the Spring/Summer 2011 AMERICAN Volume 45, No . 2 PSYCHOANALYST Quarterly Magazine of The American Psychoanalytic Association Tucson and the INSIDE TAP…

American Psychoanalyst Election Results...... 4 Leo Rangell One Hundred Years When the former editor of TAP invited me THE SCOPE OF of History . . . . . 7–12 to write something about how the American To pursue the thought, I would like to have Special Section psychoanalyst relates himself to the event in us look first at some historical accounts rela- Tucson (“This is a magazine, not a journal,” he tive to the subject as I have lived through it on Tucson. . . . . 14 –21 added, which would make the task easier.), during my three-quarters of a century as a Research Grants my first reaction was to say, “No thanks, we psychoanalyst. During the early decades of my don’t, or cannot, look into that: There is no psychoanalytic career, I was imbued with the Awarded ...... 22 room for anything psychoanalytic in this feeling that psychoanalysis stops here, that psy- Special Section wanton act.” But on second thought, the chopathy in any of its forms spells the limiting on Privacy and shootings that day came from the mind of a factor in applying analytic insights. Psychoanaly- person, and psychoanalysis is to me the sis was for the neurotic, not the psychopath. the Courts. . . . . 28–30 essence of the science of the human mind. Continued on page 15 Nothing in the latter can be omitted; there is an explanation for the mental landscape in its totality or of any part. Leo Rangell Tucson was in fact one in a series, which there is no reason to believe will Fellow Members of APsaA, not continue. Before that, there were With profound regret I inform you that one Columbine, Oklahoma, Virginia Tech, of the most forceful voices for psychoanalysis has and Fort Hood. Behind each, there was been silenced. Leo Rangell, the first man to be a human mind gone rampant, acting named honorary president of APsaA, passed away under the power of distorted beliefs. on May 28 at the age of 97. Leo had been a major, Yes, psychoanalysis is quite relevant. But and constant, contributor to our scientific literature just where does the psychoanalyst fit for eight decades, including the present one. in? I told the editor that I would try. His oeuvre constituted over 450 publications, many of them seminal. Every such exploration in the past has He served as president of both APsaA and of the IPA, each on two occasions. led to an opinion, usually an increased conviction, of the validity and applicabil- In recent years he had also been a presence on the Huffington Post as well ity of the discov- as on NPR. In addition I counted him as my personal friend and mentor. ered more than a century ago. A closer Leo was, in a word, extraordinary. view of this series of events, each I extend my sympathies to the Rangell family and to his special friend instance of which bursts upon the scene and companion, Beth Kalish-Weiss. seemingly anew, to the shock and dis- He will be missed, but not forgotten. may of the surrounding environment, Warren R. Procci, President, APsaA cannot fail to be without some benefit.

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 1 CONTENTS: Spring/Summer 2011 THE AMERICAN PSYCHOANALYTIC ASSOCIATION President: Warren R. Procci 3 Making the Impossible Profession Possible Warren R. Procci President-Elect: Robert L. Pyles Secretary: Beth J. Seelig 4 APsaA Elections Treasurer: William A. Myerson Executive Director: Dean K. Stein Child and Adolescent Analysis: Crisis and Opportunity 5 Honorary President Charles E. Parks Leo Rangell 7 A Short History of the American Psychoanalytic Association 1911 to 2011 Sanford Gifford and Nellie Thompson THE AMERICAN PSYCHOANALYST 8 100 Years of Psychoanalysis: The Timeline Project Magazine of the Elisabeth Young-Bruehl American Psychoanalytic Association Editor 11 Record-breaking Gala for The New York Psychoanalytic Janis Chester Society and Institute Editorial Board Brenda Bauer, Vera J. Camden, Leslie Cummins, Phillip S. Freeman, SPECIAL SECTION Maxine Fenton Gann, Noreen Honeycutt, Tucson Sheri Butler Hunt, Laura Jensen, Navah Kaplan, Nadine Levinson, Psychoanalytic Reflections on the Tucson Shooting: A. Michele Morgan, Julie Jaffee Nagel, 14 Marie Rudden, Hinda Simon, Vaia Tsolas, Michael Slevin Introduction Dean K. Stein, ex officio The Events in Tucson Jack Novick and Kerry Kelly Novick Photographer 16 Mervin Stewart “We are all more human than otherwise.” 17 Manuscript and Production Editors Psychoanalytic Treatment of Psychotic Patients: Michael and Helene Wolff, A View from the Austen Riggs Center M. Gerard Fromm Technology Management Communications

22 Science and Psychoanalysis: Making a Difference: The American Psychoanalyst is published quar- Your Research Contributions at Work Rosemary Cogan and Linda Mayes terly. Subscriptions are provided automatically to members of The American Psychoanalytic Asso- Accreditation for Psychoanalytic Education: Current Status ciation. For non-members, domestic and Cana- 24 dian subscription rates are $36 for individuals and Ronald M. Benson $80 for institutions. Outside the U.S. and , rates are $56 for individuals and $100 for institu- 25 COPE: Impasses and Failures in Analysis tions. To subscribe to The American Psychoanalyst, Judy L. Kantrowitz and Steven H. Goldberg visit http://www.apsa.org/TAPSUB, or write TAP Subscriptions, The American Psychoanalytic Association, 309 East 49th Street, New York, Who Will Teach in the Future? By Melissa Grady 26 New York 10017; call 212-752-0450 x18 or With Lisa Cobourn, Rana Duncan-Daston, Douglas Lane, Sergio Paradiso, e-mail [email protected]. and Daniel Rochman Copyright © 2011 The American Psychoanalytic Association. All rights reserved. No part of this publication may be reproduced, stored in a SPECIAL SECTION retrieval system, or transmitted in any form or by Privacy and the Courts any means without the written permission of The American Psychoanalytic Association, 309 East 28 Cases from the Frenkel Files: Psychotherapy Notes John C. West 49th Street, New York, New York 10017. 29 Politics and Public Policy: Ethical Versus Legal Obligations ISSN 1052-7958 in the Eist Case: A Shift in the Burden Graham L. Spruiell The American Psychoanalytic Association does not hold itself responsible for statements made in 31 Poetry: From the Unconscious Sheri Butler Hunt 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 45, No. 2 • Spring/Summer 2011 FROM THE PRESIDENT

Making the Impossible Profession Possible Warren R. Procci

As I sat down policies and their reimburse- to write this arti- ment patterns toward seriously cle for TAP, the shortchanging psychothera- Sunday, March 6, peutic treatment. I agree with New York Times these critics for this presents Photo: The New York Times Photo: The New York article about talk yet another challenge for us. Dr. Donald Levin, like many psychiatrists, does not provide therapy and its talk therapy because of insurance limits. unpredictable SAFEGUARDING future was on OUR PROFESSION For those of us who wish to continue to my mind. We as an organization and as a profession champion the value of psychoanalytic training Warren R. Procci The article need to do our best to insure that a psycho- and psychoanalytic treatment, there are a highlights Donald Levin, a Philadelphia psy- analytic career can provide one with an number of responses that we can consider. chiatrist, who was trained in the era of appropriate professional lifestyle, and I do broad-based psychiatry, as were many of us. not mean the kind of lifestyle that invest- A TRIPARTITE APPROACH Psychotherapy was always an integral part ment bankers may have, or perhaps even the We must continue to try to reverse the of professional life for these psychiatrists. kind of lifestyle that Levin thought he might insurance trends. We can certainly do what Levin describes how he has changed his have when he went to medical school prob- we can and APsaA has played its role in practice in order to be able to continue to ably 45 or so years ago. But, it is imperative advocacy much more effectively than one receive reimbursement. that individuals coming into our field be would predict based upon our size and bud- get. The problem is that no matter how assertive our efforts and how vigorously we …our level of devotion to psychoanalysis and wage our arguments, we do not have much psychotherapy exceeds that of many general mental control over this sector of the economy so success may not be certain. This area is no health practitioners who are willing to change their doubt going to be especially unpredictable in pattern of practice to follow the trail of reimbursement. the years ahead with health care reform looming and with the huge debt burden that our society is going to have to confront at He has stopped seeing patients for 45 to assured of a lifestyle comparable to those of some point. It is unlikely in this environment 50-minute psychotherapy sessions and at least some of their peer professionals, that health care is going to gain substantial instead performs 15-minute medication such as architects, accountants, academics, new benefits in any area. checks. He is no longer responsive to patient and professional managers. It is highly unlikely Another way we can think about this, and requests for psychotherapeutic assistance that one would be inclined to put in the this is much more under our control, is to do and instead refers them to other mental effort to become a psychoanalyst, with all everything we can to demonstrate the value health professionals. The article stirred much the attendant years of training, and the aca- of talk therapy and the availability of individuals interest on our listserv and a number of our demic and personal demands of our “impos- to provide it, and to provide it at a reasonable members were critical of Levin; I am not. He sible profession,” unless it opens a door to a fee, not at the $600 an hour referred to in the is merely doing what he considers necessary lifestyle comparable to individuals who have New York Times article charged by “a select to protect a certain style of living in the cur- made similar levels of effort for their own group of psychiatrists.” And not just for invest- rent environment. This represents a challenge professions. A characteristic of some of us in ment bankers as the article also suggests. The for us. Many of the respondents were critical the American Psychoanalytic Association is practice survey that APsaA will be conducting of insurance companies for changing their that our level of devotion to psychoanalysis in the near future will, I strongly suspect, show and psychotherapy exceeds that of many that most of our members already engage in general mental health practitioners who are the practice of psychotherapy and psycho- Warren R. Procci, M.D., is president of the willing to change their pattern of practice to analysis for fees that are often more modest. American Psychoanalytic Association. follow the trail of reimbursement. Continued on page 4

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 3

Making the Impossible Profession Possible Continued from page 3

Indeed, I suspect many members use sliding scales for patients who may well strongly benefit from psychoanalytic psychotherapy, especially psycho- analysis, but who cannot afford even today’s restricted full fees. There are three initiatives currently on our table, all of which I support, which will be helpful to us. One is our practice survey, which will tell us something about the practice patterns of our members and how many are interested in providing psychoanalytic psychotherapy and psychoanalysis and for what level of reimbursement. Second is the development of a stra- tegic plan for APsaA, which will help us identify organizational priorities. I suspect that the enhancement of psychoanalytic ideas, training, and the practice opportunities for our members will be major items in the develop- ment of our strategic plan. Third is the psychoanalytic outcome research being organized by Steven Roose. It is essential that we do all that we can do to assure the con- tinued vitality of talk therapy. Levin has a son in medical school. If we are successful maybe he will decide to join us.

Election Resultselections TREASURER First Round: William Myerson—344 Arthur Farley—334 Peter Kotcher—131

Second Round: Treasurer-elect William Myerson William Myerson—405—ELECTED Arthur Farley—397

4 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 CHILD AND ADOLESCENT ANALYSIS

of patterns of child analytic practice in New Child and Adolescent Analysis: York City, which was published in the Journal of the American Psychoanalytic Association Crisis and Opportunity (JAPA) in 2009. In brief, Hoffman et al. found Charles E. Parks that although there were relatively few child and adolescent cases in New York City, most Over the past 10 years, the Committee on Michigan-Ann Arbor, New York, and Seattle of these analyses were conducted by a small Child and Adolescent Analysis (COCAA) has each have 10 or more active child and ado- group of child analysts. Twenty-four percent conducted a series of three surveys designed lescent candidates. Many graduate child ana- (15/63) of child analysts were conducting a to assess the state of training in child and lysts, including those who do not have large substantial portion—73 percent (41/56)—of adolescent psychoanalysis at particular points child analytic practices, believe that their child the reported analyses. Hypothesizing that in time (2002, 2005, 2010). The results of training has been invaluable for all aspects there has always been a small, active cadre of these surveys point to the serious challenges of their work. Child and adolescent training child analysts treating a majority of child ana- as well as the opportunities for growth within programs have provided their graduates with lytic cases and that this group has enabled the the field of child analysis today. Over the five- enhanced understanding of child develop- field to endure, the authors conclude that “a year period from 2005 to 2010, both the ment and the attendant emotional conflicts systematic study contrasting the “high immer- number of child and adolescent candidates of childhood. These graduates can more sion” practitioners of C/A analysis with those and number of child and ana- who do not conduct C/A anal- lytic cases conducted by these ysis might provide the field candidates declined significantly. valuable information.” Overall, there are 20 percent fewer child and adolescent THE SOUTHEASTERN training cases and 21 percent CONSORTIUM— fewer candidates in child and A CREATIVE SOLUTION adolescent training than in 2005. To the extent that Hoffman However, from 2002 until 2005, et al.’s findings are generalizable, these percentages increased. As smaller or more geographically a result, when the survey data isolated child training programs from 2002 are compared with may be particularly burdened the 2010 data, there is a more by too few people doing too modest, but still significant, much of the work to “carry the decline. The number of child torch.” One particularly cre- and adolescent candidates has declined by 8 effectively respond to the needs of all of their ative response to this set of problems has percent and the number of cases these can- patients and have important tools to use in been the development of the Southeastern didates have in analysis is 12 percent less than advocating for the welfare of children and in Consortium for Child Analysis, an alliance in 2002. Currently there are 166 candidates countering trends toward behavior therapy developed to provide long-distance child and with a total of 110 cases in child and adoles- and medication for children. adolescent training. The Cincinnati Psychoan- cent training programs in the Association. A variety of factors, ranging from those alytic Institute and the New Orleans-Birming- that emphasize challenges from the external ham Psychoanalytic Center are the formal HIGHLY VALUED TRAINING environment (e.g., general economic condi- sponsors of the consortium with potential However, candidates clearly continue to tions, difficulty securing third-party reim- child candidates applying to and enrolling in want and value child training. A number of bursement) to those that stress factors the child training program of one of these metropolitan areas including Boston, Chicago, internal to the analyst ( two institutes. In addition, candidates from and the absence of conviction about the effi- other training programs have elected to par- cacy of child analysis) are often cited as con- ticipate in the weekly seminars when it has Charles E. Parks, Ph.D., is chair of COCAA, tributing to the challenges currently facing seemed advantageous to their training. A secretary of the Association for Child the field. Keeping both sets of issues in mind group of six candidates, along with one audi- Psychoanalysis, an adult training analyst is necessary in attempting to further under- tor, completed the first year of classes in June and child and adolescent supervisor at the stand the nature of the obstacles to child and 2010. The success of this program has stimu- Baltimore Washington Institute, and holds adolescent psychoanalysis. Potentially rele- lated interest in developing a similar consor- faculty appointments at Georgetown and vant to this understanding is a preliminary tium on the West Coast. George Washington medical centers. study by Leon Hoffman and his colleagues Continued on page 6

