Beyond Progression: Devising a New Training Model for Candidate Assessment, Advancement, and Advising at Columbia.

Research over several decades has identified significant problems with the progression model-the traditional approach to assessment and advancement of psychoanalytic candidates-including candidates' anxiety and uncertainty about the methods and fairness of their assessment, avoidance of conflictual issues with patients in order to keep cases, and reluctance to share their challenges with supervisors and advisors. In light of these findings, the Columbia Center for Psychoanalytic Training and Research restructured its psychoanalytic training programs. The progression committee, the progression advisor role, candidate application to advance through the program, and routine committee discussion of candidates were eliminated and replaced by confidential mentorship and a clear and predictable system of trainee advancement. Analytic competency-a requirement for graduation-is now determined solely from detailed written feedback regarding the candidate's achievement of the Center's learning objectives. The number of months of supervised analysis required for graduation has been reduced, as has the required length of the candidate's longest case; in addition, three-times-weekly analyses are now accepted for credit. These changes are meant to increase the transparency, objectivity, and predictability of the training experience and reduce the pressure on clinical decision making and communication between trainees and faculty. An extensive evaluation of the impact of these innovations is currently under way.

Emergency Remote Training in Psychoanalysis and Psychotherapy: An Initial Assessment from Columbia.

The Covid-19 pandemic and the social distancing required to combat it have set in motion an experiment in psychoanalytic education of unprecedented scope. Following an abrupt shift from in-person study to remote classes, supervision, clinical work, and training analyses, the Columbia University Center for Psychoanalytic Training and Research polled its psychotherapy and psychoanalysis trainees to assess their initial experience of remote training. Most candidates found the technical aspects of online learning easy and were satisfied with remote training overall. Across all programs, most trainees considered class length and reading load about right and felt their class participation was unaffected, though they found it harder to concentrate. Most found it no harder to start a training case, felt the shift to remote supervision had no negative effect, and were satisfied with seeing their training analyst remotely. Most trainees preferred in-person classes, clinical work, and training analyses to those offered remotely, yet in light of the health risks they said they were less likely to continue training in fall 2020 if in-person work resumed. Trainees suggested several modifications of teaching techniques to improve their participation and concentration in class. These findings' implications for the debate regarding remote training in psychoanalysis are explored.

Supervising away from home: clinical, cultural and professional challenges.

This paper explores some challenges of supervising clinical work of trainees, known as 'routers', who live in countries with diverse cultural, social and political traditions, and the analysts who travel to supervise them. It is written as an evolving dialogue between the authors, who explore together the effects of their own culture of origin, and in particular the legacy and values of their own training institutes on the styles and models of analytic supervision. Their dialogue is framed around the meaning of home and experiences of homesickness for analysts working away from home in an interactive field of strangeness in countries where analytical psychology is a relatively new discipline. The authors outline the findings from their own qualitative survey, where other supervisors working abroad, and those they have supervised, describe their experiences and their encounters with difference. The dialogue ends with both authors discussing what they have learned about teaching and supervising abroad, the implications for more flexible use of Jungian concepts, and how such visits have changed their clinical practice in their home countries.

Supervisory countertransferences and impingements in evaluating readiness for graduation: Always present, routinely under-recognized.

Utilizing detailed, in-depth material from supervisory hours from around the world (explored in End of Training Evaluation groups), this paper shows that supervisors are subject to multiple, diverse and, at times, ongoing intense countertransferences and impingements on their ability to evaluate candidates' progress. Multiple external and internal sources of these impingements are explored. It is suggested that supervisory countertransferences and their manifestation in parallel enactments remain under-recognized, their impact underappreciated, and the information they contain underutilized. It is argued that the recognition, containment, and effective use of the parallel process phenomena and supervisory countertransferences are essential in order to evaluate candidates' progression and readiness to graduate. Common signals of such entanglements in the supervisor's evaluative function are identified. Three remedies, each of which provides a 'third,' are offered to assist supervisors in making effective use of their countertransference: self-supervision, consultation, and institutional correctives.

A national survey of candidates: I. demographics, practice patterns, and satisfaction with training.

To better focus efforts in recruiting psychoanalytic candidates, current candidates' demographics, practice patterns, and satisfaction with psychoanalytic training were investigated. An anonymous web-based survey was distributed by e-mail to all candidates subscribing to the affiliate member e-mail list in 2009-2010. Surveys were completed by 226 of 565 affiliate members, for a return rate of 40%. The majority of respondents were women 45 to 64 years of age, married, with a doctoral degree, in private practice, with an annual household income of over $100,000. Most candidates devoted 11 to 30 hours a week to training and had no analysts or candidates in their workplace. Almost half had considered training for more than four years before matriculation, with financial issues cited most frequently as delaying entry. Over 80% of respondents were satisfied with their training. The most frequently cited reasons for dissatisfaction were a negative institute atmosphere, concerns about teaching or the curriculum, and difficulty finding cases. Candidates in training for eight years or more accounted for almost 20% of the group and were more often dissatisfied with training. This study demonstrates that the majority of current candidates are satisfied with training but suggests that recruitment may become increasingly difficult unless factors related to time, cost, case finding, graduation requirements, and institute atmosphere can be addressed.

