Last May's meeting of Council, held during the Annual Meeting in San Francisco, was marked by deliberations on a host of knotty issues. Perhaps the most controversial was a proposal by Robert Cummings of the Southern California Psychoanalytic Society that called for a marked change in the position of The American in its efforts to obtain coverage for psychoanalysis under any national health care program. The American's position is set forth in the “Action Plan for 1993” presented last December by Norman Clemens, chair of the Committee on Government Relations and Insurance. The Southern California position called for a repudiation of that plan, particularly its acceptance of “noninvasive” utilization review by managed care.
The crux of the Southern California position is that managed care is by its very nature invasive and that psychoanalysis cannot be conducted properly under a system of service delivery in which privacy is compromised and the continuation of treatment remains always in doubt. Southern California called for three motions. First was that The American shift from developing diagnosis-based practice guidelines to procedure-based guidelines and that this task be “free from conflicting interests to obtain insurance coverage for psychoanalysis.” The second motion called on The American to address the problem of third-party coverage that allows intrusive audits of records, including those of self-paying patients. (Currently, if an analyst treats a Medicare patient all of that analyst's records can be reviewed to determine “patterns of practice.”) Third, Southern California asked that The American cease its attempts to have psychoanalysis covered by third-party payers and instead work toward allowing fees to be contracted between analysts and patients outside of any federal regulations.
During the morning session, Clemens addressed the second and third of these motions. He agreed that privacy abuses indeed occur and that privacy must be maintained. In defense of the Action Plan, he reported that effective analyses are at present being conducted under managed care. Arguing that The American should continue to allow members to work with managed care if they so desire, he warned of the dangers of “not having a place at the table” during the upcoming months of critical negotiations over national health care policy.
In the afternoon session, Sheila Hafter Gray, chair of the Committee on Peer Review, discussed the first of the Southern California motions. Noting that The American is working on both procedure- and diagnosis-based guidelines, she warned that for psychoanalysis to be included as a therapeutic modality by the American Psychiatric Association, the latter are required. She stressed that they are being written as guidelines, not as standards, in order to allow flexibility. They are designed, she said, to commend the practice of psychoanalysis to third-party payers, not as weapons to be used by them in harassing analysts. Rejecting all three motions, the Council voted to reaffirm the Action Plan, with only four in opposition.
Perhaps surprisingly, given the importance of the Southern California proposal, Council discussion was focused and limited. This was due, at least in part, to procedures introduced by the recently formed Committee on Societies, chaired by Ralph Engle and Allan Rosenblatt. Information about issues coming before Council had been sent to the societies in advance of the meeting, in order to allow discussion at the local level. Thirty of the 36 societies reported deliberations back to the committee. The Councilors' familiarity with the issues and their knowledge of the opinions of their societies effectively reduced the need for lengthy discussion.
A second new committee, the “Steering Committee,” met for the first time prior to the Council meeting. The committee consists of the chairs of all Council committees and joint committees of Board and Council. President Bernard L. Pacella praised the work of both new committees.
An issue not on the agenda received considerable discussion early in the meeting. Theodore Shapiro, outgoing editor of the Journal of the American Psychoanalytic Association, announced that his successor might not receive the honorarium that has been in effect the past twelve years. Shapiro strongly recommended its continuation. Treasurer Stephen Firestein, however, said the cost of subsidizing the editor has been substantial and doubted whether The American could afford it. Others noted that The American's officers also devote long hours that interfere with their practices and that they too deserve remuneration. The Council decided to continue the JAPA stipend for two years and in the meantime reevaluate the policy. (Later in the day, the Search Committee announced the selection of Arnold Richards, current editor of TAP, as the new editor of JAPA.) The discussion reflected a more general debate within The American over how best to apportion a limited budget among a great many worthwhile projects.
In that context, it was decided to hear the Report of the Treasurer. Firestein, warning that the dues-paying membership base has remained static, reported that “step-down” dues for life members does not seem a feasible option, and that the thrust of the organization will be on recruiting members as early in their analytic careers as possible. Pacella cautioned that the option of a general dues increase might in fact occasion a decrease in membership and therefore in overall revenues.
In his report, Firestein mentioned several recent initiatives involving expenditures.
The co-morbidity project. The analytic practice of members will be surveyed to determine the degree of pathology of analytic patients. The idea is to dispel the impression that analysts treat “the worried well” by documenting the fact that patients in analysis have severe problems.