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 5 CHILD AND ADOLESCENT ANALYSIS

Crisis and Opportunity psychotherapy cases from the Continued from page 5 Centre, found evidence that psychoanalytic approaches to treatment were particularly The development of child-focused analytic effective for younger children and for those training programs in a number of institutes with more severe emotional and social allows candidates to pursue and graduate psychopathology. Importantly, the clinical from child analytic training prior to or in lieu condition of over 60 percent of the patients of training and graduation in adult analysis. with more complex psychopathology dete- Based on a carefully conducted four-year riorated if they were not treated with inten- pilot study of child-focused training (11 can- sive psychoanalytic treatment (i.e., three didates in 4 institutes), BOPS voted in June times per week or more). In this review, 80 2006 to change its training standards so that percent of more neurotic patients benefited SAMPLE CURRICULUM FOR ADULT candidates could be admitted for child ana- significantly from psychodynamic treat- AND CHILD PSYCHOANALYSTS lytic training only. These candidates would be ments. While more research in both pro- In recent years, COCAA has become increas- eligible for membership and certification in cess and outcome in child analysis is ingly attentive to the need for didactic training in the American Psychoanalytic Association essential, the existing significant body of aspects of ethical and professional conduct upon graduation. Since then, seven child- research that indicates the usefulness of which arise specifically in work with children and focused programs have been developed and intensive treatment for children is not widely adolescents. Two of the most recent COCAA- approved by COCAA. Currently, there are known, even to many child and adolescent sponsored workshops on boundary violations four candidates in child-focused training. One analysts. Particularly given the increasing and ethics in work with children and adoles- candidate has graduated from a child-focused emphasis on “evidence-based treatments,” cents have been well attended and enthusiasti- program. Importantly, several other candi- reviews of this research need to be more cally received. Current plans include developing dates have chosen to pursue adult analytic in effectively disseminated to local institutes a sample curriculum in this area with the rec- addition to child analytic training. and beyond. ommendation that such training be included in the curriculum in the adult as well as child and adolescent programs of each institute. Draw- …the existing significant body of research that indicates the ing on clinical material studied in these two workshops, as well as the work of the COPE usefulness of intensive treatment for children is not widely Study Group on Supervision in Child and known, even to many child and adolescent analysts. Adolescent Analysis, Paula Atkeson and Anita Schmukler have authored a monograph on ethical practice in child and adolescent analy- SUCCESSFUL AND The annual COCAA-sponsored work- sis, providing a much needed contribution to SUPERIOR TREATMENT shop in January 2011, titled “When Child the literature on this important topic. Recent systematic reviews of the evi- Analysis Is Indispensable,” involved further The future of child psychoanalysis depends dence base for psychoanalytic child and exploration of the potential advantages of on whether Hoffman’s small cadre of highly adolescent treatments cite a growing intensive psychoanalytic treatment through immersed child analysts and teachers can research literature on the efficacy of such the detailed comparison of therapeutic pro- endure. Much of the work outlined above treatments. Key findings from the literature cess and outcome in a four times per week, suggests that this small group can be trans- include (1) beneficial effects of psychoana- as opposed to a twice weekly, treatment of formed into a larger, more vibrant child and lytic therapy on a broad range of outcome two different neurotic patients. This compari- adolescent analytic community. Child analysis measures for children with a wide range of son highlighted the centrality of enhanced has historically played a vitalizing role in the psychological disorders, (2) the need for opportunities for and therapeutic usefulness American Psychoanalytic Association. How- intensive (as opposed to less intensive) of work with as they arose in ever, an enhanced focus by the entire Asso- approaches to prevent clinical deterioration the relationship with the analyst in the four ciation, child and adult colleagues alike, is in some cases, and (3) sustained, or even times per week treatment. COCAA is also necessary if we are to take advantage of this enhanced, improvement at long-term fol- exploring the possibility of developing a time of challenge and opportunity. low-up, including follow-up in adulthood. In national registry of child analytic cases. Such an article published in JAPA in 1996, Peter a registry would begin to provide more infor- Editor’s Note: In this issue, this article Fonagy and Mary Target, on the basis of their mation about the nature of current child and replaces the regular BOPS column by Colleen reviews of the clinical records of 763 psy- adolescent cases and treatment outcomes, Carney and Lee Ascherman. choanalytic and psychoanalytically-oriented including long-term follow-up.

6 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011

A Short History of the American Psychoanalytic Association 1911 to 2011 Sanford Gifford and Nellie Thompson

The American Psychoanalytic Association enthusiasm for Freud’s theories and later that Sanford Gifford Nellie Thompson was founded on May 9, 1911, at the Bellevue- spring at a meeting of the American Psycho- Stratford Hotel in Baltimore. James Jackson therapeutic Society, each gave vigorous pre- analysis. Jones continued his North American Putnam of Boston reluctantly accepted the sentations in praise of psychoanalysis. Putnam exile as a roving missionary for analysis, in presidency, and , who had spoke about childhood sexuality and Jones touch with both Putnam and Freud until his arranged the meeting at Freud’s request, proclaimed that free association was “in return to England in 1912. became secretary. A. A. Brill, who had previ- almost every respect the reverse of treat- For many years the annual meeting of the ously founded the New York Psychoanalytic ment by suggestion.” American Psychoanalytic Association coin- cided with the spring meetings of the Ameri- can Therapeutic Society, to which many early …“psychoanalysis was cradled in Boston but raised analysts also belonged. In 1924 this link with and grew up in New York.” the meetings of the advocates of the pre- analytic psychotherapies of suggestion came —Clarence Oberndorff to an end, and subsequent APsaA meetings coincided with meetings of the American Psychiatric Association. A. A. Brill added a sec- Society (NYPS) on February 12, 1911, was 1909 HISTORY IS MADE ond annual meeting of the Association to not present because he preferred to main- AT CLARK UNIVERSITY take place in New York, originally between tain an independent relationship with Freud As we all know, at the invitation of G. Stan- Christmas and New Year’s. As neither our and the International Psychoanalytical Asso- ley Hall, Freud traveled to Clark University in Association nor the International Psychoana- ciation (IPA). The monthly meetings of the Worcester, Massachusetts, in September lytical Association limited its membership to New York Psychoanalytic Society met in Brill’s 1909, and delivered the Clark Lectures. The physicians, the psychologist G. Stanley Hall apartment on Central Park West, in other proceedings have been described many was president of APsaA from1917-18. analysts’ apartments, and at the Boulevard times, in greatest detail by Saul Rosenzweig Café. Members vied with each other in giving (“The Historic Expedition to America,” 1992). MEDICALIZATION VS. papers and denouncing “quacks” who prac- Putnam invited Freud to stay at his Adiron- LAY ANALYST DEBATE ticed analysis without being physicians. dack camp and established an intimate cor- During the First World War, William Alan- Two years earlier, in a letter to Freud, respondence with him that lasted until son White proposed that the Association Ernest Jones described his first meeting with Putnam’s death in 1918. In 1914 Putnam merge with the American Psychiatric Asso- Putnam in Boston, at the house of Morton founded the Boston Psychoanalytic Society ciation, but this was rejected by Brill and Prince, a leader of the psychotherapy move- and wrote some 20 papers advocating Clarence Oberndorff, an early NYPS member, ment. Jones and Putnam shared an who had written “psychoanalysis was cradled in Boston but raised and grew Sanford Gifford, M.D., is director of Archives up in New York.” When Brill became at the Boston Psychoanalytic Society/Institute. APsaA president in 1919, APsaA, like For many years he has served as co-chairman the New York Society, became opposed of the History, Archives, and Library to lay analysis. In 1925, Carolyn New- Committee of APsaA. ton, who had been analyzed in Vienna Nellie Thompson, Ph.D., an historian and by , was deprived of her member of the New York Psychoanalytic “guest privileges” at the New York Psy- Society and Institute, is curator of the Brill choanalytic Society. Freud responded Library’s Archives and Special Collections. Her to American opposition with his elo- research interests include the role of women quent defense of lay analysis in 1926. psychoanalysts in the psychoanalytic movement. APsaA plaque at the Stratford Hotel Continued on page 10

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 7

100 Years of Psychoanalysis: The Timeline Project Elisabeth Young-Bruehl

Christine Dunbar and I went to the Anna Freud Centre and the Freud Museum in September 2008 to cele- Sara Fanelli’s timeliine of 20th century art featured at the Tate Modern in London. brate the publi- cation of a 20th course title) and sometimes by author. There DARWIN GIVES WAY TO PLUTARCH Elisabeth Young-Bruehl anniversary edi- is no attention to historical context or to We felt that a timeline of psychoanalysis tion of my Anna Freud biography. During our how the story of psychoanalysis’s history is, should be Darwinian, showing descent from London visit, we also went to the Tate Modern, tacitly, being told. If there is an acknowledge- an original ancestor, Freud; and showing where we were fascinated by a timeline of ment of the field’s history, that usually means graphically the evolution, by the mechanism 20th century art installed as a 50-foot long only a required course on Freud. A candidate of splitting, of different groups and concerns. mural in the entrance hallway. Later that day, may eventually begin to get a sense of intel- But it should not accept the assumption of so examining a miniature of Sara Fanelli’s timeline lectual and clinical lineage over time. But, until many Freudians that the early schismatic his- which we had bought in the museum store, that point, “the field” is just something over- tory of psychoanalysis produced groups— Christine Dunbar announced very emphati- whelming, like a jigsaw puzzle without its pic- Adlerians, Rankians, Jungians—that simply cally: “Psychoanalysis needs one of these.” ture. A timeline, we thought, could be that had no place in the later history or stopped This seed of inspiration fell on the ground missing picture. evolving or became extinct. However, we did of a conviction we share as former candi- But how could a timeline render such an not want to imply that the sub-speciation of dates and current teachers: The great weak- exceedingly complex and embattled history? psychoanalysis was a “survival of the fittest” ness of most psychoanalytic institute Could we do it without being simplistic, with- phenomenon; so we did not use the Darwin- curriculums is that the articles and books out producing just a “one damn thing after ian tree trunk with branches metaphor. assigned are organized only by topic (or another” picture? Sara Fanelli had repre- Further, we did not want to fall into any sented 20th century art without any con- metaphor of Progress beyond Freud (or Elisabeth Young-Bruehl and Christine text—art for art’s sake, as it were—and we Devolution from Freud) or fall into accept- Dunbar are members of the Toronto knew that would be completely impossible ing any kind of a successor to Freud or true Psychoanalytic Society and co-founders for our field, which has had such a two-way inheritor of Freudian ideas. So we organized of Caversham Productions in Toronto. interaction with world history. Continued on page 9

Tate Artist Timeline, a handwritten timeline by Sara Fanelli that covers the 20th century and lists all the major artists and movements.

8 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011

our story on what might be called Plutar- in which psychoanalysis went into semi-mor- much like book people. This is not a book, it chian principles, showing “parallel lives” or atorium in continental Europe, during WWI is an object in space, you can walk around it, lifeforms of psychoanalysis. The basic paral- and during WWII. These traumas had defin- like in a museum.” lel relationship shown is among groups that ing impact upon how different analysts and So, on the verso we offered a narrative concentrated theoretically on intrapsychic schools of analysis related to the role of envi- introduction which sets out our organiza- life; groups more focused on social/environ- ronmental influences in human development. tional principles and accounts, frankly, for mental influences upon people; and groups We wanted our graphic to suggest the our bias (which is toward contributors in that tried to explore interactions of inter- importance of trauma. the Anglophone world after WWII). After psychic and intrapsychic life. The nature/ With a new set of relations among color the introduction, there are 19 brief narra- nurture controversy (and our own sense of bands, which had become like Anna Freud- tive histories of particular topics that we the falseness of that dichotomy) subtends ian “developmental lines,” we started again. think are key to understanding how psycho- our big picture. This time we were satisfied, and could then analysis has evolved. These, we thought, work by accretion and adjustment, adding would be particularly helpful for students WWI AND WWII: more and more entries from our “cannot coming at this history without much prepa- THE IMPORTANCE OF TRAUMA imagine the timeline without X” files. Then, ration and thus unable to interpret at much Our first draft was made by Scotch-taping in a crucial meeting with our designer, depth the timeline itself. The narratives also together 10 heavy watercolor pages (“the Isabelle Rousset, we were prompted by her extended our ability to argue for historio- decade panels”) and making entries in pencil remark that we could, you know, use the graphical consciousness; they could prompt along banner-like bands of color. This was not verso of this thing. We did not have to readers to reflect, as we ourselves had tried a success, but we learned a great deal from follow the Sara Fanelli precedent of making to do, on how this story was being told. the failure, particularly about how important a beautiful fold-up scroll, perfect to be You can visit the final result on the Web at it would be to show clearly the two periods mounted on a wall. “You are thinking too cavershamproductions.com.