[Balint group work in Germany - results from a survey of Balint group leaders]. / Praxis der Balintgruppenarbeit in Deutschland- Ergebnis einer Umfrage unter Leitern von Balintgruppen.

OBJECTIVES: Based on a postal survey of Balint group leaders from the year 2004, this study analyses the characteristics of Balint group work as described by Michael Balint (1896-1970)in modern Germany. METHOD: A questionnaire was sent to 503 German Balint group leaders, 333 (66.2 %) of whom returned the questionnaire (40.5 % women, mean age 57.2 years). RESULTS: Most Balint group leaders are specialists in psychosomatic medicine and psychotherapy (30.6 %), psychiatry and psychotherapy (17.1 %) or are general practitioners (12.3 %). Psychoanalysts rarely serve as Balint group leaders. Sessions are normally held every 2 weeks (26.7 %) or once a month (26.4 %). Despite the original intention of Michael Balint, the idea of holding weekly Balint groups is now seldom(3.9 %). 85 %of the Balint group leaders prefer sessions lasting 90 minutes. An average of 8.6 participants attend, with 2.1 persons missing. There is a great heterogeneity in the professions of Balint group leaders. 17.4 % of them are older 65 years. CONCLUSIONS: This study shows that Balint group work in Germany is well integrated in both general practice and psychotherapy, and it is still of great interest to many specialists of other disciplines as well as a good way to realize further education. The ideas of Michael Balint are very much alive, but - because of the changed realities in the medical field - no longer as he originally foresaw, but in settings adapted to the new situations in medicine.

Creating coherence in real-life decision processes: Reasons, differentiation and consolidation.

Differentiation and Consolidation Theory describes human decision making as a process in which attractiveness values are restructured in order to reach a decision and support the decision made. Here, the theory was developed to include reasons pro and con alternatives and tested on students making decisions between two university psychotherapy training programs (cognitive-behavioral and psychodynamic therapy). Before and also after the decision, the attractiveness of the chosen alternative was upgraded and the non-chosen alternative downgraded. Different measures of evaluations of an alternative, such as "best" or "worse" converged over time until shortly after the decision. The number of reasons pro and con alternatives give a more complete picture than attractiveness and increased from the first to the last session. The reasons supporting the chosen alternative increased in strength, but reasons against the non-chosen alternative decreased. In informal comments participants reported that the study also served as a decision aid.

Drawing cure: children's drawings as a psychoanalytic instrument.

This essay deals with the special case of drawings as psychoanalytical instruments. It aims at a theoretical understanding of the specific contribution made by children's drawings as a medium of the psychical. In the influential play technique developed by Melanie Klein, drawing continuously interacts with other symptomatic (play) actions. Nonetheless, specific functions of drawing within the play technique can be identified. The essay will discuss four crucial aspects in-depth: 1) the strengthening of the analysis's recursivity associated with the graphic artifact; 2) the opening of the analytic process facilitated by drawing; 3) the creation of a genuinely graphic mode of producing meaning that allows the child to develop a "theory" of the workings of his own psychic apparatus; and 4) the new possibilities of symbolization associated with the latter. In contrast to classical definitions of the psychological instrument, the child's drawing is a weakly structured tool that does not serve to reproduce psychic processes in an artificial, controlled setting. The introduction of drawing into the psychoanalytic cure is by no means interested in replaying past events, but in producing events suited to effecting a transformation of the synchronic structures of the unconscious.

Integration through relatedness in the conversational model: a case study.

OBJECTIVE: The aim of this paper is to demonstrate the principles of the conversational model in two therapies with a patient, at 16 years of age and again 20 years later. METHOD: Described is the first therapy of L, which commenced in hospital and continued twice weekly after discharge. L was an acutely disturbed 16-year-old female admitted for 4 months to the psychiatry ward, a dynamically oriented milieu of a University teaching hospital where I was training. This is followed by a brief description of L's second therapy. Supervision was through audiotape of sessions. RESULTS: At the conclusion of the first therapy, L was functioning well. Five years later, she married and had a child. She was referred to me again after she attempted suicide following an acute stressful event which resulted in hospitalization. She is more aware and reflective at present but continues to be vulnerable. CONCLUSIONS: Attention to certain aspects of the psychotherapeutic relationship is important as demonstrated in the conversational model.

A university psychotherapy training program in a psychiatric hospital: 25 years of the conversational model in the treatment of patients with borderline personality disorder.

