There are so many important questions for those of us who work in the psychoanalytic field at the moment: - about our future in relation to our different theories; our practices and how they will develop or contract; our trainings, and thus our institutions and their relationships to each other - how will they develop; can we further our relationships with the other helping professions; our relationships to the world and to Society in general - can we improve and facilitate them? And lastly, because it is essential to our future in this modern world, how do we establish a lasting place in the designated public services, where we have progressively lost our position over the last thirty years? We need desperately to do this if we are to attract young and vigorous and intelligent people to this impossible, and aging profession. These are matters which concern all of us intimately, if the discipline that we presently call psychoanalytic psychotherapy is to flourish. But our political future is presently in question with the debate about registration, and much thinking will have to go into that.

The aim of registration, of course, is not primarily to satisfy our own narcissism by giving us a publicly recognised and approved profession, (though that would be nice) but it is in fact to protect the public, and provide a framework in which both the public and our fellow professionals can know who we are, what exactly it is we are providing, and that there are reliable frameworks to do with training, post-training development, ethical standards and ways of policing them, clinical audit, clinical governance and development of our work, both theoretical and technical. To put these frameworks sensibly into place, we are going to have to agree amongst ourselves on some definitions, some standards, and the various frameworks we shall be proposing. This will be very hard and sometimes painful work, but is very important, since, as we all know, the level of general misinformation about our related professions is very high - quite sophisticated people confuse any term beginning with the syllable 'psych', and many members of the public ignore us or are frightened of our world and what we represent. A properly regulated profession can provide the basis for finding and giving our colleagues and our patients solid facts about the efficacy of our various treatments, which treatment and therapist is best suited to whom, where our limitations are, which new fields should we usefully explore, how we can co-operate with others in the fields of mental health to provide alternatives to or supplement .other, more physiological therapies, or support those who apply them.

This debate today is about the question of who or what is a psychoanalyst? A traditional answer is that it is someone who does psychoanalysis. Confusion arises when, as happened to me as a small girl asking that question, I then asked what was psychoanalysis and I was told that it is something that psychoanalysts do! Perhaps we can do better than that. However, we might also be debating, and in fact we must, and before too long, who or what is a counsellor? Why are we looking at one definition, which we probably agree belongs well inside the debates we must have about registration, and not at the boundaries between ourselves and those working in related fields? Surely we should be defining first, and as a matter of urgency, who belongs in the wider field before arguing about who is entitled to any one area of it? But no, we are, as usual in our professional arguments, and as Sylvia Cohen points out in the opening paragraph of her recent article in the Psychotherapist, once again discussing matters to do with authority. I suspect that our other preoccupation, hierarchy, will arise soon if it hasn't already, to bedevil us too. Sylvia reminds us how often these related questions have arisen in the history of the development of psychoanalytic thinking and our different traditions and organisations, and it is not difficult to see how over the years much more important questions to do with our position in relation to the wider world have got sidelined in favour of it. My title proposes that our world represents not only the Tower of Babel, where we cannot understand each other, but also an Ivory Tower, within which we fight our local battles, isolated from the attacks from real life out there.

We live in a time of extraordinary paradox, in that more than ever, psychoanalysis itself is an important currency of intellectual life. One can hardly open the review section of a serious Sunday Paper, or a literary or artistic or even musical journal, without realising from those quoted that psychoanalytic thinking is an important tool for the critic. Politicians bandy our ideas about, philosophers not only use them, but many also tend to know from where they come. As Priscilla Roth wrote in the Telegraph recently, in any of the recent millennium lists of the greatest thinkers of the 20th Century, Sigmund Freud, the Viennese medical doctor who was the discoverer and founding father of psychoanalysis, is always among the top few. And these same, sceptical, no-nonsense citizens entirely accept and are often guided by ideas and attitudes that come directly from Freud, or from later psychoanalytic writing. For instance, everyone knows what a Freudian slip is, i.e. the sudden "accidental" betrayal of a person's true thoughts, unthinkingly blurted out from his or her unconscious. Indeed, the very idea of an unconscious from which such personal truths might spring is a psychoanalytic concept. As are "ambivalence" (as in "I have ambivalent feelings about him"), "sibling rivalry", "neurosis", and "Oedipus complex". At the end of the twentieth century, we all speak Freud.