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A Short History Meanwhile, in contrast to the Paris Continued from page 7 proposal, New York and all the local analytic societies in America warmly In 1929, at the Oxford Congress of the welcomed the huge influx of refugee International Psychoanalytical Association, analysts. An Emergency Committee there was a threat that our Association on Relief and Immigration was estab- might withdraw from the IPA, but Ernest lished in March 1938, chaired by Law- Jones arranged a compromise. Brill allowed rence Kubie, then secretary of APsaA. some non-M.D.s (i.e., non-psychiatrists) to Soon Bettina Warburg was appointed become affiliate members, provided they his co-chair and Bertram Lewin agreed not to practice analysis. The conflict served as treasurer. The committee’s was not resolved, however, and during the mandate was to help refugees with 1930s many Americans analyzed abroad travel expenses, visas, and finding jobs. Group photo 1909 in front of Clark University. Front row: , G. Stanley Hall, ; were denied membership in the New York In fulfilling this task, they often urged back row: Abraham A. Brill, Ernest Jones, Sándor Ferenczi. Psychoanalytic Society and APsaA, while émigrés to settle in communities with eminent non-psychiatrists like less well-established analytic societies that In the 1930s, another divisive issue had were admitted by means of a grandfather might be in need of training analysts. But the emerged, still related to the lay analysis dis- clause. Bulletin of Information the committee distrib- pute. This was a proposal that psychoanalysis uted to émigrés also emphasized that émigré be made a “specialty board” within the Amer- THE INFLUENCE OF WW II analysts, no matter what their status in Europe ican Psychiatric Association. Defining analysis In 1932, the Association was reorganized as training analysts, were expected to present as a subspecialty of psychiatry was a drastic as a federation, instead of an association of their credentials to training institutes recog- move toward the further medicalization of individual members, with its constituent nized by the Association in order to be recog- analysis, which came to be called “certifica- members the New York, Boston, Washing- nized as training analysts here. In fact, many tion,” in a different sense from the later cer- ton-Baltimore, and Chicago societies. In 1938, émigrés quickly became training analysts, tification of members. Ives Hendrick and at the International Psychoanalytical Associa- resulting in the rapid Europeanization of Bertram Lewin were its chief advocates, while tion meeting in Paris, some Americans pro- American analysis. In Boston, for example, the it was strongly opposed by most European posed that European analysts emigrating to recently arrived Europeans soon outnum- analysts. The certification proposal was the U.S. should not be recognized as training bered their American counterparts. defeated in the mid-1950s, and by 1976, after decades of controversy, there was a gradual reduction in American resistance to lay analy- …many émigrés quickly became training analysts, resulting sis. George Pollock’s proposal for an academic in the rapid Europeanization of American analysis. doctoral (Ph.D.) program in psychoanalysis was a step in that direction. Though it was In Boston, for example, the recently arrived Europeans defeated, the vote in the Association’s mem- soon outnumbered their American counterparts. bership showed substantial support. It was followed by Robert Wallerstein’s program for a doctorate in mental health, which proved analysts without being approved by the Asso- RELAXATION OF INDIVIDUAL more successful, and many of his candidates ciation. This was a highly insensitive proposal, AND SOCIETAL REQUIREMENTS became analysts. at a time when European analysts were flee- In 1946, another reorganization in our Nevertheless, in spite of repeated propos- ing from the Nazis in Germany and Austria. bylaws reestablished APsaA as an association als to modify the physician (psychiatrist) This restriction on the membership of for- of individual members. The M.D. (psychiatrist) requirement, a powerful faction within APsaA eign analysts formed part of a proposal to requirement for membership was reaffirmed, had repeatedly blocked any changes by refer- abolish the 1925 International Training Com- but “affiliate status” was allowed for psychol- ring each proposal to be reconsidered by mission. Once again, Ernest Jones proposed a ogists and other non-psychiatrists who signed one more committee. Affiliate and associate compromise, to postpone consideration until waivers that their use of analysis was limited members were admitted in 1976, and finally the next IPA Congress, but the Second World to research. Another restriction, that each at the May meeting, Herbert Gaskell’s pro- War supervened and there was no IPA Con- city should have only one institute, was posal was approved by 67 percent of the gress until 1946. By this time, according to rescinded, opening a new era of multiple membership. But even in this opening to Robert Wallerstein, the postponement had institutes within the same city, allowing insti- non-psychiatrists, the language of the been forgotten. tutes to split. Continued on page 12

10 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011

Record-breakingfor Gala The New York Psychoanalytic Society and Institute

Photos: Leo Sorel On February 26, The New York Psychoanalytic Society and Institute’s Centennial Gala hosted 370 guests and raised over $360,000 to celebrate 100 years of service as the nation’s oldest psychoanalytic organization in the Americas and its influence on the cultural and intellectual life of New York City. Funds raised from the gala will support the ongoing mission of The New York Psychoanalytic Society and Institute (NYPSI), which is to provide the highest level of psychoanalytic training to mental health professionals, promote excellence in psychoanalytic research, and offer a range of educational, advisory, and affordable therapeutic service programs to the New York community. Board of Directors The Centennial Gala, held in the Metropolitan Club, The New York Psychoanalytic Society and Institute also served as the official kick-off for the NYPSI Second Century Campaign which will focus on raising $1,000,000 for expanding its child and adolescent therapy programs, in-school clinical services, community outreach, and facilities upgrades. In honor of the Society’s centenary, the Office of the Mayor, City of New York, issued a proclamation for “The 100th Anniversary celebration of the New York Psychoanalytic Society and Institute” in recognition of the organization’s founding on February 12, 1911, and as a testament to the courageous and important work psychoanalysts do on a daily basis and to the vital services offered to all New Yorkers. The Centennial Gala was the best attended and most profitable gala in recent memory thanks to the tireless efforts of the gala co-chairs Themis Dimon, Maxine Gann, and Carla Solomon.

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 11

A Short History The application process required submitting In recent years there has been concern Continued from page 10 credentials and case reports, but by 1951 a about our membership numbers and substantial number of graduates had refused finances. At one time, any analyst over the proposal still professed to preserve the to comply with this requirement. In 1972, age of 70 was considered to be retired and “essentially medical nature of our organiza- the Membership Committee was renamed was granted (free) life membership. Life tion.” Further relaxation of restrictions on the Certification Committee, and the Exec- membership was later discontinued, and non-physicians was hastened by a suit four utive Council with its elected members various inducements were offered “Senior psychologists brought against the Association, the New York and Columbia Institutes, and the IPA, based on anti-discrimination statutes In 2001, voting restrictions were removed. that the plaintiffs were denied membership By 2002, candidates were given full voting membership. “in restraint of trade.” In 1990, the parties settled, allowing non-medical applicants to apply for full psychoanalytic training. Another questioned whether the Board on Profes- Members” to continue paying at reduced progressive change took place in 1991, when sional Standards, with its narrower member- rates. New members have increased from homosexuality was no longer considered ship by appointment, had the right to restrict two sources. The first source is non-psychiat- pathological and gay men and women were membership. After some controversy, the ric members. The Association now includes accepted for analytic training. authority of BOPS was confirmed. Noncer- members who are psychologists, social tified analysts were offered limited mem- workers, non-psychiatric physicians, and aca- THE ROLE OF CERTIFICATION bership for three years, renewable for demic researchers, in addition to psychia- In 1932, Robert P. Knight, then secretary of another three years with proof that the trists. The second source is graduates of APsaA, had declared that membership in our member was seeking certification. Over American institutes recognized by the Inter- Association was a sufficient credential to be time, and following “delinkage” between lim- national Psychoanalytical Association but not a psychoanalyst, and graduation from an ited membership in the Association and belonging to APsaA. approved institute guaranteed membership certification in 1992, one-third of the mem- In addition to our controversies about the in APsaA. But after the 1946 reorganization, bership (not including candidate members) certification of members and the authority membership was linked to a certification lacked certification and could not vote on of BOPS, there has been debate on training process: To become a member, one had to bylaws or hold office. In 2001, voting restric- analyst status. Various remedies have been be certified through an application to the tions were removed. By 2002, candidates proposed, including returning TA status to Board on Professional Standards (BOPS). were given full voting membership. the analyst’s local society, where her or his work is best known. The Stan- dards for Education and Training in Psychoanalysis recently under- went a comprehensive revision. This resulted in a more flexible system which allows for a poten- tial candidate to continue a per- sonal analysis, and have it serve as a , indepen- dent of the analyst’s TA status. This is contingent on the analyst meeting criteria for suitability and eligibility. In conclusion, it can be said that while many of these recurrent organizational issues are yet to be resolved, they have been addressed in some manner for the last 100 years. In recent years, some of these challenges have been met, and even resolved, in a spirit of You can follow the evolution of psychoanalysis on APsaA’s Centennial Timeline at www.apsa.org/centennial.aspx. cooperation and creativity.

12 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011

Editor-in-Chief Journal of the American Psychoanalytic Association (JAPA)

The American Psychoanalytic Association invites applications for the position of Editor-in-Chief of the Journal of the American Psychoanalytic Association (JAPA) for an initial 5-year term with a possible renewal for a second 5-year term. In December 2013, Dr. Steven Levy will end his term

the Journal in January 2014, but must be prepared to start working with the incumbent Editor inas JanuaryEditor-in-Chief 2013 to of assure the Journal. an orderly The transitionnew Editor-in-Chief of leadership. will Theofficially Search assume Committee responsibility will select for a new Editor in June 2012.

JAPA is one of the world’s most respected publications in psychoanalysis, offering insightful and broad-based original articles, ground-breaking research, thoughtful plenary addresses, in-depth panel reports, and perceptive commentaries. Included in each issue is the esteemed JAPA Review of Books, which provides comprehensive reviews and essays on recent notable literature. For over 50 years, JAPA has been the leading source of information on topics including clinical issues and new methodologies, education and professional development issues, interdisciplinary studies, and emerging theories and techniques.

Candidates should be recognized as leaders in psychoanalysis with openness to a range of theoretical and clinical interests and viewpoints. Candidates should possess an understanding of and interest in psychoanalytic writing; strong leadership qualities; intellectual vision; interpersonal skills; and experience relevant to editing a leading scholarly journal. Candidates must have the ability to tactfully assist contributors in the development of their submissions to the requisite level of excellence in order to meet the Journal’s high standards.

Interested individuals should submit a letter describing the nature of their interest in the position, and a current CV detailing editorial experience. Send completed application materials to Dean Stein October 31, 2011.

at the National Office ([email protected]) no later than

NATIONAL OFFICE: 309 East 49th Street, New York, New York 10017 • Phone: 212 .752 .0450 • Fax: 212 .593 .0571 www apsa. org.

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Psychoanalytic Reflections on the Tucson Shooting Introduction Michael Slevin

Our cover article In January, Congresswoman

is by Leo Rangell; he Gabrielle Giffords was shot in the Michael Slevin wrote it last winter. head outside a grocery store in Tuc- I learned with deep son, Arizona, where she was meeting with her constituents. The regret on May 28 man who shot her was tackled by bystanders and arrested. His that he had died at Web site showed him to be severely mentally disturbed. Psy- the age of 97. Until choanalysts have worked hard, beginning with Sigmund Freud, to his death, although understand mental illness. But Freud understood psychoanalysis his body had begun to be a general to fail him, his mind psychology. Fur- was sharp. He con- ther, beginning tributed an article with Freud, psy- with grand sweep choanalytic theory and analytic preci- and praxis has sion—a rare com- engaged with bination. He brings society, both to up to the present understand it and time his work from to act in it. From the 1970s on what he named the “compromise of integrity,” wrap- the consulting ping into it his then-ongoing analytic work with patients. His many room to the soci- contributions, to the literature, to the institutions of psychoanalysis, ety at large, psy- and, I note, his patients, led to his being honored at the recent choanalysis has been an art and theory of social engagement. APsaA conference in San Francisco, held two weeks after his There was much talk at the time of the shooting of Rep. Giffords death, as the first honorary president of the American Psychoana- about inflamed civic discourse and its impact on the gunman. lytic Association. It is an honor he intended to receive in person This, I thought, is an important national discussion to which psy- and richly deserved. On a personal note, he was non-flagging in his choanalysis could contribute. On further reflection, I thought, devotion to his colleagues and the following generations. A decade this event was an octopus with ago, when I edited the Affiliate Council Newsletter, a modest publi- many tentacles. So I asked four cation, he contributed a front page article. This year, he again distinguished analysts to weigh in. responded with alacrity, lucidity, and relevance to an invitation to Leo Rangell, Gerald Fromm, and write for The American Psychoanalyst. With characteristic exuber- Kerry and Jack Novick responded ance, he expressed to me his pleasure in making this synthesis and with rich articles which show contribution. I only regret it is being published posthumously. how productively psychoanalysis, working outward from the con- * * * sulting room, continues to engage with the cultural moment. As a Michael Slevin, M.A., M.S.W., a former TAP editor, graduated as academic associate from the Baltimore Washington Institute secondary benefit, it is especially for Psychoanalysis, where he completed as a clinician the Adult appropriate that they are a window into the vigorous history of Psychotherapy Training Program. He works at Sheppard Pratt psychoanalysis in this, the 100th anniversary year of the American and has a private practice. Psychoanalytic Association.

