Does it still taste like psychoanalysis?: Experiences of collaborating with universities in psychoanalytic training

Abstract

There has been a striking lack of interest in reforming training and creating new forms of transmitting the essential knowledge required to function as a psychoanalyst. This paper presents a model for training psychotherapists in use in Finland, in which private institutes offer training in collaboration with the universities. The roles and functions of the universities and the institutes in the training are described. The implications of this mixed-model training are discussed, viewed through the experiences of some teachers involved in implementing the model. The teachers were asked to describe their experiences in regard to certain questions: What happens, when a third party becomes involved in the training process? Is it possible to maintain a psychoanalytic curriculum of studies in such a context? What does the relative loss of autonomy signify? What are the implications for the psychoanalytic institutes? Regarding the content of the training, the experiences seem more positive than expected. Institutes seem to have managed to adapt to the new requirements while maintaining the psychoanalytic core of the training. However, the model contains elements that can pose threats to the roles of the institutes and the position of psychoanalytic thinking as the base for psychotherapy in the future.

Key words:

• psychoanalytic training
• third-party involvement
• implications for societies
• psychoanalytic curriculum
• institutional autonomy

The background of this paper is a reform, made in 2012, to the training of psychotherapists in Finland. At a structural level, the reform changed the system of how psychotherapists are trained and made it the responsibility of the universities. The impetus for me was a felt need to take a step back and reflect on the effects of this change. My interest is mainly in the position of the institutes and societies: what happened when a third-party became involved in the training process? There are also other questions that interest me, related to the possibility of maintaining a psychoanalytic curriculum, the relative loss of autonomy brought about, and the implications for the societies and institutes providing training. In this text, I deal with issues from the perspective of my own institute, the Therapeia Institute.

In this paper, I start out by making some remarks concerning psychoanalytic training in general. I then proceed to describe a model introduced ten years ago of how training in psychotherapy is carried out in Finland. The last part will be an evaluation of the experiences of the model of collaboration with universities in implementing training in psychotherapy. It is based upon reflections to the questions above that were provided by some teachers involved in the implementation of the model on the side of the institutions.

Some problems with psychoanalytic training

In the last forty years or so, there has been an increasing critique of the ways psychoanalytic training is organized. One of the most vocal and consistent critics has been Otto Kernberg (1986, 1996, 2000, 2014, 2016), who has written extensively of the problems inherent in the traditional ways of psychoanalytic training. If it were to be summarized in one phrase, his observation is that psychoanalytic training suffers from a dissonance between the structure and the goals of training. The ways in which training is organized do not contribute to the goals and ideals set. In his view, the focal point is the position of the training analyst and the system of training analysis, which he sees as central to the pathological organizational dynamics that he observes in societies providing psychoanalytic training. In his critique he also points to the lack of an open discussion within psychoanalytic institutions. Kernberg calls for a university-like organizational structure, in which merits instead of connections or status would be decisive.

Jürgen Reeder (2004), building on the work by Kernberg and others, developed the concept of the “psychoanalytic superego complex,” by which he tries to clarify the ways in which the professional superego of the analyst intertwines with the institutional superego systems of the society or institute, creating a pathological organizational system. According to Reeder, the ways in which psychoanalytic training has been and is being organized contains both explicit goals of fostering creative psychoanalysts of personal integrity, and other, not explicit, goals transmitted by the immanent pedagogics of psychoanalytic training.

By the term immanent pedagogics he means the ways in which the unconscious conceptions of values and wished-for qualities contrary to the expressed goals are transmitted below the surface, in a hidden agenda. These goals are connected to the unhealthy dependency, primitive idealization and power structure flourishing in the societies. This creates a pathological form of organizational dynamics. He sees the pathology mainly centering around paranoid anxiety, both within the institute and as an integral component of the relation with the outside world.

Psychoanalysis has had a tendency to view the outside world with suspicion. Already from its outset, psychoanalysis held a view of itself as being in enemy territory. And, to be fair, that conception is not totally wrong. As it is dedicated to the research and understanding of the unconscious, psychoanalysis poses a constant threat to the rational world. However, an effect of this paranoid view has been the tendency of psychoanalysis to deflect contributions that do not fit into the narrative. There has been a striking lack of critical openness, both within and in relation to the outside.