In addition, an increasing number of universities teach and qualify their undergraduates and post-graduate students in psychoanalysis or psychoanalytic studies. More psychoanalytic literature is read today than ever before, books fly out of the shops, the internet has a multiplicity of websites when one clicks on the word psychoanalysis. Yet, and this is where our future comes in, there is presently a dearth of patients suitable for training, and of candidates for training, the health service, which was never enthusiastic, has embraced the idea of counsellors, and short-term therapies, and we are attacked, not only by psychiatrists and psychologists of different persuasions, as we always have been, but now also by certain academics bent on proving our deviousness, greed, megalomanic tendencies, elitism and general stupidity.
But do we have an adequate definition of this thing called psychoanalysis? One that we could all agree on? For before we can possibly inform the politicians, and after them our colleagues in the world of health care, and eventually the patients who need our help, what we are, we need to be able to talk amongst ourselves, to develop a common language, or at least one that we can translate between ourselves easily. Let's try to do something about our Tower of Babel, then perhaps we can venture outside our Ivory Tower.
Psychoanalysis is traditionally held to be three things, we all agree. A method of investigation; a body of theory arising from the observations made by that method, and the practical applications of those theories which in the case of psychoanalysis is treatment. This statement can be applied to any discipline claiming to have a scientific basis - I will repeat myself, that a method of observation is developed, giving rise to theories, unitary or multiple, and thus to applications.
We can go further. We can state that the method of observation is basically that invented by Sigmund Freud, who made the first observations when he created, almost by accident, the setting which was to become his laboratory, the quiet and consistent consulting room where the patient reclined deprived of many external stimuli, particularly facial interaction with the analyst, and where free association became a possibility. There he created the first theories and by thought, and trial and error, his practical applications, which were further developed by him, by his colleagues, and in turn, by their colleagues, and so on. After this, we are in difficulties, since, as we know, there have been bitter disputes about the ownership of various theoretical and technical positions, and in every part of the psychoanalytic world splits have disrupted the community of those who are basically aiming at the same thing - the understanding of the mind, and the optimal treatment of the mentally suffering patient.
So, if psychoanalysis is a theory, what kinds of applications of clinical psychoanalysis are there? First, there is the method that Freud himself chose - seeing patients for fifty minutes five or six times a week, lying on a couch looking away from the analyst, abstaining so far as is possible from judgment, gossip or speaking about the analysts personal matters, trying to permit free association, allowing for dreams and attempting to reach the unconscious meaning behind the patient's communications including especially the relationship with the analyst. This method is about one hundred years old and is known as classical psychoanalysis. It is the oldest form of what has been recognised as psychoanalysis. Some would go so far as to describe it as the most respectable, certainly the most traditional.
The next most traditional is a method in which the frequency is the same, but there is often no couch, the patient may run round the room, attention is paid to behaviour as well as verbal communication - indeed in some cases the patient is not able to communicate very well by words, and the behaviour may include playing with, screaming at or attacking the analyst, who may have to restrain the patient physically. This method was developed about eighty years ago and is called child psychoanalysis, and is the second oldest form of recognised psychoanalysis.
Third, a method in which a number of patients come once or twice a week, for perhaps an hour and a half, and sit on chairs with one or maybe more analysts, interacting with those analysts and with each other. This method was developed about sixty years ago and is called group psychoanalysis. 
We could agree that all these methods of treatment and many others might be entitled the applications of psychoanalysis - in fact several eminent practitioners, including Joe Sandler and Otto Kernberg have stated as much - and of course there are further applications, though these have their own titles - brief psychotherapy as developed in the fifties and sixties, psychoanalytic psychotherapy as now understood, based on the same principles but with less frequent attendance, psychodynamic psychotherapy, as well as other psychotherapies that have less to do with development from the thinking of Freud or his original circle. It is no wonder we are a confusing world even to our quite close colleagues. 
I referred earlier to the splits that have occurred in the very short history of the discipline we all, from one point or another, work in. They have occurred apparently around theoretical and technical differences, though in fact most frequently different organisations have grown up around particular workers or groups of workers engaged in developing particular theoretical or technical positions, so that personal loyalties, idealisations and defensiveness have led to the bitterest and most painful antagonisms between these organisations. This, of course happens in all communities, and has happened frequently in the world of ordinary science, but in our world it has been more complicated and more passionate on account of the training analysis itself bringing in transferential elements and identifications, which affect not only relationships with our analytic parents and siblings, but with our analytic children, our trainees. Such transferences are complicated. On one hand, our loyalties to our analytic families can come to resemble clan or family loyalties, with rivalries both within the family and between families as to which of us resembles our admired predecessors more, which of us can imagine ourselves to be our leaders' favourite children, following the true line and bringing up our own analytic children in the true family tradition. This can lead to strengthening rather than modifying the analytic superego, each school claiming the most direct and true descendantship from, say, Freud or Jung. And like clan or family loyalties, they are felt most strongly when it comes to the ways the youngsters are brought up - that is, the traditions that are installed within our different trainings. Attacks, or perceived attacks on those traditions seem to threaten our very identities, our theoretical and technical territories, and we fight like tigers to defend them. It is thus that the power of the institutions that we differently belong to takes root, and grows.