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American Psychoanalyst analysis. For Continued from page 1 whatever rea- son, only an When it came to behavior acted out against adolescent turn- society, where it was the values, mores, and ing to an antiso- ethics of the group that were impinged upon, cial sphere analysis was to lay down its arms. continued to At the time of the first active definitions of draw the inter- analysis and discussions of its range and ests and formu- scope, roughly around 1954, besides internal lations of the refinement, its border in relation to the out- psychoanalyst. side world was being drawn. While Leo This remained Stone was writing his well-known “Widening that way for me Scope” paper, extending the reach of the until a series of analytic instrument to include psychosomatic events and states and a good deal of borderline phe- experiences led nomena, Anna Freud, in the same round of me to enter this behavioral area with the full Still, I doubt that this switch of focus discussions, was writing about “the narrow force of psychoanalytic theory and applica- would have come about without a one-of- scope” as well. The goal and motivation of tion. While the mainstream had always a-kind, compelling event. That came in the her approach was to be ever vigilant to the remained aloof and even overtly opposed to form of the most disturbing scandal at the danger of overextension of the applicability shifting its interest to the mental behavior of top level of government seen by the existing of analysis, leading ultimately to subsequent the psychopath or even criminal, my own life public in many a decade, which was the disappointment and disillusion. If the criteria positions had kept me struggling against such news of the Watergate incident. The event were strict enough to begin with and analysts automatic distancing and separation. Although itself was not the worst that ever happened; did not stray too far, such negative effects I had gravitated toward being at the center in fact it is referred to as “a two-bit burglary,” could possibly be forestalled. of the classical seg- but it broke into news reports with relent- The one exception during this ment of analysts, I have lessly increasing intensity—the Senate Inves- historical period that kept a win- described elsewhere tigating Committee under the crusty Senator dow open to antisocial behavior the conflicts I had from Sam Ervin was just beginning to meet in was the respected work of August the start of becoming Washington, concomitant with my second Aichhorn, who early established an analyst in accepting outgoing presidential address to the IPA the field of adolescent delin- a definitive cleavage in 1973. quency as within the purview of between psychological And it came to one psychically prepared, psychoanalysis. Interestingly, Anna and sociopolitical life. or well groomed, as to the Nixon charac- Freud is said to have been particu- ter. I had begun to be “a Nixon watcher” larly close to Aichhorn, in a per- BEHAVIOR OF 25 years before, when he and I arrived in sonal way. Since the target area AN INDIVIDUAL California in 1946 after World War II. In his was seen as within the spectrum WITHIN A GROUP early political campaigns and skirmishes, of early development, this interest My years as presi- for Congress against Jerry Voorhees and may have been borrowed from an August Aichhorn dent of the Interna- for the Senate against Helen Gahagan empathic attitude toward child tional Psychoanalytical Douglas, which introduced him to the public Association (IPA), as well as previously of domain, Richard Nixon was said not to have APsaA and even more local levels, had always defeated his opponents but to have killed presented to me observable phenomena them. At least both their political careers which counteracted such divisions, impress- were over—in neither case for valid reason. ing me more with the overlap between the Nixon waved accusatory documents in two, particularly in behavior within a group, front of the TV audience without any which was the case in each of these milieus. attempt at proof (that one was a Commu- Administrative life in our field pressed upon nist, the other pink to her underwear), my consciousness an awareness of combined ruthlessly and recklessly riding the passion behavior, the individual psychological admixed of the times. Anna Freud and August Aichhorn with conflicting forces within the social group. Continued on page 20

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father’s moralizing and insisted that thinking is The Events in Tucson not the same as doing, Freud exclaimed in a Jack Novick and Kerry Kelly Novick footnote, “Well done, little Hans! I could wish for no better understanding of psychoanaly- When we mentioned that we were writing sis from any grownup” (1909). The distinc- something about what psychoanalysts had to tions between wishes and actions, between offer in relation to the events in Tucson, our pretend and real, between magic and effec- well-informed, non-analyst friend said, “What tive action, between grandiosity and ambi- events?” This brought home to us the con- tion, between omnipotence and competence, tinuing centrality of Freud’s revolutionary dis- are fundamental assumptions and contribu- covery of the operation of defenses. The tions of psychoanalysis. news cycle has “moved on.” This reinforces Thoughts are private; actions are public. It , repression, and splitting affect from Jack Novick Kerry Kelly Novick is not a breach of privacy or confidentiality to ideas, all among the earliest defenses Freud tell an adolescent that his action plan or described. As psychoanalysts, we know that culture and isolated from reality corrections actions cannot be kept secret. He or a change does not occur unless people have to magical, omnipotent ideas. There is no responsible adult, whether a parent, therapist, the courage and strength to put aside their other stage of life in our culture when impor- college counselor, or teacher, has the duty to defenses and engage with reality. tant people accept being completely seek assistance to forestall dangerous behav- excluded, depriving the adolescent of the ior. Every postmortem account of terrible THREE MISTAKEN ASSUMPTIONS wisdom of others. “Get off my back!” and events of violence perpetrated by individuals ABOUT ADOLESCENCE “it’s none of your business” are accepted as includes a list of presaging activities or If we engage with reality there are several “natural” for adolescents, rather than as sig- speeches that should have been taken more denied truths that we can assert. The first is nals of trouble and distress. As analysts, we seriously. Their possible significance should to counter the prevailing cultural and fre- can offer the alternative formulation that the not have been denied or minimized. People quent psychoanalytic idea that adolescence goal of adolescence is transformation of the of any age should be held responsible for is normally a time of intense turmoil, akin to relationship to others and to the self. their activities and what they say. mental illness. This idea encourages people to rationalize pathological behavior as expect- able in adolescence. The accused perpetrator Every postmortem account of terrible events of violence of the Tucson shootings behaved very perpetrated by individuals includes a list of presaging strangely for years before the events. No one is served by normalizing pathology and wait- activities or speeches that should have been ing for it to be outgrown. taken more seriously. The second mistaken idea is that the goal of adolescence is separation from parents and other adults. This leaves young people This leads into a third mistaken belief— PUBLIC EDUCATION potentially floundering, turning only to peer that everything an adolescent says or does BY PSYCHOANALYSTS has to be kept secret. Analysts and non-ana- As psychoanalysts conversant with the Jack Novick, Ph.D., and Kerry Kelly Novick lysts have all generally confused privacy and operation of defenses and the interference are International Psychoanalytical Association secrecy, with sometimes terrible results in they can pose to competent functioning, our training and supervising analysts and child both clinical and non-clinical realms. Privacy organization is well positioned to both edu- supervisors on the faculties of numerous is a given of mental life, a fact and a right to cate the public and offer alternatives. The psychoanalytic institutes around the country. be respected. It is a developmental achieve- American Psychoanalytic Association has Fearful Symmetry: The Development and ment for small children when they realize recently joined many other professional Treatment of Sadomasochism was reprinted they have a private mental life, that their organizations in making a definitive statement in paperback in 2007, as was Working with thoughts belong to them alone. Knowing against corporal punishment. In that state- Parents Makes Therapy Work in 2011. that no one can read their minds creates the ment APsaA described the dynamic and Good Goodbyes appeared in 2006. They possibility of the pleasure of sharing oneself defensive roots of the impulse to overpower are founders of the award-winning Allen with others. and intimidate children, the futility and Creek Preschool in Ann Arbor, Michigan, and Psychoanalysts have always emphasized destructiveness of doing so, and suggested a have recently published Emotional Muscle: the distinction between thoughts and actions. more realistic and humane set of solutions. Strong Parents, Strong Children. When five-year-old Hans stood up to his Continued on page 19

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“We are all more human than otherwise.” Psychoanalytic Treatment of Psychotic Patients: A View from the Austen Riggs Center M. Gerard Fromm

“We are all INFLUENCE OF inclination to offer free analyses to the poor, more human ROBERT KNIGHT and an encouragement of innovation, espe- than otherwise.” Riggs became a cially in the treatment of psychotic patients. Of all the memo- psychoanalytic hospi- Frieda Reichmann had already run a hospi- rable statements tal in 1947 when tal unit for brain-injured soldiers, where she made by Harry Robert Knight, even- learned that neurologically damaged people Stack Sullivan, tually the president of differed markedly, one from the other, in their this one—with the American Psy- pathologies and their paths toward recovery. Robert Knight its pithy Irish elo- choanalytic Associa- In Berlin, she was inspired by Ferenczi’s quence—might tion, brought a cohort of impressive young examination of countertransference impedi- M. Gerard Fromm best summarize analysts—David Rapaport, Roy Schafer, Mar- ments to a patient’s progress and Georg his years of working with and learning from garet Brenman, Merton Gill, and eventually Groddeck’s insistence that no patient was psychotic patients. The news these days, from Erik Erikson—to study and treat what came beyond hope. And she was inspired by Freud Tucson and elsewhere, appalls us so deeply to be understood as borderline conditions. in whose work she found a confirmation of that it tests our willingness to take seriously Many of these patients had clear psychotic her own intuition: “I had known from the first Sullivan’s remark. It strains our capacity for liabilities. Knight’s successor, Otto Will, day I was in psychiatry that something funny empathic understanding as it also frightens us brought with him years of experience at went on in the doctor-patient relationship, about our own human vulnerabilities. Chestnut Lodge in Rockville, Maryland, and a but nobody seemed to know anything about We all know the statistics. The vast major- wish to treat the overtly psychotic patient in it and nobody talked about it…And this man ity of deeply troubled people are never vio- the context of Riggs’s open therapeutic said he knew it happened!” lent toward others. Their violence, if it can be community setting. In this article, I will touch called that, is toward themselves and their on the roots of Will’s effort, its conceptual AND connections to the world. They withdraw frame, and its evolution at Riggs. PSYCHOTIC PATIENTS from human discourse and seem to simply In some ways, the thread of Riggs’s work Where she eventually differed from Freud want to be left alone. What we may have lost with psychotic patients began in Berlin, in was in his conclusion that psychotic patients sight of, in today’s mental health climate, is 1923, the year of , the year could not form transferences. Indeed, her that many people suffering major mental ill- Winnicott began his 40 years of mother-child experience led her to a near-opposite conclu- ness, including psychotic conditions, are quite consultations at Paddington Green Hospital, sion: that they could only form transferences, treatable. From my vantage point at the Aus- the year Sullivan opened his unit for psy- that psychotic fragmentation represented the ten Riggs Center in Stockbridge, Massachu- chotic patients at Shepard-Pratt, and the year ongoing disaster of pathology in the earliest setts, where close to a quarter of our patients 33-year-old Frieda Reichmann began her psy- phases and relationships of life, and that the present with psychotic problems, the variabil- choanalytic training at the Berlin Psychoana- task of the analyst included differentiating ity of these conditions, the surprising and lytic Institute. Led by , the Berlin herself out of this chaotic matrix and into the sometimes idiosyncratic paths toward recov- Institute combined a scientific attitude, a role of, as Clare Winnicott put it, “the other ery, and the patient’s longing to escape isola- standardized training program, and intellec- person.” Forced to flee the gathering storm in tion impress themselves upon us regularly. tual rigor with an avant-garde spirit, a socialist Continued on page 18

M. Gerard Fromm, Ph.D., is director of the Erikson Institute for Education and Research, Austen Riggs. He is on the faculties of the Massachusetts Institute for Psychoanalysis, the Berkshire Psychoanalytic Institute, Harvard Medical School, and the Yale Child Study Center.

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Austen Riggs Center Continued from page 17 her beloved Germany, she wound up at a small hospital outside Washington, D.C. She would spend the remainder of her career at Chestnut Lodge, treating psychotic patients, promoting the interpersonal perspective of , and, in the late ’40s, welcoming Otto Will to the Lodge staff. Will had heard Frieda (now) Fromm- Reichmann speak while he was working at St. Elizabeth’s Hospital, amidst its 8,000 patients. Listening to “her version of the ‘mentally ill,’ I began to see individual persons in the masses unconscious communication that something disorder “at the most personal juncture that were crowding the facilities of the fed- had gone wrong in the relationship with the between the subject and his sense of being eral hospital.” At the Lodge, he undertook a therapist. Tracing things back to the injury or alive.” Their work powerfully links the clinical training analysis with Sullivan and then with disconnection interrupted regression and got arena with the historical and the political, and Fromm-Reichmann. Theories were not fancy the therapy process moving forward again. suggests that the patient’s psychosis is not at the Lodge, Will’s included. Patient and This fine attention to the mini-history of simply an attack on the social order, but at a therapist meet and while a story unfolds, the therapeutic relationship was mirrored in a deeper level, a frantic effort to bring a fore- “bonds of attachment form. Attempts are different way by Francoise Davoine and Jean- closed social order into existence. made to understand how and why each par- Max Gaudilliere, who began a series of visits Recently, a chronically and quietly psychotic ticipant experiences what is happening to Riggs in 1978, the year that Otto Will com- patient, following the death of her mother between them. The self is revealed—to some pleted his tenure. Their outpatient work with “wanted to be psychotic for awhile” and so extent—and the question ‘Who are you?’ psychotic patients had led them toward see- discontinued her medication. She became begins to be answered. Then comes separa- ing meaning in the “area of death,” so intrinsic uncooperative and incomprehensible, and tion.” Attachment, self-revelation, mutuality, to both the patient’s and the therapist’s expe- required the highest level of containment change, separation, the most basic aspects of rience of such treatments and so related, they Riggs can provide. When she decided to human relationships. This was the evolving thought, to the Big History of social catastro- resume her medication, she did so finally feel- Sullivanian framework of understanding at phe in the families of patients. Indeed, they ing “real.” Indeed, her breakdown came to the Lodge, including the need-fear dilemma discovered in the work of Thomas Salmon, seem like a breakthrough. “I want to find my and twin dangers of annihilation or abject a psychiatrist, a version of the voice. I want to be heard,” she said, and she loneliness for people whose early develop- principles that had come to underlie their seemed to have integrated anger for the first ment has included profound boundary dis- approach: simplicity (no jargon), proximity time. She also had advice for her therapist: turbance. As Will wrote in 1982, “What is (being with the traumatized person’s raw “If it happens again, tell me you are not my now called attachment theory is a vital part experience), immediacy (depending on intu- mother.” There is indeed a Big History of of my own work as a therapist.” ition and on the seeming coincidences within trauma and betrayal in the generations the transference), and expectancy (the before her, but in the Little History of the INFLUENCE OF OTTO WILL dimension of hope, of getting better because therapeutic relationship, this is a patient who When he came to Riggs, Will brought with those at the front need you). lost her mother at a time when her therapist him a number of Lodge staff, most notably In their 2004 book, History Beyond Trauma, did as well, and a new twosome seemed now Martin Cooperman, whose concept of the Davoine and Gaudilliere argue that psychosis to be forming from this context of death “defeating process” recognized that when a and trauma go hand-in-hand, and that the both parties were now in. patient feels deeply injured by his therapist, psychotic patient is madly conducting a he may destroy the therapy in response. Like research into the rupture between his family FREUD’S ARCHAIC HERITAGE Will, Cooperman held the core conviction and the social fabric, a rupture brought AND VIOLENT ERUPTIONS that therapist and patient were “in it together” about, more often than we realize, through With psychotic patients, we often find and, like Winnicott, believed that the earlier large scale trauma (wars, mass displace- major traumatic histories, problems of the trouble, the less the patient would be ments, societal regression), betrayal by those unbearable loss, and obliterating forms of able to think in two-person terms. Cooper- in authority, and suppression of the truth. denial in the preceding generation or two. man saw any move backwards as an They agree with Lacan that psychosis is a Continued on page 19

