rein- Freudian Society and reported organized psychoanalysis knows this dynamic corporation was essential, and it proceeded in their newsletter. well. From every psychoanalytic society and largely as just discussed, via a series of “new” institute that has established a psychotherapy developments within psychoanalysis proper.

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 27 LEARNING OBJECTIVES

Educational Objectives for psychoanalytic education is their highest A second objective addressed skills Continued from page 15 category, self-system thinking. required in many advanced clinical courses The six levels are: and relied on previously acquired learning. NEWER TAXONOMIES OF LEARNING 1. Retrieval of information “Analyze clinical material so as to identify The accumulation of many years of expe- 2. Comprehension of content and evaluate the theory underlying the rience and research with educational objec- 3. Analysis—identifying similarities and dif- analyst’s work.” This objective assumes the tives has led to revisions of Bloom’s original ferences, classifying categories, analyzing learner already can detail relevant factual taxonomy, two of which offer promising sys- errors, and creating new generalizations information about the case being pre- tems for organizing psychoanalytic objec- 4. Knowledge utilization—decision mak- sented and can also comprehend the con- tives. They are constructed with hierarchical ing, problem solving, investigating, and tent of differing theoretical perspectives. categories from basic to more complex experimenting Applying Anderson’s classification, the abilities as is Bloom’s system. Yet, these tax- 5.  Metacognition—monitoring process, emphasis is on procedural capabilities, dis- onomies attempt to go beyond that early clarity, and accuracy cerning from the material which theoretical effort by incorporating research findings and 6. Self-system thinking—examination of a) perspective is represented. Further, the updated thinking about learning processes. importance of the information to the objective involves the metacognitive skill of Both also include new conceptual foci espe- self; b) efficacy of one’s competence or evaluating and articulating the usefulness of cially pertinent to our field. One of these, understanding and capacity to improve; that particular theoretical perspective as called metacognition, pertains to the capac- c) emotional response to the learning compared with others. ity for self-reflection regarding one’s thought experience or material; d) motivation to With Marzano and Kendall’s system, it is processes. Much of our clinical work depends improve or understand the information important to note that they use the term on being able to observe ourselves, emo- or procedure. “analysis” in a different way than we do, as tionally and cognitively, and to apply that To demonstrate the usefulness of both of analytic teachers. We generally consider it understanding to patient encounters. The these taxonomies, I have selected two learn- to include investigation and generation of second taxonomy emphasizes the impor- ing objectives from the APsaA 2013 National hypotheses (knowledge utilization) as well tance of the subject matter to the learner as Meeting. Each emphasizes different kinds and as consideration of the validity and clarity well as his/her motivation to learn. The dif- levels of learning. of our ideas (metacognition). The above ferences between the two lie in what cate- The first, more characteristic of introduc- objective incorporates both of these and gories the systems choose as the basic tory courses, had as its goal that the successful more broadly the consideration of the value elements of learning. learner could “describe several developmental of the theoretical perspective to the learner Loren Anderson and Krathwohl, in 2001, features of preschool children that make play (self-system thinking). edited A Taxonomy for Learning, Teaching, and the preferable therapeutic technique.” This Assessing that identifies four major types of objective would be seen as demonstrating PROGRESS TOWARD CLARITY knowledge present in the cognitive process- conceptual knowledge, using Anderson and We are fortunate to be making progress ing of information. Krathwohl’s categories, since description toward greater clarity of definition in our edu- 1. Factual—including terminology, specific requires familiarity with developmental stages cational endeavors through the use of learn- details and elements and tasks as well. It also incorporates proce- ing objectives. Cabaniss and others have 2. Conceptual—incorporating classifica- dural knowledge (level 3), concerning the demonstrated that there are useful exercises tions, principles, generalizations, theories application of the play technique and its par- that help students and candidates simulate and models ticular suitability to preschool aged children. clinical decision making. In these ways, candi- 3. Procedural—how and when to apply In Marzano and Kendall’s system, the session dates can practice in vivo skills before applying knowledge and methods of inquiry planners direct learners toward both content them. The groundbreaking efforts to improve 4. Metacognitive—strategic thinking as (level 2) as well as analysis (level 3) learning. psychoanalytic education have contributed to well as awareness of one’s own cogni- The content level stresses knowing what our ability to effectively describe the complex tion, i.e., the capacity to evaluate one’s developmental tasks are typically accom- tasks of analytic work. own thinking plished by preschool aged children, what This is the job we have before us: carving Robert Marzano and John Kendall pub- research says concerning the ways preschool out the higher ground between the pros lished Designing and Assessing Educational children are growing, and the nature of play and cons of educational objectives. Surely, Objectives in 2008. They emphasize the levels as a therapeutic approach. Analysis of the our aim is to use objectives for what they of cognitive processing of information and information enters into consideration of play can offer us in enhancing educational efforts, also provide a more detailed look at the dis- as contrasted with other technical interven- while keeping an eye to the fact that our tinctions between cognitive and metacogni- tions and the capacity to state advantages for goals are always larger. We are still on a tive tasks. Perhaps most important as a model children of that age group. learning curve.