But transferences contain the negative too. 
There is another question that exists in terms of our relationship to our history, which can be stated more in terms of a psychic mechanism, not often mentioned as such these days - that of reaction formation. Is it possible that our own ambivalent feelings about our predecessors, their successes, failures and conflicts are so difficult for us to deal with that we inhibit ourselves in relation to what they did both for psychoanalysis and in society in general, that we fail to continue their good work and even unconsciously undermine it? Do we, while at one level idealising our professional forebears, unconsciously sabotage their ongoing influence by setting them in stone, fossilising our thinking not so much in imitation as in parody, so that we stop thinking for ourselves and progress stops?
I think that in much the same way that our bodies have continued to develop physical organs which in an earlier stage of evolution may have served a practical purpose but nowadays only catch us out by causing sickness, in some areas we have preserved habits of thinking and relating to each other that are more appropriate for the days in which our predecessors lived, and that we may be ignoring changes in the world that we find ourselves in these days, and to which, I believe, we have not yet adapted adequately.
It seems that the rigidification of ideas and institutional habits that once were useful and suitable for the times in which they evolved, may do worse than be useless, they may have become idealised and thus ritualised so that they are actually hampering us, constricting us - I am thinking of elements in some trainings that can resemble ritual rather than a flexible approach to the problems of today. Some occur in the insistence on various elements of training, others happen in the stages by which a candidate may progress towards qualification, and rituals resembling tribal initiation ceremonies are instituted, for instance around reading in ceremonies.
We admire and respect our psychoanalytic ancestors; they worked in hard times and developed our institutions against the odds; in order to be worthy followers must we exactly copy the ways of working that they instituted; or can we emulate the freshness of their thinking and the energy that allowed them to be innovative? 
Also, can we overcome the negative transferences to our trainees? They, after all, are enviably younger than we are, on the whole, and though we may react by pitying them as being farther from the pure gold than us, they may have a richer and wider diet than we ever had as trainees. Do we need to confine them, to make their trainings ever longer, to move the goalposts so that when just on the point of achieving a goal, another obstacle is thrown in their way, the tribal initiation rite is made even harder? Or is this an unconscious revenge for their hope, enthusiasm, and energy?
Let me go back to the history of psychoanalysis as a treatment in this country. I suggest we imagine something of the first days of the discipline. Before the first war there were only a handful of curious people, but as a result of that conflict interest grew so that the phenomenon known as shell-shock inspired several psychiatrists and psychologists to investigate mental activity - recently the work of Rivers in Edinburgh was highlighted by the novel and film Regeneration, while at the same time Millais Culpin in Portsmouth was studying broken down soldiers and Freud's ideas. It was Culpin who asked an ophthalmologist to find a control group for his studies, among the patients whose eyes were damaged, and who found that psychological damage was as great among the physically damaged as among the shell-shocked group. Notably, it was the ophthalmologist who then trained in psychoanalysis. It was also in the twenties, as a direct development of the aftermath of war that both the Cassel Hospital and the Tavistock Clinic were founded.
So curiosity arose in the twenties, about this new phenomenon, psychoanalysis, and this meant a great deal of concern about what it implied. Even today we often see anxiety about fiddling with the mind and in the times of social and economic restriction that were the twenties it must have taken a great deal of courage to begin to indulge that interest. The world had been turned upside down, frightening social change was occurring, women, having contributed to the war effort as never before, were becoming emancipated, they got the vote, universities were beginning to accept them, Marie Stopes pointed out that they need not be enslaved to childbed. A generation of young men had been slaughtered, economic conditions worsened, a new world was emerging, political splits were widening alarmingly. Psychoanalysis, while intriguing, must have seemed a new threat to the precarious status quo, especially as it was taken up by the unconventional and such social rebels as the Bloomsbury Group.
Rescue, however, came from the British Medical Association. Doctors, who in those days had very little in the way of a therapeutic armamentarium for psychological problems, must have been both puzzled and a little alarmed by this new treatment, mysterious and foreign as it was, and practiced by both medical and lay practitioners. Help for disturbed patients was desperately needed, but was this sort of treatment useful, or just mumbo-jumbo, and would using it or even taking an interest therefore be unethical? 