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How are we to at a sociocultural level. For example, thought understand the violent disorder is split off from the person, to be eruptions that, rarely treated as a symptom without meaning, mir- but very publicly, come roring the psychotic person’s depersonalized from people who seem splitting of his thoughts from his feelings and to be psychotic? The from his relationships to people. Similarly, work at Riggs suggests though studies document degree of denial as that we should look for a pathogenic factor in high-risk families, multi- the interrelatedness of ple forces have pushed the treatment culture the mini-history of the toward its own denial of interpersonal, devel- individual’s life with the opmental factors in the shaping of psychosis larger history of their and toward seeing the psychotic patient as an family and societal con- isolate, ironically mirroring a primary defensive text. What tragic his- strategy while it replicates pathogenesis. tory is the individual It would be a small step further to won- The patient-to-be seems to receive the dis- carrying as the representative of what Freud der about the free-floating rage, intolerance sociated fragments of this history and to be called the family’s “archaic heritage”? But of difference, and paranoia in our society charged, in the double sense of both an there are larger questions as well, including and to consider the possibility that it is not energy and a duty, to represent it, and with the one that surfaced immediately after the only projected onto vulnerable people, but luck, to communicate it to someone. Davoine Tucson shootings: How susceptible are vul- perhaps into them as well. Indeed, the ratio- and Gaudilliere, as did Cooperman, offered a nerable individuals—perhaps especially those nalizations that allow for such unlimited frame for the treatment of such patients that with fragile boundaries, concrete thinking, access to weapons—really weapons of mass recognized meaning in a potentially dissoci- and impulse problems—to the rage and destruction—in our country seem full of ated history, the history of the therapeutic incendiary speech of those around them? the denial, splitting, projection, and even dyad itself or the larger histories shared by delusional thinking we ordinarily associate both parties. Not only did they show us how PROBLEMS WITH THE DISEASE MODEL with psychotic processes. To other civilized psychotic patients can be treated successfully And perhaps there is a yet larger question, countries, this looks insane. What happens if with psychoanalytic psychotherapy; they also which builds on the work of psychoanalyst we take that diagnostic term seriously? show us how psychosis—far from being a Michael Robbins with psychotic patients. Does it make any sense to think of a collec- violent disorder in itself—is actually an effort Robbins argues that a simplified psychiatric tive societal process as psychotic? What to bring varying levels of interpersonal vio- approach to the psychotic patient, within a would be the implication for its psychotically lence to the light of understanding. disease model, is actually enacting the disorder vulnerable members?

The Events in Tucson and adults. We also know what is needed for medicating children into submission, we can Continued from page 16 normal, optimal development. Interdisciplin- enlist them as partners in their own growth ary research with developmentalists in allied from birth through adolescence into a shared, It may now be time for us to stand up for fields offers understanding of important responsible adulthood. sweeping gun controls in our society. Immedi- distinctions, for instance, between assertion ate responses to the murders and assassina- and aggression, which operate in distinctly tion attempts in Tucson included huge separate parts of the brain. Society needs increases in gun sales, hoarding of the multi- these ideas to support the everyday work of ple ammunition clips used by the accused raising children who are equipped to meet killer, and higher attendance at Glock stands life’s challenges and frustrations with strength, at gun shows. We have a duty to puncture assertion, and creative problem solving, the omnipotent defensive delusion that hav- rather than violent, magical eruptions of ing a gun keeps you safe and we should foster destructive action, as we saw yet again in the more effective and realistic social controls. Tucson shootings. Psychoanalysis has always been a general As analysts, we can provide parents and theory of development, both normal and teachers with tools for better understanding pathological. We are equipped by our training of building inner strength, what we have to diagnose and treat pathology in children called “emotional muscle.” Rather than

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 19 SPECIAL SECTION: TUCSON

American Psychoanalyst advocates. “C of I,’’ as I abbreviated the new that holds out much promise. It is—and this Continued from page 15 syndrome, could be seen everywhere, and should be admitted—hardly possible or was completely explainable under the tripar- expectable to monitor, let alone check, an THE MIND OF tite psychology of Freudian theory. The places impulsive act by one misguided individual, WATERGATE to look and what is seen are different, but prepared to execute an act with the aid of My book, The these are only some of the variations that are modern weaponry that can wipe out multi- Mind of Water- possible. In one case it was an overactive id, in tudes in seconds. gate, published a this new syndrome a deficient or corruptible few years later superego. In neither case are we speaking of THE ROLE OF UNDERSTANDING was not about extremes but the center. C of I is to crime as Nevertheless, I will answer the quest of Nixon but about neurosis is to psychosis—both are at the the editor to examine the role that psycho- the American crowded, central, more “normal” segments of analysis might play by turning to Otto people. The the population curve. Fenichel’s pithy aphorism about the multi- American popu- From the top layers of government or cor- plicity of psychoanalytic technique, “You can lace elected a porate life to everyday man, from the deceit do anything as long as you understand it,” man as president by the second largest land- handed the American public through five which I would supplement with “Under- slide in history whose nickname for over a presidents about the Vietnam War, to tax standing helps, whether or not you can cure; quarter-century had been “Tricky Dick,” and evasion and other ego-syntonic, corrupt perhaps that will come.” It is still desirable to who had been linked to the Watergate behavior in ordinary people, trust was understand acts against society, establishing robbery for some six months prior to the deserved in very few places. It is the diagnos- a platform upon which to view and study the election. The subtitle of my work was An tic task of the analyst to pinpoint psychopa- occurrences, while the ability to master, or Exploration of the Syndrome of the Compro- thology and to attempt to discover the better prevent, such situations must await mise of Integrity. nature of its etiology. Every source of infor- future developments. The sociopolitical experience was incor- mation can be valuable in leading to insight, In seeking such help, we can neither dismiss porated into the psychoanalytic lexicon. As a and therefore to control and eventually mas- the endemic ranting and rhetoric of a whole widespread psychological phenomenon, by ter. And it is important to keep visible and political party nor the selective incorporation this time in the unfolding of the psychoana- examine both ends of the etiologic spectrum, of the pathological ideas by a single individual, lytic century, the paradigmatic neurotic syn- at the pole of society as much as at the pole be it a Jared Lee Loughner, or Major Nidal drome initiated at the previous turn of the of the individual. Hasan, Sirhan Sirhan, or John Hinckley or the Oklahoma bomber Timothy McVeigh, or the Virginia Tech shooter Seung Hui Cho, or C of I is to crime as neurosis is to psychosis—both are going further back in history, to a John Wilkes at the crowded, central, more “normal” segments Booth. Each can supply us with unexpected findings, ideas, and leads. of the population curve. Not to be overlooked is the study of “ordi- nary” group behavior, that results in the elec- tion and backing of a Bush the second, who is century had been replaced by another syn- Empirically, while audiences, to either the not above taking the country to war on what drome, of equal frequency and intensity. Hys- spoken or written forms of these messages, turned out to be a pretense, or other presi- teria and its parallels had given way to the unanimously agreed as to the premise, any dents similarly inclined, or the retention and syndrome of the compromise of integrity. reference to action which seemed to be adulation of a Kissinger, who comes away This was as ubiquitous as were the former called for was met with apathy or an inner from dark and unreliable behavior with a neuroses, as built-in to the human psyche silence. Clearly, the task or the consequences clean slate, or a disgraced governor rewarded and, above all, as capable of being absorbed which would be expected to follow insight with further important and visible public and explained under the umbrella of total meet the strongest resistance. And in this functions, corporate executives at the center psychoanalytic theory. case, I am moved to comment, “As it well of scandal, religious and moral leaders who The new, as the old, was subsumed under should”; the obstacles to action are obvious disappoint with clay feet—or disastrous the supremacy of the structural view and the and not to be minimized or skipped over financial advisers who destroy peoples’ eco- metapsychological formulations described by lightly. While the press, when it attends to the nomic lives. There is no end to the list. Politi- Freud. I did not share in the widespread prac- issue, writes emotionally about the break- cal leadership and unbridled aggression are tice of giving up these central formulations, as down of the mental health system, it is diffi- routinely coupled. had some of their previously strongest cult to counter with any rational program Continued on page 21

20 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 SPECIAL SECTION: TUCSON

UNCONSCIOUS VOLITION AND RESPONSIBILITY Yet in the meantime, there was also an important change on the psychological landscape which was clarified but conspicu- ously resisted. That has to do with the sub- ject of unconscious volition, from which emanate the issues of responsibility and accountability for one’s actions, uncon- sciously as well as consciously initiated or motivated. In the middle years of this psy- choanalytic century, Heinz Hartmann, David Rapaport, and Kurt Lewin all have held that a psychology of action has been absent from the psychoanalytic body of theory. Following decades in which I described the process of unconscious decision making, I wrote “A Psychoanalytic Theory of Action,” filling this gap in theory. In this description, I wrote that all action has its origins in unconscious motivation, yet no external behavior has a valid claim to freedom from responsibility. As Freud Sirhan or Hinckley been allowed to go SUPERORDINACY OF stated about the dreamer being responsi- scot-free? The area has always been under SUPEREGO PATHOLOGY ble for his dreams—who else?—so does it a theoretical cloud. In spite of new reason- While emphasis on the id occupied the follow that the individual is responsible ing, it cannot be denied that psychotic acts early years, and was well and accountable for the gamut of his acts, are under less control than neurotic or entrenched during the middle period, we not just those overtly conscious. Man is normal ones, and that some judgment as have not even begun to plumb the variations more responsible for what he does than to the quality and relative degree of mas- and vicissitudes of superego development, he thought—while at the same time also tery needs to be exercised. within psychoanalysis or out. The superordi- nacy of superego pathology in today’s world needs hardly to be argued, as citizens world- wide watch events unfold in the powder Political leadership and unbridled aggression kegs of the human map, the Middle East, are routinely coupled. North Africa, as previously in the dictator- ships of South America. There is a whole world waiting here for what we can say, as we bear witness to a Mubarak or a Kadafi, as being less so. Ambivalences and contradic- This subject was recently energetically previously to General Pinochet in Chile. tions have always resided side by side in joined by William Meissner (2009), in a All this goes on while the field itself analytic thinking. lengthy paper on unconscious volition shortly engages in a global lament that the day for before his death in 2010. My related writing psychoanalysis is over. It is of course to be UNCONSCIOUS VOLITION on hypocrisy in 2000 was followed by Anton kept in mind that, as with psychosis, antisocial AND RETRIBUTION Kris in 2005 on the subject, who also joined behavior needs to first be converted to Analysts have known this without know- my papers on unconscious choice conflicts neurosis, to ego-dystonic suffering, en route ing it (viz., Christopher Bollas). While by emphasizing either-or dilemmas in 1977. to self-amelioration. Adaptations need to be expressing the view, since the historic Leo- The matrix behind this cluster of subjects, understood and utilized. pold and Loeb case in the ’20s, that man is the interstices that bind them together— Hopefully, I find that a change is occurring on not responsible for his unconscious, have unconscious decisions, actions chosen after the couch, which is where we should continue they not automatically required some unconscious volition, hypocrisy, coherence, to look for trends. All of my remaining patients degree of retribution for crimes commit- and consistency—have to do with the status speak frequently of living a life of integrity. ted under unconscious influence? Has of superego functioning. That is what would be warming today.