OBJECTIVE: The aim of this paper is to describe the development, delivery and experience of a university psychotherapy training program for psychiatry trainees in a public psychiatric hospital, demonstrating that patients with severe borderline personality disorder can be treated successfully with psychodynamic psychotherapy and stressing the need for structured psychodynamic psychotherapy training in psychiatry. METHOD: Two of the authors (JH and JS) were part of the first group of eight trainees supervised by Professor Russell Meares and several other experienced psychiatrists. RESULTS: Ninety trainees have successfully completed the course. Two hundred and forty patients have been treated by trainees in this program to date; 49 patients have dropped out. CONCLUSIONS: The training program provided a sound psychodynamic base and an improved capacity to relate with our patients, not only in the program but also in our routine work as psychiatrists. An important public health issue and community need was addressed, which also proved to make sound economic sense as the number of patients who were treated might not have otherwise received long-term psychotherapy. An integrated process model of psychoanalytic psychotherapy--the conversational model--has evolved and continues to be offered as a 3-year part-time clinically oriented course leading to a Masters in Medicine, Psychotherapy at the University of Sydney. Several outcome studies and papers have been published and workshops have been presented both in Australia and overseas. The patients improved considerably--their self harming behaviour stopped within 6 months and they were no longer clinically depressed at the end of 1 year.

A qualitative analysis of student Balint groups in medical education: contexts and triggers of case presentations and discussion themes.

OBJECTIVE: No previous rigorous qualitative studies exist on student Balint groups. The aim of this study was to explore the contexts and triggers of cases presented in student Balint groups and to clarify the themes in the group discussions. METHODS: Fifteen student Balint sessions in two groups were organised. Nine female students participated. A grounded theory-based approach with thematic content analysis of the field notes was used. RESULTS: We identified five triggers for case narrations (witnessing injustice, value conflict, difficult human relationships, incurable patient, role confusion) that originated from three distinct contexts (patient encounters, confusing experiences in medical education, tension between privacy and profession). Four main discussion themes could be identified (feelings related to patients, building professional identity, negative role models, cooperation with other medical professionals). CONCLUSION: The concept of case in student Balint groups was wider than in traditional Balint groups. Feelings related to patients and to one's own role as a doctor were openly discussed in groups. The discussions often touched on professional growth and future professional identity as doctors. PRACTICE IMPLICATIONS: The Balint groups may support medical students' professional growth process. This topic warrants further study in more heterogeneous student groups.

She can be put to work: Joan Riviere as translator between Freud and Jones.

The psychoanalyst Joan Riviere (1883-1962), who came from an established family, was one of the first to translate Freud in Britain. After a failed analysis with Ernest Jones, she became Freud's patient in 1922. Freud recognized her talent and entrusted her with translations of his works. Over her head, he negotiated her position as Translation Editor of the International Journal with Jones and secured her nomination against his resistance. Some examples are given to demonstrate the special quality of Riviere's translations of Freud's writings.

Being analysed by Freud in 1921: the diary of a patient.

This article presents a unique document, a hitherto unpublished diary of a patient analysis with Freud in 1921. Conclusions on how Freud worked with patients at that period, particularly insofar as transference is concerned, are drawn.

Finding Freud: a personal tribute on the 150th Anniversary of Sigmund Freud's birthday.

OBJECTIVE: To briefly describe my own development from medical student, through junior resident and psychiatry registrar and finally qualified psychiatrist, to feeling the need to undertake psychoanalytic training in order to grapple with the complexities of treatment of personality disorders. CONCLUSIONS: My encounter with the concepts developed by the Viennese physician, Sigmund Freud, as represented by a number of significant teachers and clinicians was a formative experience in my early career. My subsequent development as a psychiatrist and psychoanalyst was highly influenced by the understandings of human mental development and function set in train by Freud's clinical findings and ground-breaking thinking in the early 20th century. It is hoped that registrars-in-training and young psychiatrists may be particularly interested in how things 'once were' in NSW Mental Health Services which permitted this course of development.

Teaching psychodynamic psychotherapy in the 21st century.

Special challenges face the 21st century teacher of psychodynamic psychotherapy. Time for careful psychodynamic reflection, of necessity, competes for space with the current explosion of psychiatric knowledge in psychopharmacology, genetics, health care policy and multiple other agendas. Thus educators must be clear about the goals of psychodynamic psychotherapy, engage students in the special interviewing techniques to elicit sensitive information and appreciate the special needs of today's physicians launching into this field. Educational objectives must be clear, the goals of psychoanalysis and psychoanalytic psychotherapy well articulated and the means to gather information enhanced. With the expansion of neuroscience into the mysteries of implicit and explicit memory this is also an area where the 21st century educator must develop integrative expertise. There are tools available to expand ones proficiency in each of these areas.

Melanie Klein and Repression: an examination of some unpublished Notes of 1934.

Fifteen pages of unpublished Notes were found in the Melanie Klein Archives dating from early 1934, a crucial moment in Klein's development. She was at this time, 1934, moving away from child analysis, whilst also rethinking and revising her allegiance to Karl Abraham's theory of the phases of libidinal development. These Notes, entitled "Early Repression Mechanism," show Klein struggling to develop what became her characteristic theories of the depressive position and the paranoid-schizoid position. Although these Notes are precursors of the paper Klein gave later to the IPA Congress in 1934, they also show the origins of the emphasis she and her followers eventually gave to "splitting" rather than repression. The Notes give us an insight into the way that she worked clinically at the time. We see Klein's confidence develop as she diverged from the classical theories and technique. Her ideas were based on close attention to the detail of her clinical material, rather than attacking theoretical problems directly. The Notes show her method of struggling to her own conclusions, and they offer us a chance to grasp the roots of the subsequent controversy over Kleinian thought.