28 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 FILM

As It Is in Heaven The film, like our Continued from page 25 dreams, like music, reso- nates with our biologically Terror of contact is desensitized with pro- more primitive affect sys- gressively safe contact experiences. tems. Our nervous sys- As with our patients, frozen developmental tems, like superbly crafted capacities can then unfold, activating calm- violins whose woods ing influences of the parasympathetic ner- resound with the harmon- vous system, balancing the fight/flight/freeze ics of the strings, have feelings of the sympathetic nervous system. This results in a deconditioning of the Rivers flow. We actually can feel in our terror of these sensations bodies the warmth in Lena’s smile, excite- while curiosity, interest and ment in her sexuality, liveliness in her child- a sense of mastery rise, just like expressions of anger and longing. We as our patients in psycho- belly laugh at the antics in the little choir analysis and psychotherapy room where the singers romp, play and pile talk about and renegotiate on each other, dancing, drinking and feasting the stories of their lives. as in an overtly sexualized Dionysian bac- chanal. We constrict with terror and hold MASTERING ANXIETY our breath, as Daniel is facing Connie in the Anxiety changes from a icy river once again having his chest beaten, dreaded harbinger of overwhelmedness to a evolved to respond cognitively and emo- or Stig with a shotgun plans to kill both Daniel signal for more attention to feelings of excite- tionally to sound, story, facial expressions, and himself. In the film, the skillful deliberate ment as body and mind encounter new color, patterns and word connotations con- focus on facial close-ups and musical accom- opportunities for challenge or fulfillment. sciously and unconsciously. Pollak is a sophis- paniments draws us as viewers into empathy Daniel in his exuberance in learning about ticated director who uses these elements to and energetic activation patterns. love, riding a bicycle, the joy of childlike play evoke deeper emotional experiences in the Bion suggests our minds, awake or asleep, in his work with the choir, emerging sexual viewer. For example, the landscape itself are always working with linkages and ana- and tender love for Lena, spontaneously mirrors the theme of transformation. As the logues in sensation and symbolization, which explores new capacities for sensation and snow melts, the river flows, the sun shines he calls the alpha process that is the same as emotional activation in relationships. He longer; as the iceberg melts inside Daniel’s in dreaming. He further suggests that our learns to manage conflict and sexuality with mind and heart, we melt with sympathetic waking lives, psychoanalyses, and dreams are others through discussion and negotiation. sorrow and joy. all constructed by processes that bring the ultimate unknowable cosmos into the indi- vidual who is open and achieves mature inner development in a relationship with another human being. Daniel’s lifelong goal of unlock- ing the music in the human heart is linked with his view that it already exists in heaven. Pollak in his emphasis on “no chance encoun- ter” parallels the findings of the attachment researchers, neuroscientists, evolutionary biologists, and infant researchers that there are, inside the core of us, systems, evolved over millennia of astronomical and biological evolution, that suggest we are more transper- sonal and intersubjective beings than intrapsy- chic beings. As Pollak and other mystics would say, there are no chance encounters. We are here to learn to be human… to love each other… on earth as it is in heaven.

THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014 29

Psychodynamic Perspective Some of our earliest efforts were aided by psychopharmacology. That combination would Continued from page 17 psychoanalysts, including William Frosch and not be satisfactory at Weill Cornell. We want the late Arnold Cooper, as well as the late our residents to be able to think about what is I made a very fast trip and was totally Sam Perry, a psychoanalyst who was the vice in their patients’ heads, how their worlds are enchanted by a place that covered much chair for research in the department and had constructed. We do not expect our residents wider areas than most people realized and a magical ability to encourage multiple areas. to become analysts—some do, most do not. had a spirit of collegiality, an interest in ideas, Later, David Silbersweig, now chair of psychia- Believing that it is helpful to better understand a reputation for excellence in its clinical and try at the Brigham, became the vice chair for themselves and that they are part of the educational activities, and was a center of research and, while not an analyst, was pleased instrument of treatment, I urge residents to outstanding scholarship, with extraordinary to be helping those projects and even had a have personal therapy, a practice common full-time and voluntary faculty. joint project with Otto Kernberg. years ago, less so now. I found such therapy While some of my friends in neurobiology Another significant direction was made helpful both personally and professionally. had taken chairmanships and then enforced possible by the Sackler family with the estab- And I have always been impressed by the wis- massive changes, I did not feel that was lishment of the Sackler Institute for Develop- dom and advice persons with psychodynamic appropriate for Cornell. Indeed, when offered mental Psychobiology, through the wonderful experience can bring to the discussion of the position, I felt it was more like a trustee- philanthropy of Mortimer Sackler, a psychia- issues on any subject, from patients to the arts. ship for me to preserve and protect its best trist interested in both biology and psycho- Aaron Beck, the great cognitive behavioral aspects and build some additional foci that analysis. Ilene Sackler, one of his daughters and therapist, once told me that when young psy- might interact. With Philip Wilner, the excep- a voluntary faculty member, was particularly chologists ask him for advice about places to tional executive vice-chair of the department, interested in the project to which the entire take an internship, he often suggests they it has been possible to undertake such a plan. family has contributed. In this case there was consider Payne Whitney. They will say, isn’t it We have a developmental focus from child- also major input from others, all psychoana- just psychoanalysis in its orientation? He tells hood through geriatrics, a remarkable array lysts. Bob Michels was a force for the project, them it is actually everything—you can do of specialized clinical programs and research, which was also inspired by the late, beloved various forms of psychotherapy, or have and initiatives in many other subjects such as Dan Stern. Ted Shapiro helped with the interests in completely different areas, but history and social policy. Analysts are involved development of the project. An individual the key is to do whatever you do with excel- in all aspects, but so too are persons with who made a major difference was the late lence. I think that describes Weill Cornell quite different interests working together in a Ethel Person, who served on the founding quite well. As Francis Lee, a brilliant neurobi- cooperative manner. board and was an important advisor to me, ologist, now vice chair for research, said when We have tried to facilitate scholarship in encouraging the combination of psychody- he chose to come here for a faculty position many areas for the department. In terms of namic approaches and biology. The institute when he was one of the, if not the, hottest psychoanalysis, that has included support for was first headed by Michael Posner, the pio- prospect of his year on a national basis, “I like projects such as that of Bob Michels as a neering developer of cognitive neuroscience, the tapestry of the place.” So do I. We are a coauthor of the new classic edition of the and is now headed by B.J. Casey, considered large clinical program but a smaller research volume on interviewing; Otto Kernberg and one of the best developmental psychobiolo- program with few silos, so there are strong his colleagues dealing with psychodynamic gists of her generation in the world. natural pressures for people to work together treatment and biological aspects of border- I must admit that one other effort on behalf and that encourages collaboration and intel- line personality disorder; George Makari and of psychoanalysis did not work out as I had lectual interaction, a feature that is relatively his brilliant text on the intellectual history of hoped. When I came to New York 20 years rare and is prized by the faculty. psychoanalysis; John Barnhill in his able writ- ago, I believed there would be an advantage Years ago, one of my mentors, Maurice ing on diagnosis and various approaches in to a merger of some of the analytic institutes. Grossman, told me, “Someday it (referring psychiatry; Betsy Auchincloss with her coedit- Toward that end, I met with the leadership of to the combination of psychodynamic medi- ing of the fascinating dictionary of psycho- several institutes—all agreed it might be a cine and biology) will all come together.” I analysis; Milt Viederman with a project on good idea someday, but “not now.” believe we are entering that phase. The interviewing patients in consultation liaison Interestingly, while we do have analysts on result will be good for a renewed under- using psychodynamic approaches, and Bar- our staff, most faculty members are not ana- standing of behavior and treatment for bara Milrod with her pioneering projects on lysts. The difference is that many places now patients with a wide range of problems. We anxiety. A number of these projects and vol- have almost no full-time faculty with such a will truly be able to have individualized ther- umes have received national and interna- background—we do. Some have none. A apy that will take into account factors of tional acclaim. We are proud to have been friend told me that at his nationally ranked which we now have only a faint glimpse. able to facilitate them as we are of projects in institution he is happy if his residents have Biology in its various forms will be impor- other areas of psychiatry. memorized DSM and a textbook of tant, but so, too, will be behavior.

30 THE AMERICAN PSYCHOANALYST • Volume 48, No. 2 • Spring/Summer 2014

CPT Codes strictly limits the scope of information that Study Group Continued from page 20 can be disclosed to insurers. Continued from page 13 Documenting with “data points” creates an Therapists will increasingly practice “off incentive to use computerized templates, We hope that by reaching a wider reader- the grid,” treating patients who can pay out because the electronic health record’s ship we are helping the supervisors, new and of pocket. Paradoxically, the expanded mental “checklist” format saves time. But aside from experienced, in the supervision of candidates health provision of the Affordable Care Act convenience, using the electronic health in their work with child and adolescent ana- will be associated with decreased availability record increases the risk of privacy breaches, lytic cases. We also hope that we have con- of psychotherapy. In the aftermath of atroci- thereby further eroding the bedrock of trust tributed to making the art and science of ties like Newtown, as well as other massacres in the therapist-patient relationship. supervision a subject that will be taught and involving untreated mental illnesses, it is dis- The new codes’ impact on quality of care, discussed within the institutes of the Ameri- graceful that those most in need of treat- payment, access and confidentiality could can Psychoanalytic Association and other ment will have less access. make psychodynamic psychotherapy scarce training institutes as well. for patients using their insurance. Psychother- While our work is under the general head- PRIVACY apists should advocate for patients by raising ing of child analysis, many of the areas of Patients’ records are now created to justify such concerns to professional organizations study we address are applicable to the work payment, rather than chronicle treatment. and patient advocate groups. As profession- of supervisors of the analysis of adults as well. The expectation is for records to be audited. als, we should demand a clinically sound, fis- The study of finding ways to help supervisors Such audits starkly conflict with our profes- cally manageable billing infrastructure that work more effectively is clearly not intended sional ethics regarding patient confidentiality will safeguard and sustain the practice of exclusively for analysts who treat children and the “minimum necessary” policy, which psychodynamic psychotherapy. and adolescents.

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