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 21

SCIENCE and Psychoanalysis Making a Difference: Your Research Contributions at Work Rosemary Cogan Linda Mayes Rosemary Cogan and Linda Mayes

developmental components of the play activ- ity of mainstream children. From this work APsaA’s Fund for Psychoanalytic Research was established in 1976 will come a DVD and new manual to train and is dedicated to the support and nurturing of psychoanalytic raters interested in using this scale. Several investigative scholars and to the facilitation of a spirit of investigative groups are already using the CDPI and sev- inquiry based on psychoanalytic theory and principles of mental eral groups have expressed an interest in functioning. Below are summaries of the research projects to which using the measure, designed to provide a the fund provided financial support in its recent grant round. For more common measure across various observa- tion sites. Chazan is a psychotherapist associ- information about the Fund for Psychoanalytic Research, please visit ate of the American Psychoanalytic Association and a research associate at the http://www.apsa.org/Programs/Research/ Pacella Parent-Child Center. Support from Fund_for_Psychoanalytic_Research.aspx. APsaA will help to further this work which continues the legacy of important psychoan- alytic work with children. RESILIENCE IN MILITARY MARRIAGES the non-deployed spouse and physiological Jessica Borelli, Ph.D., and David Sbarra, measures, and symptoms and quality of life CONTINUATION OF ANALYTIC Ph.D., at the University of Arizona, are study- before, during, and after the deployment of PRACTICE AFTER GRADUATION ing resilience in couples experiencing military one spouse. This work is potentially very Sabrina Cherry, M.D., Columbia University deployment. Grounded in psychodynamic significant beyond the important issue of and a faculty member at the Columbia Cen- principles, the research will investigate resil- deployment because the larger issues con- ter for Psychoanalytic Training and Research, ience in military personnel and their spouses cern understanding the stability and well- with Luke Hadge, Ph.D., Juliette Meyer, Ph.D., and marital relationships before, during, being of intimate relationships. We are proud Lionel Wininger, B.A., and Nicole Yoskowitz, after, and three months after one spouse that APsaA is able to support this conceptu- B.A., are following the career paths of analysts has been deployed to Afghanistan or Iraq. ally and clinically promising research work who have graduated from the Columbia Cen- The work combines the interests in marital and anticipate that our help will provide ter for Psychoanalytic Training and Research. resilience of an investigator with a sophisti- grounding for the researchers to successfully They have found that half of graduates cated background and training in adult obtain research funds from other sources in continue new four-times-per-week analytic attachment interviews and reflective func- the future. cases and half do not. They are interviewing tioning and a co-investigator with longstand- graduate analysts, and in this project are ing work in attachment and in physiological CHILDREN’S DEVELOPMENTAL particularly interested in graduates who do measures. The measures include narratives of PLAY INSTRUMENT not continue intensive analytic work even Saralea Chazan, Ph.D., in private practice, though they are motivated to do so. The working with the Pacella Parent-Child Center researchers are also interested in how non- Rosemary Cogan, Ph.D., is professor of of the New York Psychoanalytic Society, will immersed analysts view their work and psy- psychology at Texas Tech University, Lubbock. carry out a project to standardize training in choanalysis. Support from APsaA will assist Linda C. Mayes, M.D., is Arnold Gesell work with the Children’s Developmental Play this research team to interview graduates Professor Child Psychiatry, Pediatrics, and Instrument (CDPI): Pacella Adaptation for each year and expand the number of gradu- Psychology, Yale Child Study Center; special Toddlers and Preschool Adaptation. Working ates followed in this longitudinal work which advisor to the dean, Yale University School with existing videos of parent-child play, the the researchers anticipate will help institutes of Medicine; and on the Anna Freud Centre’s investigators will formalize training in scoring plan training and educational programs. directorial team. scales for affective, cognitive, narrative, and Continued on page 23

22 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 SCIENCE AND PSYCHOANALYSIS

SUPERIOR RESULTS FOR PSYCHOANALYTIC PSYCHOTHERAPY IMPULSIVITY AND RESILIENCY AMONG TRANSFERENCE-FOCUSED THERAPY IN A COMMUNITY MENTAL THOSE ATTEMPTING SUICIDE Ken Levy, Ph.D., Pennsylvania State Univer- HEALTH CENTER Jane Tillman, Ph.D., is a staff psychologist, sity, John Clarkin, Ph.D., Cornell University Meghan Tiedemann-Fuller, Ph.D., is now in A. Jill Clemence, Ph.D., is a clinical research Medical College Institute and Research Fac- practice in Napa, California, and is a member associate, and Jennifer Stevens, Ph.D., is a ulty, Columbia Psychoanalytic Institute, and of the American Psychoanalytic Association. staff psychologist at Austin Riggs Center in Kevin Meehan, Ph.D., Long Island University, She plans to study the effects of long-term Stockbridge, Massachusetts. The research are following-up patients with borderline per- psychoanalytic psychotherapy treatment pro- here concerns states of mind in people sonality disorder (BPD) after treatment in a vided to community mental health patients who have recently survived near-lethal randomized clinical trial with supportive psy- with complex mental disorders including suicide attempts and are hospitalized at chotherapy, transference-focused therapy, or personality disorders and mixed Axis I and Austin Riggs Center. Participants will com- dialectical behavior therapy. The initial work Axis II disorders. Patients seeking services at plete questionnaire data and structured found that patients in transference-focused the Access Institute, which serves low- interviews to reflect their current state of psychotherapy showed significant changes in income and uninsured residents of San Fran- mind and their state of mind before the reflective functioning, which did not change in cisco, will be recruited and followed during attempt. The two sets of materials and the patients in the other two groups. The treatment with a variety of self-report, inter- responses will be compared with data from researchers intend to follow-up the patients view, and projective measures at the begin- normative samples. The investigators antic- eight years after having completed treatment. ning of treatment and at one year or 50 ipate that participants will be more impul- They hypothesize that social cognitive mea- sessions of treatment and, if possible, at one sive and less resilient than normative data sures (including reflective function and coher- year after treatment has been completed. In and will have lower affect tolerance and ence of mind) may be the mechanisms central this project, support from APsaA joins sup- recall fewer reasons for living. The team to change in the treatment of patients with port from the International Psychoanalytical hopes that APsaA support will help in BPD. The researchers will use work resulting Association (IPA) in making this research understanding an important clinical and from APsaA support to help gain external program possible. social problem. research funds from other sources. SUPPORTIVE VS. ANALYTIC CHILD ATTACHMENT INTERVIEW EFFECTIVENESS OF INTERPRETATION TREATMENT IN PATIENTS Robert Ziegler, L.M.S.W., is a family con- ACROSS TREATMENT MODALITIES WITH EATING DISORDERS sultant at the Harris School in Houston and a Trevor Olson, Ph.D., is working at the FIT Dana A. Satir, M.A., a doctoral candidate member of the Houston-Galveston Psycho- for Active Living Program in Saskatoon, Sas- at Boston University, has received support analytic Society. He has been awarded funds katchewan. The research here is a study of the for the second year of an ongoing study of to receive training at the Anna Freud Centre effects of defense mechanism interpretations the treatment of eating disorders. Working in administering the Child Attachment in an ongoing randomized control trial com- with Heather Thompson-Brennar, Ph.D., Interview (CAI). As part of his commitment paring the effects of psychodynamic therapy, she is testing responses to alliance-focused on this grant, he will also write a proposal cognitive behavior therapy, and supportive treatment for anorexia. The treatment to work with the CAI at the Harris School. clinical management. From existing transcripts focuses on the rigid defensive functioning The investigator and the school personnel of dynamic and relationship anecdote para- and the interpersonal problems of people want to learn more about and study the digm interviews before treatment began and with anorexia and integrates two manual- attachment styles of children in their educa- at the end of treatment, and from therapy ized treatments: supportive treatment tion and therapeutic program. The support transcripts, the investigator will study the rela- with goals involving weight restriction and from APsaA will help this committed devel- tionship between the accuracy of a defense analytic treatment focused on transference oping scholar build a sound platform for interpretation and the patient’s subsequent and interpersonal dynamics in and outside future clinical and research work. use of the defense in the session and the of treatment. The intensive measures accuracy of defense interpretations and treat- include self-report measures and inter- ment outcome in each of the three treatment view measures coded for a full range of modalities. The investigator views this APsaA domains at intake, during treatment, and Editor’s Note: support as helping provide a platform for a post-treatment assessments. At the end of This column has replaced research career by supporting time for the first year of the project, the work was Andrew Gerber’s intense research work with a very sophisti- well under way with the integrated treat- cated existing research team that will enable ment protocol manualized, several patients regular science column him to move toward becoming a successful in treatment, and other patients scheduled in this issue. independent researcher in the near future. to begin treatment.

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 23 ACPE

Hafter Gray, president; Penny Rosen, secre- Accreditation for Psychoanalytic tary; Phil Lebovitz, treasurer; and Joseph Palombo, financial secretary. I am vice-presi- Education: Current Status dent for accreditation. Ronald M. Benson ESTABLISHING BYLAWS In January 2005, I was elected to the Board that such stan- AND BUSINESS PLAN of Trustees of the Accreditation Council for dards amplify Bylaws for the new organization were Psychoanalytic Education, Inc. (ACPEinc). and are not in adopted in 2003 as well as a detailed busi- When some of our members learned of my conflict with the ness plan. This was a precondition for finan- appointment, the most frequent comment core standards of cial support of the fledgling accreditation was, “What’s the ACPE?” I thought it might be ACPEinc. These board by consortium organizations. So far, useful to describe the organization. carefully negoti- ACPEinc has been supported financially by ated standards the consortium members and grants from INCORPORATED IN 2001 were adopted by the Group for the Advancement of Psycho- TO SET CORE STANDARDS ACPEinc when it analysis and Psychotherapy in Psychology. It Ronald M. Benson The Accreditation Council for Psychoana- was spun off as is anticipated that ACPEinc will eventually lytic Education (ACPE) was incorporated in an independent corporation. be self-supporting from the fees paid by 2001. It was established as an independent training programs that seek its accreditation. accrediting agency by the Psychoanalytic ACPEinc BOARD ACPEinc’s policy is to conduct all accredita- Consortium, an informal organization of four The initial Board of Trustees of ACPEinc tions and site visits at no charge to the apply- major psychoanalytic mem- consisted of one representative from each of ing training programs until ACPEinc receives bership organizations: The American Acad- the four consortium organizations. They, in recognition by the U.S. Department of Edu- emy of Psychoanalysis, The American turn, elected a board of 14. There were three cation (DOE). This was adopted in order to Psychoanalytic Association, Division 39 (Psy- nominees from each of the four organiza- establish the reputation of the new accredita- choanalysis) of the American Psychological tions and two public members. The next tion credential. To date, ACPEinc has accred- Association, and the National Membership generation of members of the board of ited five training programs and one more is Committee on Psychoanalysis in Clinical trustees was elected by the board itself. The in the final stages of accreditation. Three of (now the American Association original members who were identified with these training programs are affiliated insti- for Psychoanalysis in Clinical Social Work). APsaA were nominated by the president tutes of APsaA. ACPEinc encourages new Together, these organizations represent the and chairman of the Board on Professional applicants to take advantage of this period of majority of psychoanalysts in the U.S.A. Rich- Standards. They were Gerald Margolis, Alvin free accreditation. ACPEinc also suggests that ard Fox was the APsaA identified incorpora- Robbins, and Allen Rosenblatt. Terms of APsaA institutes consider applying when they tor of ACPEinc. office were of varying lengths so that the are in the site visit process of the Committee As early as 1994, the intention to develop an entire board would not change at one time. on Institutes (COI) in order to avoid duplica- accrediting board for psychoanalytic training At the conclusion of Margolis’s first term, tion of effort. programs was agreed upon by the consortium he declined to continue his service. I was organizations. The process of developing a set elected for a full three-year term to replace PROTECTING THE PUBLIC BY of standards that was acceptable to all parties him. When Rosenblatt died, Phil Lebovitz PROMOTING EDUCATIONAL took several years. Extensive discussions at was elected to complete his term. Robbins EXCELLENCE consortium meetings and frequent checking decided to leave the board after his term ACPEinc sees its mission as twofold: to with the parent organizations resulted in a ended and David Turner replaced him. In protect the public by evaluating and accredit- mutually agreed upon core set of standards addition, several other members of APsaA ing psychoanalytic training programs in the that allows for some variability in requirements serve as trustees because they are also United States and to promote excellence in for any particular training program, provided members of other psychoanalytic organiza- psychoanalytic education. With this dual mis- tions. In the future, new members of the sion, it hopes to ensure that practitioners of board and new officers will be elected by psychoanalysis are educated to appropriate Ronald M. Benson, M.D., is training ACPEinc members. Each time a training pro- standards by the institutes in which they are and supervising analyst at the Michigan gram is accredited, it becomes a voting trained. ACPEinc therefore mandates that Psychoanalytic Institute, chair of the BOPS member of ACPEinc. psychoanalytic training programs require Finance Committee, former chair of BOPS, The officers of ACPEinc are Nathan their students to participate in the three and vice-president for accreditation, ACPE. Stockhammer, chair of the board; Sheila Continued on page 27

