Access Institute: Psychoanalytic internship training for community work

One intern therapist is assigned a couple.  The woman is physically disabled, with misshapen arms and hands.  The man is a student.  He hasn’t been to school in months and doesn’t work.  He spends every session berating both his partner and the female therapist.

Another intern has an immigrant patient who commonly talks about suicide in a threatening and manipulative way.  In this hour, he sounds more serious.  He has a plan this time.  He will lie down over commuter train tracks near where he lives.  But, he has to take care of a few things first…like selling his guitar. 

An intern in our school-based program sees a 10 year old African American boy who, while strapped in a car seat when he was 3, witnessed the murder of his father.  The mother won’t come in for collateral sessions. 

A petite Caucasian woman is assigned a large African American man who has recently been bitten by a small white dog and is now experiencing psychotic symptoms. He came to his second session drunk.

Psychopathology.  Culture.  Class.  Ethnicity.  Trauma.  Substance abuse.

These are the kinds of patients that the interns at Access Institute are called upon to see, just like interns at community mental health centers across the country. However, unlike many interns in these settings those at Access Institute receive rigorous, psychoanalytically-based supervision and training and the patients receive intensive, longer-term psychodynamic treatment. We know that fewer and fewer sites offer such training which is a tragedy, not only for the many young clinicians seeking internship training, but also for the many patients who, like the ones described above, can't afford private treatment, don’t have insurance and desperately need quality services. 

Ten years ago, in response to clinic closures and considering the needs of both prospective interns and patients, Bay Area mental health professionals joined with concerned community activists to form Access Institute for Psychological Services,  an organization with the dual mission to provide low-fee, psychoanalytic treatment to local residents, and high-quality training for pre-doctoral and post-masters interns. 

Access Institute, a non-profit organization, was designed to be immune to state and federal budget woes by eschewing government funding.  Fifty percent of the operating budget is derived from patient fees and the other 50% from private donations.  In addition, the 20 interns in the two-year internship program are supported by professionals in the psychoanalytic community, over 50 of whom donate 1,500 hours of teaching and supervision to the program every year.

Access Institute serves low-income people at its Hayes Valley Clinic (a comprehensive psychology clinic offering individual psychotherapy, couple/marital therapy, group treatment, medication consultation, and neuropsychological testing to people of all ages), at two public schools (serving children and families) and an adult day health center (providing comprehensive care to seniors). Last year, Access Institute provided over 9,500 hours of psychological services in both English and Spanish to more than 350 patients.  

Back to the vignettes. These are real vignettes from Access Institute. But they are not unique. Interns everywhere are called on to see complex patients like these.  But how do we help our interns help their patients whose struggles are so profound?  Which theory will be most useful?  How is theory useful at all? Is meaning-making so critical when the exigencies of real life are so extreme?  How do we contain the interns’ experiences so that they can contain those of their patients? How do we foster the growth of our interns’ clinical capacities and help them develop their personal voices? 

Keeping in mind both the needs of the community mental health population we serve and the interns we train, it is useful to recall Daniel Siegel’s 1999 work on trauma.  Siegel coined the term “window of tolerance”, which is the neurophysiological state in which thinking can occur and the patient is neither “hyperaroused”…in a fight/flight state, or “hypoaroused”…shut down and withdrawn.  We must encourage our students to monitor their patients and keep them in a state in which thinking can occur. Our task in training is similar. Students working with patients with complex trauma histories experience trauma themselves. Sometimes they come to us for supervision feeling hyperaroused…extremely anxious, and feeling they have to do something for their patients.  At other times, they feel resigned and hopeless about what psychoanalysis has to offer.  By offering our students a strong foundation in psychoanalytic theory, we help them to stay in their own window of tolerance and, therefore, to be able to think about their patients and what they need.

Unfortunately, for our students theory sometimes turns persecutory.  Students talk about the “psychoanalytic superego”, or “psychoanalytic police” who tell them…”that wasn’t analytic”, or “don’t be too gratifying”.  This punitive version of psychoanalysis is not useful to them and especially considering their patients who are contending with internal worlds marked by trauma and persecution.  We must attend to the subtle scorn we can give to “case management” and “social work”.  We must remember that we can be psychoanalytic psychotherapists even as we help our patients with the more concrete exigencies of their lives. 

The teaching of psychoanalytic psychotherapy, both in the classroom and in supervision, involves providing content (theory, technique, history and context), while interns are under the pressures and anxieties of performing difficult clinical work with traumatized patients.  Because we as supervisors have real concern for patients for whom we bear ultimate responsibility, it often feels efficacious and necessary to tell our students what to think about their patients, and what to do with them.  Students often ask for this kind of direction and are relieved, at least momentarily, when we gratify their request.  While this approach may be at times developmentally appropriate for therapists in training, it is not useful to them in the long run.  Providing psychoanalytically oriented training involves teaching our students to think in new ways.  Thinking for them doesn’t help them learn to think.  Modeling with them ways of thinking and thinking with them does.

The approach we take at Access Institute recognizes that no particular theory is the "right" theory to teach even though certain clinical situations might call for particular approaches.  You can call this the “pedagogical attitude” which is akin to an analytic attitude, not of evenly hovering attention, or with neutrality about our students’ progress.  Rather, it is an attitude that has the dual goals of the transmission of content, and the motivation of developing healthy internal relationships to psychoanalytic theory.  We keep in mind and model a process by which we teach theory along with the process by which we develop our clinical stances.  In this way they can meet the needs of their patients in flexible and appropriate ways.

This model understands that learning is a difficult endeavor that requires regression and that learning to become a psychoanalytic psychotherapist requires the involvement of all parts of the self. It also honors the fact that the interns themselves are both full, responsible adults and professional neophytes who need our actual support as they face clinical challenges, and that bridging these two worlds brings pain and conflict. In the end we must model for our interns something akin to what we expect them to achieve on behalf of their patients: participation in a course of growth that is theoretically sound, yet is malleable enough to be responsive to individual needs. 

A successful community clinic and psychoanalytic internship program does require us to develop some new ways of thinking about psychoanalytic theory and training. It's a thinking that needs to question some basic assumptions about theory, frame, power, privilege and assumptions we make about culture, not only of the patients we see, but that of psychoanalysis itself.

Siegel, Daniel J. (1999) The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are Guilford Press.