The psychoanalysis of today seems to me to be in need of more flexible and permeable boundaries with the outside world (Gonzalez Torres, 2013). Closing itself off makes psychoanalysis a self-sustaining domain, interesting only for the true believers. Viewing advances made in science outside psychoanalysis with suspicion and disdain contains the risk of positioning ourselves among the flat-earthers or the Covid-deniers. I think we need the courage to reflect on and integrate the findings of science with psychoanalysis, instead of trying to rank psychoanalysis as some kind of master-science that already has given us all the answers we need. We do not need to repeat the story of the Catholic church and Galileo.

Psychotherapy training in Finland

Due to a reform implemented in 2012, all training in all types of psychotherapy is confined to universities that have a license for education in medicine or psychology. The reform accords the universities the task of training psychotherapists, either on their own or in collaboration with another party. Since the universities, for the most part, lack the necessary competence for training in psychotherapy, the education is mostly carried out by some outside entity, usually an organization or society that has previously trained psychotherapists, although some universities provide training themselves.

The legislation gives guidelines for how such an education should be structured and contains criteria on the extent of the curriculum. The minimum level of the extent of the studies is set at a rather low level, since the guidelines aim to encompass all types of psychotherapies rather than just psychoanalytic ones. There are two levels of training: basic training in psychotherapy and an education aimed to train teachers in psychotherapy. These are organized slightly different and have different criteria. Training in psychoanalysis proper is considered to belong to the latter group.

The training programs in psychotherapy are conceived as continuous education, which in a way places them outside the ordinary university structure. Depending on the university, the programs are connected to the psychiatry department at the medical faculty or the psychology department, but the programs themselves remain as outsourced tasks. The teachers remain outside the university, hired by the institutes or societies that are tasked with the training.

Being conceived as continuous education also has its implications in terms of economic aspects. In Finland, university training is traditionally free of charge. However, this does not apply to continuous education, which means that candidates in psychotherapy training have to pay for everything out of pocket: personal analysis, theoretical seminars and supervised cases. Although the candidates are enrolled as students at the university, which gives them access to some resources, such as the free use of libraries, they still need to put up the money for the training, as they did before. If there were hopes that the reform would make training in psychotherapy more accessible and affordable, at least on the latter point these hopes have not been fulfilled.

Another consequence of not being within the university structure proper is the lack of forward pathways within the program leading to a PhD. To pursue that kind of track, the candidate needs to enroll as a doctoral student in some department at the university.

A general overview of the structure of the training

In the Finnish model, the universities are responsible for the basic training in psychotherapy, meaning that they have a member on the steering group of each program. The training of teachers in psychotherapy is the responsibility of the providers, although the program itself must be approved by the university. Each university training psychotherapists has a board responsible for the organization of the training programs, consisting of members of the faculty. The programs in psychotherapy – cognitive, psychoanalytic, and so on – are put out for tender by the board, which also reviews and approves the offers made by the different training providers. Applicants can apply to several programs but are required to rank their choice as it is only possible to start on one program.

The university preselects the applicants, based on formal criteria – basic training, work experience, and so on. The providers then conduct interviews to determine the applicants’ suitability and select the candidates – although these still have to be approved by the university. The final say is the applicant’s since they must decide with which program they want to commence.

The approval process for the programs

Previously, the content of a training program could have been solely determined by, to use an example, the Therapeia Institute, within the boundaries set up by international organizations such as the IFPS to which it was affiliated. Beginning in 2012, due to the legislative changes, the final say on the structure and content of the program was removed from the institute and given to the universities. In fact, the process of constructing a program within the institute did not change very much, but it became more burdensome. It became a process of negotiation between the university and the institute. That a non-psychoanalytic entity had the final say on content issues was not an easy thing to accept, and the process as a whole became more bureaucratic and time-consuming.

The selection of candidates

Whereas previously the selection of trainees was completely in the hands of the institute, the decisions are now made by the board of psychotherapy training at the university. The institute has its say on the suitability of applicants, and no applicant that the institute deems unsuitable can be selected. At the level of the institute the selection process does not differ very much from before. Applicants are evaluated on several dimensions: the length and relevance of their work experience, the status of their personal analysis or psychotherapy, their interpersonal skills and capabilities, their motivation, and so on. Based upon the interview, the steering group of the program decides whether to accept or reject the application.