24 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011

COPE Impasses and Failures in Analysis Judy L. Kantrowitz and Steven H. Goldberg

Our COPE Study Group on Impasses and the role of supervision in these processes, Judy L. Kantrowitz Steven H. Goldberg Failures in Analysis has been working together often studying clinical material presented for the past five years. It was initially formed first in the Thursday discussion group. The Nonetheless, their exploration of what to complement an APsaA discussion group presenters in this discussion group have occurred began to reveal previously on the same topic that we created some- most often been candidates or recent grad- unrecognized effects of the supervision. what earlier. As we had hoped, the two uates, and the cases they have presented Sometimes there were overlaps in charac- groups have functioned synergistically in have been supervised. In the course of their ter or blind spots in the candidate that the offering somewhat different vantage points presentations, many of these new analysts supervisor shared. These became appar- on our areas of interest. In the COPE group, have discovered that their thinking in the ent when the study group was able to in particular, we have wondered about the discussion group begins to expand. They offer a new perspective on the case and impact of impasses and failed cases, especially realize, as people often do while presenting, sometimes on the supervision. Other on candidates and on analysts early in their that something has been limiting the scope times it became more clear in the course careers. How could supervisors and faculty of their awareness. of the presentation and discussion that best help younger colleagues not only to transference to authority by the analyst/ weather such experiences but also to learn FROM DISCUSSION GROUP TO supervisee, combined with a supervisor’s and to grow from them? To what extent STUDY GROUP: A SECOND LOOK critical tone, led to inhibitions in the clini- could supervision contribute to the problem, The effect of supervision frequently cal work. Sometimes the group could dis- and what was the relationship between clini- emerged as more central to the impasse cern and demonstrate to the analyst how cal and supervisory impasses? How could than these analysts had previously consid- institutional conflicts and institute history supervisors, faculty, and the overall institute ered. Often it came up as something of a were played out in the supervision, result- structure best foster an atmosphere of open- surprise. When this was the case, we invited ing in a constriction of the candidate’s ness in which these clinical outcomes and the analyst to come back to meet with our thoughts and creativity. derailments of supervision could be con- structively discussed? In the early meetings of both groups, we To what extent could supervision contribute to focused on impasses in treatment with a the problem, and what was the relationship between view to unraveling patient and analyst over- laps and disjunctures. In the COPE group, clinical and supervisory impasses? we increasingly found ourselves studying

COPE group to explore in greater depth the INFLUENCE OF THE INSTITUTE Judy L. Kantrowitz, Ph.D., is a training and role of supervision and its contribution to In most, if not all, cases it emerged that supervising analyst at Boston Psychoanalytic the impasse. Other analysts, who had not problems in the supervision, if they were Institute, clinical associate professor at previously presented at the Thursday discus- within the awareness of supervisee, Harvard Medical School, and the author of sion group, also brought us similar situations supervisor, or both, were not explicitly The Patient’s Impact on the Analyst and for us to try to help them explore. In general, discussed. Understanding why this occurs Writing about Patients: Responsibilities, these cases were not ones in which the ana- so consistently in a learning and profes- Risks, and Ramifications. lyst initially believed that the supervision had sional environment that emphasizes open Steven H. Goldberg, M.D., is a training and contributed significantly to the impasse. In inquiry is a problem we plan to continue supervising analyst at San Francisco Center for fact, most often the analysts had positive to explore. Psychoanalysis, where he is currently serving things to relate about their supervisory Having heard dilemmas brought to us as dean of students. He is also a personal and experience, and did not focus on the contri- both by supervisors and by supervisee/ana- supervising analyst at Psychoanalytic Institute bution of the supervisory experience to the lysts over these past five years, in a variety of Northern California. clinical impasse. Continued on page 27

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 25 TEACHERS’ ACADEMY

foster the development of practitioners and Who Will Teach Psychodynamics leaders who will take this Association and others into its next 100 years. in the Future? For this yearlong experience, APsaA By Melissa Grady through an application process selected six teachers, two each from three different disci- With Lisa Cobourn, Rana Duncan-Daston, Douglas Lane, Sergio Paradiso, and Daniel Rochman plines: social work, psychology and psychiatry. All applicants were required to submit a pro- The above question is what the leaders include psychodynamic and psychoanalytic posal for a teaching project that they would within the American Psychoanalytic Associa- theory and practice into their training set- develop over the course of the year. During tion sought to answer and, upon reflection, tings. By targeting those who are directly the development process, through the Asso- they found that the answer was not clear. involved in training future practitioners, the ciation, each teacher was assigned a mentor The Association is an organization with a rich Association’s goal is to help practitioners or who is a master teacher in his or her disci- history, now spanning over 100 years, with a academicians with a psychodynamic back- pline. Together, the mentor and the teacher diverse membership of different disciplines, ground and inclination develop skills specific will work to develop the proposal further, to representing a multitude of specialty areas to teaching psychodynamic thinking to train- anticipate and prepare for any barriers, and within psychoanalytic and psychodynamic ees in psychiatry, psychology, and social work, to come up with concrete ideas on ways the practices. It has grown from a practice- project can be implemented to have based organization where practi­ the greatest impact within the respec- tioners from around the country and tive treatment or teaching settings. world could come together to discuss The mentors and teachers began this theory, practice challenges, and their exciting process at the 2011 National most illustrative cases to one that Meeting in January through individual includes researchers and leaders that meetings and now are continuing reach beyond the organization into through phone calls, e-mail, Skype, and different disciplines and orientations. other contacts until January 2012. While these changes have enriched the organization and broadened its CREATING A HOLDING appeal to others as the scope of the ENVIRONMENT IN THE work supported by the Association CLASSROOM expands, most university settings have Although we are at the beginning of significantly reduced content in psy- this process, we feel invigorated, choanalytic and psychodynamic prac- excited, and inspired by our experi- Psychoanalytic and Psychodynamic Teachers’ Academy tice in their training programs. This participants (from left): Richard Summers, chair of the ences to date. At the January 2011 reality led the leadership within Teachers’ Academy Committee; Sergio Paradiso, National Meeting, we had the oppor- Daniel Rochman, Douglas Lane, Lisa Cobourn, Melissa Grady, APsaA’s Education Department to Rana Duncan-Daston, and members of the Teachers’ Academy tunity to meet and learn from several begin to consider who would be the Committee, Susan Sherman and Elisabeth Schreiber. master teachers representing our next generation to carry on the work various disciplines. These teachers of the Association that previous generations including trainees who have no previous exposed us to applied teaching skills as well have so tirelessly promoted. exposure to or are prejudiced against psy- as broader issues related to pedagogy and chodynamic thinking. Teaching teachers will the parallel process of creating a holding TEACHERS’ ACADEMY: achieve the goal of reaching out to exponen- environment in the classroom where affect MENTORS AND TEACHERS tially more trainees and exposing them to and unconscious processes can evolve and Out of this discussion emerged the idea psychodynamic theory and practice. The enrich the learning of our students. In addi- of the Psychoanalytic and Psychodynamic impact of this effort in its inaugural year is tion, we attended many workshops of our Teachers’ Academy: a program designed to unknown. However, we as the program’s par- choice, further enhancing our own knowl- support the efforts of teachers working to ticipants have planned to share our initial edge of psychoanalytic theory and practice. impressions of the experience to date in the These workshops, along with the experi- hopes that as the first tier of this experiment, ences with the master teachers, armed us The authors are the first class of participants we may inspire the Association (and other with new knowledge and inspiration that we in the Psychoanalytic and Psychodynamic psychodynamically oriented organizations) to can bring back to our own training sites. Teachers’ Academy. continue to think creatively about how to Continued on page 27

26 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011

ACPE To date, ACPEinc has developed an appli- goes on the relationship between the two site Continued from page 24 cation procedure, a self-study protocol, and a visiting organizations will further evolve. site visit protocol. These documents and It is hoped that the accreditation by components that are nationally and interna- other information about ACPEinc are avail- ACPEinc will become widely accepted and tionally recognized as essential to psychoana- able at its Web site, ACPEinc.org create a national core standard for all psy- lytic education: a comprehensive course of choanalytic training in the U.S.A. However, didactic study; a personal psychoanalysis of a ACPE VS. APsaA STANDARDS licensure laws in New York state and other frequency, intensity, and duration adequate to ACPEinc standards match the core of places, already seem to accept a much provide a deep psychoanalytic experience; APsaA’s requirements, but differ in some lower standard both for prerequisite train- and substantial experience treating patients ways. The principle differences are in the ing before psychoanalytic training and for with the supervision and support of senior number and duration of supervised cases the training itself than these ACPEinc faculty. It also encourages research by candi- and the minimum frequency for training requirements. This is a matter of concern dates and faculty. analyses and supervised analyses. It accepts for all the consortium organizations and all ACPEinc believes, on the basis of its con- and applies APsaA standards for APsaA- who advocate for high standards in psycho- tacts with the DOE, that accreditation of affiliated institutes. ACPEinc has established analytic training. These apparent trends psychoanalytic training programs recognized a cooperative and collegial relationship with place ACPEinc in a challenging uphill battle by a DOE-recognized accrediting agency is BOPS and COI. Several of the accredited as a champion of high quality training psy- rapidly becoming necessary to ensure these institutes of APsaA used their preparations choanalytic standards. programs are recognized as legitimate for a COI site visit for applying to ACPEinc Further information about ACPEinc can be within the United States and to ensure the and vice versa. The accrediting process by obtained at its Web site, ACPEinc.org. continuation of clinical psychoanalysis and BOPS is much more a consultative and psychoanalytic training programs as a legiti- ongoing matter than is the usual relation- Editor’s Note: This article first appeared in mate professional endeavor. It is also the ship between the organization to be “Free Associations,” Michigan Psychoanalytic opinion of ACPEinc that accreditation by an accredited and its accrediting agency. Society and Institute Newsletter. V. 36:1, independent organization is essential to rec- ACPEinc site visits are also consultative, but February 2006. It was republished, slightly ognition of psychoanalysis as a professional are mainly focused on ensuring that the revised, in the Fall 2007 AAPCSW newsletter. specialty by all organizations and grant training program is fully in compliance with This is a further revision. awarding entities. the core standards. We anticipate that as time

Psychodynamics Impasses and Failures casebook to communicate some of our Continued from page 26 Continued from page 25 experience and what we have learned from it to colleagues. We continue to invite col- We believe that the Teachers’ Academy is a of educational and institutional contexts, the leagues to present cases involving impasse vital step in ensuring a future for psychoanalytic supervisory process and the impact on or failure at our Thursday discussion group, practice. Infusing university and other training supervision of other factors in institutional and we will continue in our COPE group to settings with information to creatively engage life is appearing to us as ever more intricate study analyses in which supervision itself is future professionals is critical if younger practi- and complex. The impact on both treatment an issue and has played a significant role in tioners are to be exposed to and enriched by and supervision of institutional conflict and the impasse or failure. We welcome supervi- psychoanalytic training. Educational and train- dysfunction is an area to which we have only sors and supervisees to contact us about ing projects such as these are well worth the recently focused our attention and which we bringing such situations to our Friday morn- effort. What we know from psychoanalytic hope to study further. To what extent might ing COPE group. Situations in which a candi- theory is that healthy functioning emerges an impasse represent not only a co-construc- date has been supervised by an analyst who through attention and nurturing during the tion between analyst and patient but also a is known to have been involved in a bound- early developmental years. Through the nur- more complicated construction involving the ary violation or boundary crossing, and turance and attention the Psychoanalytic and institute itself? where the case has foundered or ended pre- Psychodynamic Teachers’ Academy provides maturely, would be welcomed as we try to to early trainees, APsaA is setting the stage ONGOING THURSDAY understand some of the possible ripples and for a richer and healthier future. For more DISCUSSION GROUP collateral damage from these events. Please information on APsaA’s Teachers’ Academy, As we continue to gather case material, contact [email protected] visit: www.apsa.org/teachersacademy. we are beginning to consider writing a or [email protected].

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 27 SPECIAL SECTION: PRIVACY AND THE COURTS CASES from the but the best answer is usually to involve counsel, particularly in sensitive cases. It is Frenkel Files generally necessary to do something when records are requested and their release is questionable: Do not simply ignore the Psychotherapy Notes request. Nonetheless, the decision to release John C. West a patient’s records should never be made lightly without the patient’s authorization. On the eve- If the tape had inaudible sections, it could be This case also highlights the humanity of ning of January enhanced by an expert to determine the legal system. The legal system is, of course, 18, 2003, Marcus whether an accurate transcription could be governed by rules and sometimes seems Weiss made a made. The court denied the request to hard-hearted. It is also, however, a system call to Harvard review Weiss’s psychotherapy records. designed and implemented by humans, and Vanguard’s tri- run by humans. Judges are not immune to the age unit regard- NO SINGLE RIGHT ANSWER issues of humanity that come before them. In ing the status of This case highlights a perennial problem for this case the judge recognized the heart- his son, Jordan psychotherapists: When should the records wrenching nature of the matter before him. Bennett Weiss, of patients be disclosed? If there is a validly The judge noted: John C. West then nine years executed authorization for release, the issue old. It is not clear from the opinion whether is resolved, but otherwise care must be taken. Some may suggest that with the defendant nurse practitioner, Ann Bragan, In this case it appears that Weiss never con- took the call or acted upon the information sented to the release of his records, and no passage of time, memory will received during the call. It appears that demand other than through discovery was diminish Jordan’s parents’ sense of Bragan gave advice regarding Jordan’s care. made, so the psychotherapist was not really loss. But anyone who has suffered The call was taped and the tape existed at called upon to make that decision. However, such a tragic and catastrophic loss the time of the litigation that arose out of attorneys sometimes will seek records or could not possibly feel this way. the events of that night. The details of the information directly, without the patient’s How often are we asked in daily conversation were not disclosed in this opin- authorization, from the practitioner, either by ion. At some time subsequent to January 18, request or by subpoena, and practitioners conversation, “How many children Jordan died and suit was brought against need to know how to respond. There is no do you have?” The father or mother Nurse Practitioner Bragan. single right answer to that question given the who has lost a son (or daughter) Weiss entered counseling to help him to multitude of jurisdictions in the United States, must answer: “Well, I had—, deal with his grief. After litigation ensued, but my son (or daughter) died.” Bragan sought discovery of Weiss’s psycho- Every time parents are asked that therapy records, allegedly to obtain proof of the guilt that he felt as a result of the informa- casual question, their hearts break. tion conveyed during the telephone call in question. Bragan alleged that the tape of the Here, the Court is asked to allow telephone call contained inaudible sections, Marcus Weiss’s deepest grief and hence she needed the psychotherapy records dearest thoughts to be splayed in a to prove what was said. most public forum. After deliberation, The trial court disagreed. It held that the I simply cannot countenance such best evidence of the conversation is the tape. an effort.

