SMALL INSTITUTE SURVIVAL

How Small Institutes Can Survive and Grow

Sam Robertson

Sam Robertson, M.D., is a child and adult psychoanalyst and training analyst at the Cincinnati Psychoanalytic Institute. Consulting with other institutes as a Committee on Institutes member provided opportunities to recognize and consider the phenomena described in this writing.

Sam Robertson

All of us who belong to a small institute experience challenges to survival and growth in our own community. Visiting and consulting with other small institutes offer an opportunity to see these challenges more clearly and to recognize their universal elements.

In an expansionary time, growth promises a solution for the limited resources in a small institute. Strains on the small number of faculty will be time limited, the workload will soon be spread and the future will be bright. In a time of contraction the future promises the opposite; an increasingly smaller number of faculty each having to do more, for a dwindling number of candidates. Eventually, some faculty, exhausted or simply wanting to return to a larger life, withdraw. This increases the workload for those who remain. With little time for outreach and less involvement in the larger community, recruitment suffers; contraction continues.

This is in complete contrast to an expansionary period in a large institute where typical problems more likely include competition to teach and obtain positions or power. While there may be many ways to address this, I describe two ideas that can operate independently or synergistically. The first focuses on reducing fixed costs, largely manpower. The second is designed to create more efficient outreach.

LOWERING FIXED COSTS

Many fixed costs are approximately the same across the spectrum, leaving small institutes on the wrong side of economies of scale. Regardless of the number of candidates or faculty, institutes have approximately the same leadership needs, the same number of committees, the same number of classes, and the same needs for outreach programs.

A potential remedy would be created if several small institutes simply combined or joined a larger institute but that would lead to lack of local autonomy. However, if several small institutes joined together in a voluntary partnership to share certain functions, overall autonomy could be preserved. For example, curriculum, ethics, progression and selection could be joint committees with the chairs rotating to create balance and equal representation from each institute. Each institute’s Education Committee (EC) might select representatives to the committees and approve or disapprove proposals from the partnerships committees. Generally speaking, willingness to accept these proposals would foster greater efficiency and sense of cooperation, but a dynamic tension between efficiency and autonomy would be a natural result of this system. Recognizing this potential for dynamic tension, by prior agreement, each institute could choose to go it alone at certain times and in certain ways, for example teach a particular class separately or have an independent elective.

Using electronic means and shared teaching would create greater range and depth in faculty talents, ideas and courses. Since classes could be offered more frequently, potential candidates would not have to wait. Of course, this system might generate power struggles and competition for roles. But this is a lesser evil compared to no manpower at all.

There are existing programs that have elements of this organization, such as the Southeastern Consortium for Child Analysis where child analysts from several institutes cooperate to make decisions and teach.

IMPROVING OUTREACH, CREATING CANDIDATES

Effective outreach requires interested manpower, efficiently invested. The efficiency of the above recommended partnership frees talent. What follows is a design to utilize that talent in a more focused and efficient way. The details are less important than the basic idea of “creating analytic candidates” in an organized way. And, importantly, the organized whole is greater than the sum of the parts.

Consider for the moment, outreach having four primary functions:

• Altruism, providing something of value to the community;
• Advertising, making the presence and value of the institute and its members better known;
• Economic, some who attend programs might seek treatment;
• Generating students, especially analytic candidates.

Various offerings will serve one or more of the four functions. For example, programs designed for the general public automatically serve the first three. But to serve the fourth goal, it will help to have a thoughtful cascade of programs, sequentially offered, with gradually increasing depth, sophistication and requirements for greater investment.

Imagine this tiered array:

• The first tier is the entry level, offerings for the general public, supervision or teaching at the residency level or a chance encounter and might be completely independent of the EC. Any clinician engaged in these activities would be invited to attend a second tier event.
• The second tier, offered to clinicians, by invitation only, would be more analytically oriented but, importantly, of short duration. Examples might include: a single 90-minute case presentation; an ethics workshop with CME credits; the presentation of an accessible paper or a combination of these. All attendees to a second tier event would receive a personal invitation to attend a third tier event. Beginning at this level and for each following tier, some degree of oversight by the EC would help integrate the offerings.
• The third tier would involve a slightly longer time commitment, for example six weekly or six monthly clinical seminars, perhaps accompanied by accessible readings. To maintain touch with those attending more recent events on the second tier, these could be offered twice a year. All who attend a third tier program would be invited to level four courses.
• The fourth tier involves more time commitment and reading, perhaps a six-month weekly course, 90 minutes a week, offered annually. If there are multiple offerings at this level, each could occur every second or third year. Potential offerings include courses on child psychotherapy, adult psychotherapy, adolescents, sexual issues, dreams or any relevant interesting topic. Those who attend a fourth tier course should be invited to other level four courses, and invited to apply for level five programs.
• Level five includes both the analytic and psychotherapy programs. Each requires application and acceptance. The partnership allows each program to occur more frequently. Without this, small institutes are often stuck delaying acceptance because they don’t have a critical mass, or in order to avoid delaying a class, adding students to a program that is not an ideal fit. With the partnership available, acceptance to each program is more likely to be based on what is best for each applicant (and for the programs). Depending on the desire and ability of the applicants, they would be admitted to either the analytic program or the psychotherapy program. Some accepted into the psychotherapy program might be considered able to do the analytic program but, as yet, unwilling to do so. All psychotherapy graduates would be invited to apply for the analytic program.

STEPPING STONES

This tiered system is similar to the idea of “creating” analytic patients, taking them where they are but gradually helping them move toward increased deepening rather than immediately recommending analysis. The tiers are largely structured to encourage a similar deepening process in the community. When analysis was idealized, it was easier for clinicians (and patients) to take a long step into the unknown. Also, when the analytic ideas were more consistently part of earlier training, the step from what they knew to analytic training was shorter. Given the current environment, taking a series of small steps with minimal incremental investment is both more rational and more likely than a large leap into the unknown. Of course, it is essential that each step proves useful so each subsequent step is both logically and emotionally enticing.

Where would the manpower come from, a problem at every level in small institutes? The partnering would free manpower but the actual number of people needed for the lower tiers is not as onerous because the system is efficient. The first level requires whatever time each individual presenter wishes. At the second level, there is little strain leading a one-shot clinical conference. The third tier could involve two people (at a minimum), each teaching six 90-minute periods a year, not a major strain. The fourth tier would require more investment but, assuming several people developed different topics, no one need teach in successive years. The real manpower problem would occur at level five, the separate psychotherapy program and an analytic program. Circling back to the first issue, economies of scale, the consortium, used for one or both, provide one answer.