Using the institute’s proposals, the board for psychotherapy training at the university makes its decision. Since applicants can apply to and be selected for several psychotherapy training programs, the final decision on which course to begin is made by the applicants themselves. This has brought a new feature to the group candidates. Especially in the basic training program for psychoanalytic psychotherapy, we nowadays have candidates who initially opted for some other kind of training, candidates whose primary choice was not psychoanalytic psychotherapy, and this can initially affect their motivation.

There is yet another kind of problem connected with this. Previously, when a person applied for training, they usually knew the situation. They had some insight into and appreciation of what psychoanalytic theory is about. However, the situation now is that we get students that might have a very superficial, if any, understanding of psychoanalysis. Presently, we might have rather heterogenous study groups, where some members are frustrated and some feel the content is beyond their understanding.

As another consequence of the reform, access to psychotherapy training has become more or less restricted to medical professionals – medical doctors, nurses, psychologists, social workers. In future, it is going to be even more restricted, as new requirements concerning work experience include a mandatory period in public psychiatric healthcare. Earlier, individuals who had graduated from faculties of theology, teachers, or philosophy graduates could apply, be accepted, and train as psychotherapists or psychoanalysts. Sadly, the reform seems to be promoting the medicalization of psychotherapy.

Training put into practice

The impact of this reform put into practice has been varied. On a structural level, there has not been much change. However, the leadership of the training has been clarified. Two members from the institute and one representative from the university form a steering group that is responsible for the implementation of the program. The steering group reports both to the board of the institute and the board for psychotherapy training at the university. The final authority rests with the university.

This means a loss of autonomy for the institute regarding various issues – the content of the program, rules and procedures for dealing with candidates, criteria, and so on. All this is not necessarily bad: some of it has strengthened the position of and access to due process for the candidates. But, with regard to content issues, there is reason for more caution. Psychotherapy training in universities is trying to accommodate the education process to several, incongruous modes of psychotherapy, and there is a tendency to suggest similar solutions for different programs. Consequently, there is a tension between the interests of the institute and of the university.

The programs begin with the meta-theories of psychoanalysis, proceeding to the study of the psychoanalytic process. There is then a study of the treatment of different disorders, and at the end studies of different forms of psychotherapy and the identity of a psychoanalyst/psychoanalytic psychotherapist. Alongside these threads are the supervisions of clinical cases and, if not completed before, the personal analysis or psychotherapy. The training is concluded by writing a short scientific report and a case-study of one of the supervised cases. In the program for psychoanalysis, and the advanced courses of psychoanalytic psychotherapy, candidates also study the pedagogics of teaching psychotherapy.

What the reform brought about in the form of content changes is primarily the inclusion of teaching in research skills, using and conducting, on a minor scale, psychotherapy research and the writing of a scientific report. The scientific report written by the candidate is usually a case-study of one of their supervised cases, even if some opt for the possibility of a theoretical paper. The subjects vary from, for example, analyzing the patient’s responses to pauses in the treatment to discussing theoretical concepts such as projective identification. Often the theoretical papers are also connected to the supervised cases, discussing concepts important for them. In conducting the research project, the candidates receive supervision from experienced supervisors.

As it stands now, the training in research tends to be something that remains an isolated part of the training, in the sense that encouragement to move forward on a scientific path is mainly lacking. However, at the level of candidates being able to communicate about their work, the training seems to offer steps forward from the situation as it was before.

Moreover, there has been an introduction of studies in pedagogy at the advanced level. Another change is the extension of studies in different modalities of psychotherapy and short-term psychotherapy. A further change is the expressed wish of the universities to modernize the literature, and, in my opinion, this has been a change for the better. It prompts the teachers to stay better up to date in their fields, and to offer new perspectives and angles for subjects, instead of repeating the same old story over and over again.

Additionally, there have been desires for change concerning supervisions. Within the psychoanalytic tradition, the supervision of the clinical cases has mostly been based upon the candidate reporting the sessions orally and/or in writing. The expressed wish from universities has been to allow for different kinds of reporting, using recorded sessions, for example. The rationale  for this is the possibility that this offers for using session material in psychotherapy research and experiential learning.