John C. West, J.D., M.H.A., is a senior It often seems that requests for records health care consultant with Global Loss are mechanical operations that require little Prevention, Inc., a Chartis company. This thought. This case stands for the proposition column constitutes general advice not legal that that is not always the case. advice. Readers should consult with counsel for legal concerns. For questions or comments Weiss v. Bragan, 26 Mass. L. Rep. 331 contact [email protected]. (Mass. Super. Ct. 2009)

28 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 SPECIAL SECTION: PRIVACY AND THE COURTS

POLITICS and bitter divorce proceeding. Eist, following the advice of counsel, also wrote a letter to the PUBLIC POLICY mother, informing her of the complaint filed by her husband and of the subpoena from the board; he explained that if she did not Ethical Versus Legal Obligations respond within one week he would be com- pelled to forward her complete medical in the Eist Case record and the records of her two sons to the board. A Shift in the Burden In response to his correspondence with Graham L. Spruiell the mother, Eist received a letter from the attorney representing the two sons, indicat- After 31 subpoena or a motion for a protective order. ing they would not waive their right to confi- months of delib- Ruling in favor of the board, the Court of dentiality. He also received a separate letter erations, on Jan- Appeals reversed the judgments of two from the mother, stating that she would not uary 21, 2011, administrative law judges and three lower consent to the release of her medical records. the Court of courts. The court did not address the impor- Appeals decided tant question of who owns or regulates infor- SCYLLA AND CHARYBDIS in a divided 4-3 mation contained in the medical record, nor Imagine being in Eist’s position. The board decision in favor did it opine about the impact of its ruling commands you to release your patients’ of the board in upon confidentiality. medical records and informs you, contrary to Maryland State your professional ethics, your own sense of Graham L. Spruiell Board of Physi- FACTS OF THE CASE right and wrong, as well as advice from coun- cians v. Harold I. Eist. The Court of Appeals Eist was treating a mother and her two sel, that your patients’ consents are unneces- upheld the board’s reprimand and fine sons. The mother was in the midst of a con- sary and irrelevant. You inform your patients against Harold I. Eist (a psychoanalyst and tested divorce and custody battle with the about the subpoena and your patients are child psychiatrist) for failing to cooperate estranged husband, an attorney. At the moth- emphatic that they do not want you to share with a lawful investigation conducted by the er’s request, Eist issued an affidavit attesting, their private information with the board. board and failing “to obey, timely, a subpoena based on his observations, that the mother In sorting out ethical and legal obligations, for the production of certain patients’ medi- was a competent caretaker for her children. Eist believed that it was his ethical duty to cal records in his possession.” Seven months later her husband filed a com- maintain confidentiality. He considered the plaint with the board, accusing Eist of over- possible harm that might occur to his STUNNING REVERSAL OF medicating his wife and sons. patients as a result of disclosure. In addition FIVE PREVIOUS FINDINGS Eist received a subpoena from the board to state laws such as Section 4-306(b) of the The court held that the board’s action to on April 19, 2001, ordering him to produce “a Maryland Code, he considered landmark reprimand and fine Eist be affirmed because copy of all medical records” of the mother cases that protect patient confidentiality, Section 4-306 (b) of the Health-General and two children within 10 days. The board such as Jaffe v. Redmond. He conferred with Article of the Maryland Code expressly did not inform the mother or her children of trusted colleagues regarding professional requires a health care provider to disclose the request for their records. Eist immedi- ethics and his obligations to his patients. He the medical record in the context of an inves- ately called the board’s representative and tried to be responsive to the board. In con- tigation without the consent of the patient, informed him that the complaint was false sultation with highly respected and compe- and neither Eist nor his patients exercised the and that the complainant was an estranged tent counsel, he initially delayed in complying prescribed legal remedies necessary to chal- husband involved in a contentious divorce with the subpoena. lenge the board’s subpoena specifically, they proceeding. He also informed the board rep- On July 7, Eist received a response from did not file either a motion to quash the resentative that, under standards of ethics, he the board again demanding production of could not release the records without the the medical records, this time within 48 Graham L. Spruiell, M.D., is co-chair of patients’ consent. Eist consulted with counsel, hours. The letter reminded Eist that in accord the Committee on Government Relations and who confirmed his belief that the records with Maryland statute, provision of records is Insurance. He participates in the Program could not be turned over to the board unless not contingent upon the consent of his in Psychiatry and the Law and has an interest his patients consented. The next day, Eist patients. On July 11, Eist’s attorney wrote to in confidentiality as the basis of trust in the wrote a letter to the board restating that he the board and related the history of the doctor-patient relationship. believed the complaint was motivated by a Continued on page 30

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 29 SPECIAL SECTION: PRIVACY AND THE COURTS

Eist Case confidentiality with respect to board investi- Patients also assume a burden in terms of Continued from page 29 gations, but it does damage this right. Physi- a potential loss of trust in the clinician-patient cians now must assume the burden of relationship. If confidential information is dis- matter and informed the board that he wrestling with the ethical dilemma about closed by the clinician according to Section wanted to cooperate, but that all of his whether to comply with the subpoena or to 4-306 (b), and if patients conclude that their patients had asserted their confidentiality take legal action to quash the subpoena. Upon clinicians no longer have control of the infor- rights. His attorney added that it should not receiving a subpoena from the Board of Reg- mation that they have entrusted to them, be Eist’s responsibility to explain to his istration, physicians practicing in Maryland they might be more reluctant to seek treat- patients, that in relation to a board investiga- should carefully consider their options and ment and to be candid about ailments, know- tion, their consent was not necessary. consider legal advice and assistance from pro- ing that it is possible that the board could fessional organizations before responding. access their protected health information, EIST’S ATTEMPT AT PATIENT When a clinician receives a subpoena that regardless of what the clinician believes is CENTERED RESOLUTION advises the clinician that a patient’s records ethical, and regardless of what the patient Eist informed his patients about the letter can be legally released without the patient’s wants and decides. from the board, and said that he wanted, “to consent, a clinician might be tempted to Given the possibility that this decision could try and bring this matter to a close.” He noti- comply, even if it meant breaching a patient’s become a precedent and be followed in simi- fied his patients a second time that he was confidentiality. Compliance with the board’s lar cases in other states, it might be practical in being compelled to make their entire medical subpoena might seem more attractive than the course of discussing the usual limitations records available, unless they indicated that investing resources in the legal system to of confidentiality with patients to include they would obtain a court order to prevent quash a subpoena, or alternatively urging the some reference to the rare event of a board him. In a third letter on July 16, Eist specifically patient to quash the subpoena. In either investigation, even though no psychoanalyst requested, in a nine-page single spaced letter, event there is the risk of antagonizing the will savor reading a Miranda-like warning to a a response regarding the subpoena, given his board, the patient, or both. An unintended patient. The statute, the board’s action, and quandary about ethical versus legal obliga- consequence of this decision may be that it the decision of the Court of Appeals together tions. Eist was making an effort to be respon- encourages clinicians to act against their ethi- signal major shifts in the triangular relation- sive to the board, but the board was not cal code by providing an incentive in the ships of patient and physician, patient and being responsive to Eist in the respect that it direction of breaching their patients’ confi- board, and physician and board—such that a disregarded his legitimate questions about dentiality. This decision is troubling, both patient’s expectation for confidential treat- responsibilities to his patients. Eventually, Eist because the clinician is in the impossible role ment can no longer be assured. After a did agree to forward the records, when his of serving two masters with mutually exclu- 10-year battle, Eist will now have to petition patients failed to obtain a court order to pre- sive demands, but also because it leaves no the United States Supreme Court, his only vent him. A peer review quickly determined room for discretion when it comes to mat- legal remedy. The next step will be to rally the that the complaint was false, as Eist had said. ters of conscience and professional ethics. 28 professional and privacy organizations The board, however, continued to sanction (including our own Association) that sup- Eist for his lack of prompt compliance with TROUBLING CONSEQUENCES ported him from the start and will no doubt the subpoena. From the point of view of patients, it might support him again. He is greatly admired by also be an overstatement to say that as a patients and colleagues for his willingness to THE BOARD’S UNYIELDING RESPONSE result of this decision, this is the end of confi- fight for the rights of his patients. Eist successfully challenged the board’s dentiality. Nevertheless, it is patients who will reprimand and fine, whereupon the board now be expected to assume a new burden. “doggedly appealed,” losing its case four They will be faced with either allowing a more times before finally succeeding in the breach of their personal information or hiring Special thanks to Jim Pyles for Court of Appeals. The board prevailed by a an attorney to quash the subpoena; that is his invaluable legal expertise, single vote, reversing five decisions of the assuming they are familiar with the statute lower courts and affirming the board’s com- and can afford an attorney. It is troubling that president-elect, Robert Pyles, plaint against Eist. Until this holding, the bur- the board did not inform the patients that and TAP editor-in-chief, den had been on the state to show how and their records were being sought for purposes why the patient’s right to privacy should be of an investigation, as if this information by Janis Chester, all of whom have abrogated without the patient’s consent. default belonged to the board or to the phy- been involved in the Eist case From the point of view of physicians and sician, and not to the patients, and as if the from its beginning. other clinicians, it might be an overstatement patients’ wishes and Eist’s ethical duties were to say that this decision eliminates the right of not worthy of consideration.

30 THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011

From the Unconscious Sheri Butler Hunt poetry

John Tieman, an educator associate with the American Psychoanalytic Association, has had poetry published in prior editions of The American Psychoanalyst. His local affiliation is with the St. Louis Psychoanalytic Institute. Tieman has had an interest in eastern poetic forms including the haibun, originated by Basho. He describes his poem in this way, “‘The Sacred Heart’ is a thoroughly Western piece that borrows, and modifies, the structure of a Japanese art form. In this case, I begin with a haiku, write a prose poem, and then finish with a tanka, another form of Japanese poetry.” The work is direct and powerful, moving in what it says and what it does not say.

The Sacred Heart

a maroon leaf drops stem to stem with a yellow an autumn death pact

My mother is 101. She lives in a home. She had a private room until last month. Until her privacy didn’t matter because reality doesn’t matter. Because I live half-a-country away, I never met the new roommate. Until my visit last Monday. There is a simplicity to our visits. Mother likes the relationship. I like the relationship. Beyond that, there is nothing. Mother has dementia. So when we talk about the old days, nobody’s dead to her and everyone—husbands and parents and friends—are all in the next room. I’m in there. Like when she tells me about the other son named John, “the teacher,” the one she delivered last week “in the next room.” To her nurse, dementia is a complex disease. To me, it’s as simple as emptiness. But about the roommate. Mother says the roommate’s husband once visited, that and something about him kneeling. Their room is just over there. So I look. She’s beautiful. The roommate is half my mother’s age. While Mother has all manner of personal items— her rosary, snapshots, a box of Kleenex, a drawing of the Sacred Heart—the roommate has just one photo, her and her husband at something formal. The husband is the kind of guy who wears a tuxedo well. She is tan, 35-ish, shapely, charming in that Southern big-haired sort of way. She effortlessly wears the low cut dress of a woman who knows she’s sexy. The shot captures her mid-laugh. Today she stares out the window on her right. She pays no mind to her photo, to me, to the nurse who comes up behind me. Her nurse says she’s been staring for fifteen years this way. But this isn’t about the window. She simply stares to the right.

just before I leave I stare out the living room window to the street a basketball rolls by followed by nothing no one not a soul —John Samuel Tieman

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

THE AMERICAN PSYCHOANALYST • Volume 45, No. 2 • Spring/Summer 2011 31 NONPROFIT ORG. US POSTAGE PAID ALBANY, NY PERMIT #370

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Associating with APsaA

AFFILIATION CATEGORIES FOR EDUCATORS, STUDENTS, RESIDENTS, PSYCHOTHERAPISTS, RESEARCHERS Over the last several years, APsaA has developed a number of categories of affiliation to allow colleagues and friends interested in psychoanalysis to establish a tie to our organization. Associates of APsaA get more out of the national meetings, can start to network nationally with like-minded professionals, and contribute to the richness and vibrancy of the psychoanalytic community. Each Associate category is sponsored and supported by a committee of the American Psychoanalytic Association. EDUCATOR ASSOCIATE—available for teachers, professors, and administrators at all levels of education, pre-school through university, who are interested in the integration of psychoanalytic principles and ideas into their teaching and scholarship. PSYCHOTHERAPIST ASSOCIATE—available for psychoanalytic psychotherapists with a minimum of a master’s level degree and licensed and/or certified by the state in which they practice. Individual Psychotherapist Associates are listed in a National Directory of Psychotherapist Associates, prepared annually. RESEARCH ASSOCIATE—available for research scientists, research oriented clinicians, and others with an interest in psychoanalytically oriented research. The sponsoring committee will facilitate presentations of research at psychoanalytic meetings. STUDENT/RESIDENT ASSOCIATE—available to medical students, psychiatric residents, psychology, social work, graduate, and undergraduate students of all academic disciplines. Standard benefits provided to Associates in all the above categories include reduced APsaA meeting registration fees, advance notification of meetings, and subscriptions to this publication. Reduced subscription rates to the Journal of the American Psychoanalytic Association (JAPA) are also available. Please note: Individuals who qualify for full APsaA membership are not eligible to join as Associates. Contact APsaA’s National Office for more information: 212-752-0450 ext. 18. E-mail: [email protected]. Or go to the APsaA Web site, www.apsa.org/associates, to download the latest brochures.