In those days medical ethics were such that the rules could be condensed into a prohibition on the five forbidden activities for doctors, briefly abortion, addiction, adultery, advertising, and associating with unqualified practitioners - breaking any of these rules risked a doctor being struck off and losing their livelihood and thus their position in society permanently. On account of the fear that taking an interest in, and referring patients for psychoanalysis might risk the accusation of associating with unqualified practitioners, the Sussex Branch proposed a motion at the Annual General Meeting of the BMA in 1926 that the Council should investigate and report on the subject of psychoanalysis. Accordingly, a Special Committee was set up, consisting of 21 senior medical practitioners, physicians, surgeons, a gynaecologist, neurologists, psychiatrists, a psychotherapist, a paediatric surgeon, Ernest Jones from the London Clinic of psychoanalysis, JR Rees, deputy director of the Tavistock Clinic, and TA Ross, director of the Cassel Hospital. There were two women members. In contrast to what would happen today, there were no lay members, they were all doctors. There were 28 meetings of the Committee in all, they requested and examined thirteen documents and several memoranda and they reported in 1929, concentrating on the consideration of the criticisms advanced against psychoanalysis, 
The whole report was published in the British Medical Journal, June, 1929, and consists of 16 closely argued pages, it is not uncritical of psychoanalysis, and we should recognise that similar criticism can be heard today. However, while it does not address the therapeutic efficacy of psychoanalysis it does accept that psychoanalysis is a valid and legitimate treatment, and so far as the BMA is concerned states firmly that the term psychoanalyst is properly reserved for members of the International Psychoanalytical Association. It was this ruling, over 70 years ago, that allowed doctors to be confident that referring patients to a psychoanalyst who was a member of the IPA (and membership went with membership of the British Psychoanalytical Society) would not endanger the referrer from an ethical point of view. It also meant that doctors could train in psychoanalysis without risking their own careers, and this allowed such people as Bowlby, Bion, Gillespie, Winnicott and Fairbairn to become part of the psychiatric establishment and to teach, as well as supporting such institutions as the Tavi, the Cassel, the Davidson Clinic in Edinburgh in spite of violent opposition from the more medically based psychiatrists, who of course were fighting their own battle for what they saw as respectability. (It is important to remember that up to the late 1960s psychiatric trainees at the Maudsley Hospital were strongly discouraged from engaging in a personal analysis or undertaking psychoanalytic training while employed there.)
Attacks on psychoanalysis are not new, and they increase; attacks on Freud and his own integrity, attacks on his colleagues and their ideas too, interestingly often using concepts that the authors of these attacks could not have used had Freud not described them. We have been described as charlatans, as conscious and unconscious greedy cheats, as brainwashers, as having no effect, and at the same time as being dangerous to mental health. The only defences we have had have been recognition by our professional colleagues, those who have been able see our value. The BMA report, though old, has stood us in good stead over many years, and gave a certain amount of protection which allowed the development of psychoanalytic thinking in this country. This development has not been inconsiderable, and probably everyone in this room has directly or indirectly benefited from it.
The question before us today would involve agreeing a change to that definition of a psychoanalyst as being someone who is a member of the International Psychoanalytic Association. 

(Here Dr Johns quoted from the Institute's rules on this issue)

However, in view of the continuation of attacks on our discipline, there can be no doubt that in making such a change, much thought and argument would have to go into providing a definition. Today's world is different, we live in the era of evidence-based medicine, of audit, of clinical governance, of great faith in the psychiatric profession in their new drugs and their increasing neuropsychiatric knowledge. The enemy outside the Ivory Tower has different weapons, and we need to understand them if we are to reply and protect our work, our thinking, and above all, our patients. There is an important debate to be had about the difference between psychoanalysis and psychoanalytic psychotherapy, and even about the validity of our terms, which have grown up haphazardly. It is a long and difficult debate, and will require very clear thinking, and a retreat from the kind of hierarchical cul-de-sac we can get into by assuming that one modality is intrinsically superior to another, rather than one being more useful than another depending on the situation one is facing. When we have it it may allow us to study seriously the efficacy of our different treatment modalities, which will allow us to inform the public that we are a proper, self-examining profession. My last question is a return to my earlier one. Is this the most important debate for us at the moment? Should we not be concentrating on defining the wider question of who we include in our definition of a psychotherapist? If we are to stay in our Ivory Tower, before deciding who wants which bedroom, should we not be aware of what is outside and consider closing the door?

A report on the conference by a participant, Janet Low, can be found by clicking here