This has not been greeted with cheers throughout the institute. For many, there are concerns about privacy issues and a fear of loss of the confidentiality and sense of security in the patient–analyst relationship. However, recording sessions is not mandatory. It is up to each candidate to decide how they want to present the material. As for the loss of confidentiality, supervision itself is a break in the exclusivity of the communication between the therapist and the patient. Having listened to some recorded sessions, I am personally impressed by the potential it offers for learning about the relationship and about oneself as a therapist/analyst.

How does it feel, 10 years on?

In setting out to write this paper, I was interested in what changes there have been for training in psychoanalysis and psychoanalytic psychotherapy since the 2012 reform. What happens when a third party becomes involved in training? Is it possible to maintain a psychoanalytic curriculum under such circumstances? What does the relative loss of autonomy signify? And what are the implications for the institutes and societies? To evaluate what has happened in the ten years since the reform was implemented, I asked some of those involved about their experiences. They were mainly from our institute, but also others. My sample is small and not selected in any scientific way. In the main, the individuals I turned to were involved at the beginning of the collaboration and responsible for creating the first set of programs in psychotherapy and psychoanalysis.

What happens when a third party becomes involved?

It seems that third-party involvement has created more fears than actual problems. As the reform gave the universities a stronger hand compared with the institutes, it was feared that there would be many calls for change. Because, on the academic level, both the medical and psychological establishments have for some time been mostly influenced by biological and cognitive/behavioral orientations, the fear was that there would be only a minimal understanding of psychoanalysis and psychoanalytic education. Consequently, there was a fear that, once in an position of authority, the universities would try to influence the ways and contents of the training.

Judging from the replies to my questions, it seems that the university is regarded slightly suspiciously, the fear being its interference in training. Still, the aspects that are most important – the content of the curriculum and the elements needed for a truly psychoanalytic education – have been left to the institute. What has happened, on a content/structural level, has mostly been the addition of some new elements: education in scientific methodology, an introduction to short-term psychotherapy, the positioning of psychotherapy within the psychiatric health care system. These are not necessary for psychoanalytic training but, on the other hand, neither are they contrary to it. Having the power balance hanging as it is, this is, however, still worrying. As the social objectives for the reform implicitly support time- and resource-limited approaches, the future could bring bigger pressures for changes geared towards “more efficient” therapies.

An issue recurring in the thoughts of the respondents is the growing bureaucracy combined with the financial agreements. The collaboration with the universities has brought about new regulations and procedures. This has compelled the institute to formalize and make the decision-making concerning the admission process or student progress more transparent. The changes concerning the students have been mainly good, since they have enhanced the basic rights and access to due process for applicants and candidates and reduced the impact of organizational dysfunctionality and pathological traditions. When functioning well, a bureaucracy can provide reliable and transparent boundaries, reducing the inherent paranoid anxiety in an organization. But on the downside, the bureaucracy has also brought in its wake much more reporting and other workloads for the institute. The financial agreements are heavily favoring the universities.

Also, due to the growing bureaucracy and the economic interest of the universities, tuition fees have risen. Previously, candidates paid for their personal analysis and tuition out of pocket, without any funding from anywhere, apart from when a candidate had an employer that paid for some parts of the training. Sadly, in that respect, the situation has not changed for the better. Candidates still pay for their analysis and teaching in full. But because of the inclusion of administrative fees and so forth from the university partner, the burden on the societies has risen, with a rise in tuition fees for candidates as a consequence. So, in essence there has been a reallocation of funds from the institute and the candidates to the university.

Is it still possible to maintain a psychoanalytic curriculum?

The greatest fear attached to the new system of training in psychotherapy has been the threat it could pose for the maintenance of a truly psychoanalytic curriculum in education terms. However, the respondents had rather similar, positive views on the matter. Although there have been requests for the inclusion of new elements, or questioning of the scope of the studies, the consensus seems to be that the accepted programs are in accordance with the conceptions of such training prevalent at the institute.

One of the concerns regarding the collaboration in constructing the training programs was the lack of expertise on the university side. The power balance within the board for psychotherapy training at the universities is not favorable in regard to psychoanalytic understanding. The lack of insight into the specific nature of psychoanalytic education has been recognized in the work of some of the steering groups. Mostly, the university representative has been a psychoanalyst, or somebody with a knowledge at least exceeding the obvious. In instances when the representative has been someone with a different orientation, some disagreements and conflicts have been discernable. Despite this, the friction has not been fatal for the psychoanalytic nature of the education.

One discernible trend regarding training is the push by the society and the university towards positioning psychotherapy as a cog in the wheel of psychiatric care. As a consequence, there has been pressure on the programs to take more note of the recommendations for best practices used in psychiatry. Although some of the demands can be viewed as legitimate from the perspective that society provides for much of the funding for psychotherapy, this is still a deviation from a psychoanalytic view. Efficient evidence-based treatment and symptom reduction are not the objectives that really should be in the forefront when trying to learn how to facilitate the patient’s access to unconscious processes.

What does the relative loss of autonomy signify?

As pointed out by one respondent, the question begs the answer; it implies that autonomy is lost. On this, the respondents hold somewhat differing positions. Some feel that autonomy has at least diminished; some find that not much has changed. First, we need to define what kind of autonomy we are discussing.

When talking about economic autonomy, there certainly has been a lessening. Given the initial setting for the negotiations, the university clearly has the upper hand. The resulting agreements have, as said earlier, been favoring the university.

The economic aspect, being only one, is still important. It certainly has its implications at the budgetary level, but also on the emotional level. The feeling of being exploited is a powerful one and can be very disturbing. If not processed, it lessens the motivation for working towards a common goal. It creates aggression that can have disruptive effects at the institutional level. So there is clearly a need for dealing with aggression, due to the lessening of economic autonomy.

When we are talking of autonomy in the sense of having the right to decide on issues concerning theory and training, we are confronted with other kinds of problem. On one hand, it can be argued that, at the end of the day, it is the institute that decides what is being taught, what theories, and in what way. But, even so, the final authority rests with the university. And the position the university has gives it the possibility to alter the terms when dealing with the next program. So, even though the situation now is good, we do not know about the future, and what is most important is that we have limited possibilities to affect the outcome.

What are the implications for the institute and the society?

The roles of both the Therapeia Institute and the Therapeia Society have been thrown into a process of change. Whereas previously the applicant was admitted as a candidate to the institute and the connections between the institute and the society were clear, nowadays applicants, if admitted, are students at the university. The role of the institute is under threat, to be reduced to that of a service provider, and the connection to the society becomes obscure. As the applicants, less so than before, have a preconception of psychoanalysis as a whole and the psychoanalytic inclinations of the Therapeia Institute specifically, the starting point of training has become more challenging. For the Therapeia Institute, the implication of this is, through the quality of the training and the supportiveness and receptiveness of the community, making sure that the candidates are well received on both a professional and a personal level.

According to the respondents, at the beginning of the collaboration 10 years ago the candidates of the first course were quite identified with the Therapeia community. The role of the university was felt more like that of a background organizer, a third party that was at times felt to be somewhat threatening or intrusive or demeaning towards the psychoanalytic method. But already in the following year the relationship started to change. The position of the university as felt by the candidates has become more neutral, more like someone providing the structure of the studies. Presently, the candidates might feel somewhere in between. They are students at the university, study at the Therapeia Institute, but in fact do not identify strongly with either of them. To me, it seems that the primary object of identification is the study group.

Within the Therapeia Institute itself, the start of the collaboration caused strong feelings, ranging from strong suspicion and refusals to participate to hopefulness. There were fears were that there would be strong pressures from the university to alter the structure and content of the training, but so far these fears have not been borne out; however, no one knows what the future will bring. On the positive side there were hopes that being connected to a university would increase the status of the training and of psychoanalysis itself; that the image of psychoanalysis as a respected scientific orientation would become clearer; and that the monastery-like structure of psychoanalytic training would change. I am not sure if this has been borne out either.

Concerning the implications for internal cohesion, the views differ somewhat. On one hand there is a feeling that the societies are strong enough to counter the pressures coming from outside. There is a conviction that the society is secure enough and can accommodate to changes and defend the values that are felt to be important. If the collaboration with one university becomes difficult and autonomy becomes threatened, it might still be possible to forge ties with other universities, where there is more room for a true collaboration. Persons more acquainted with the universities, having worked as researchers or teachers, tend to be more confident in regard to the collaborative effort.

The broadening of the identity of candidates to include a self-representation as students at a university rather than being identified only with the psychoanalytic movement is not necessarily bad. It might carry in its wake the possibility for a positive change for the societies. As they need to develop and adapt to new demands posed by the changing status of psychoanalytic societies and institutes, there might be room for a more fruitful interaction with neighboring sciences and fields.

Concluding remarks

The reform of psychotherapy training came about as a solution to the growing need for psychotherapists and the need to develop a system that would guarantee some societal quality control over the money spent in subsidizing psychotherapy. Although the reform was not the result of growing insight into the need for a change in psychoanalytic training within psychoanalysis itself, it still afforded the institutes a possibility to evaluate their training systems and the need for development.

The reform presented the societies and institutes with large challenges to overcome. The biggest have been the fears of losing our identity as psychoanalysts and psychoanalytic organizations. Relinquishing a part of our autonomy created anxiety and, in some cases, the urge to withdraw to a defensive position. The institutes have shown a great deal of adaptational resilience in transforming their training systems to new frames, still being able to protect the unique nature of psychoanalytic education. After an initial decline, there have been enough applicants to keep the training rolling. How to keep the candidates affiliated to the institute during and after training remains a challenge for the future of the institute and the society.

Another threat looming in the future concerns the role of the institute. There seems to be some interest on the universities’ part in taking over the control and implementation of the training courses. This might imply the creation of eclectic and integrative approaches to therapy, obliterating the differences that exist in how the nature of man or the problems afflicting them are conceived.

At an institutional level, there traditionally has not been much collaboration among the psychoanalytic institutes. One factor in the present situation reducing the collaboration between the societies is the way psychotherapy training is organized. Different institutes collaborate with different universities. And different universities have slightly different approaches to collaboration. Usually, one university opens up only one program in, for example, psychodynamic psychotherapy for adults, so, by implication, the societies become competitors.

But there also is room for cooperation. Societies providing, let’s say, psychoanalytically oriented programs in adult psychotherapy, psychotherapy for adolescents, or child psychotherapy have much in common in their dealings with the universities. As the university collaborates with institutes offering training in psychotherapy across a wide range, the interests, needs, or traditions of the psychoanalytic orientation are not always adequately addressed. This opens up space for collaboration between psychoanalytic institutes and societies, which has also happened between some institutes in various situations. Still, looking at the future, there is a growing need for coordination and cooperation between different strands of psychoanalysis, regarding not only training, but also the position of psychoanalysis in the healthcare system in Finland.

Heading for the future, psychoanalysis is confronted with new challenges. How are we to adapt to new insights brought about by development both within psychoanalysis itself and in science and society in general? Traditionally, and I think according to the essence and ethos of psychoanalysis, we have found ourselves on the margins. A psychoanalysis seeking popularity and approval is in some sense a psychoanalysis lost. On the other hand, a psychoanalysis existing only at the borders has a great risk of becoming irrelevant. As a science, psychoanalysis cannot thrive in isolation. We face a huge task in positioning ourselves in regard to new insights and developments of science and the humanities. In that situation, how do we remain in contact with what is regarded as the domain of psychoanalysis, the unconscious? How do we keep intact the basic tenets of psychoanalysis, the thought of unconscious processes, the conceptions of transference and resistance as vehicles for internal change?

Acknowledgements

I would like to thank my colleagues Kaj Davidkin (Therapeia Institute), Matti Pesola (Nuorisopsykoterapiasäätiö), and Irma Saarimäki, Hannu Säävälä, and Pirjo Tuhkasaari (all Therapeia Institute) for kindly sharing their experiences and making the writing of this paper possible.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Jan Johansson

Jan Johansson is a psychoanalyst in private practice in Finland. He is currently a member of the board at the Therapeia Institute, and has since 2006 been a member of the board of the Therapeia Society. He has been involved in issues concerning psychoanalytic training for the past 15 years. Besides being interested in questions around psychoanalytic education, other points of interest are issues of sexuality and gender.