A telephone hookup of meetings of The American. Under consideration is a plan to broadcast the major panels to four areas of the country and to allow dialogue between panelists and the radio audience.
A meeting of the Joint Committee on Foundations. A productive meeting was held in Chicago last April to address the possibilities for creating foundations to support local societies and institutes. Although participants paid their own way, The American incurred various other expenses.
The June 1993 meeting in Santa Fe. Called to discuss the critical issues facing psychoanalysis, the meeting was financed along the lines of the Chicago gathering.
The feeling was voiced within the Council that it often acts too impulsively in approving expenditures. With limited knowledge of The American's finances, it was remarked, it is difficult to judge the priority and practicality of budgeted items. Firestein noted that the Central Office's new computer system is capable of providing Councilors with monthly financial reports.
Next Rosenblatt, speaking for the Committee on Societies, described its functions as implementing the exchange of information between The American and the societies, providing site visits and consultations to societies at their request, and enhancing relations with the affiliate societies. He reported feedback on five issues sent to the societies for discussion.
The societies were not in favor of the Southern California proposal against the Action Plan (see above).
The societies were in favor of a bylaw amendment proposed by Richard Fox, chair of the Strategic Task Force on Membership, to offer membership at the time of candidate matriculation.
Comment was generally favorable on a plan to develop a consortium with other analytic groups that would address their common concerns.
There was little support for a proposal by Morris Peltz for The American to fund a Washington representative to provide input to the Clinton Administration's developing health care
plans. It was felt that the expense, if considered at all, should be borne by a consortium.
There was considerable support for a proposed statement by the Baltimore-Washington Society enumerating the dangers of providing information for claims review. (The following day, at the Meeting of Members, when Barry Landau formally presented the statement, Gray responded that she and the Peer Review Committee were in general agreement with the position. The American has written policies on preserving confidentiality with claims review and continues to address these issues.)
Homer Curtis mentioned that discussion is under way on a possible bylaw amendment to extend membership in The American to members of IPA institutes located in the United States that are not affiliated with The American. The proposal will be discussed by local societies and institutes before formal presentation to the Council, which may occur at the Fall Meeting.
Clemens, in his report, mentioned that representatives of The American have presented its position on federal health care legislation at the White House. He noted that even after the legislation is passed, many decisions will be made and implemented at the state level. Local organizations, therefore, will have opportunities for further input. Clemens emphasized that The American is not only fighting for psychoanalysis but in fact is “the only voice for long-term psychotherapy.”
Stuart Hauser, director of the Fund for Psychoanalytic Research, reported eleven applications for funding. The one approval was to Professor Mary Main of the University of California at Berkeley for “Predicting Coherence vs. Incoherence in Adolescent Attachment Interviews from Security vs. Insecurity of Early Attachment: A Study of Interest to Psychoanalysis.”
Once the Southern California proposal was defeated, the afternoon's business was conducted rapidly. The Council voted unanimously to approve Fox's bylaw amendment allowing membership to candidates upon matriculation. The amendment had been approved by BOPS the previous day and will now go to the membership for a vote. The measure is part of an initiative to reverse the “greying” of The American. Maimon Leavitt, chair of the Committee on Membership, had reported that although the total number of members remains more or less constant, the number of life members continues to increase, resulting in a shrinking base of dues-payers.
Passed overwhelmingly was a position statement by Raymond Raskin, chair of the Committee on Social Issues, that deplores “threats to disrupt scientific meetings, intimidation of clinical researchers, and sexual politics” in attempting to understand sexual behavior, and calls for “a scientific atmosphere of free and open exploration.” The statement reaffirms that the contract between analyst and analysand is private and that the goals of an analysis are of concern to them only.
Marianne Goldberger and Ralph Roughton were elected to the Subcommittee of the Nominating Committee. Robert Tyson, Scott Dowling, and Alan Skolnikoff were elected to the JAPA editorial staff as experienced members, with Fred Busch, Axel Hoffer, and Dorothy Holmes elected as new members. (Anton Kris was also elected but later declined.) It was announced that Richard Almond and Charles Jaffe were appointed associate editors. Since Richards will be the new JAPA editor, he will step down as editor of The American Psychoanalyst (See box below). Melvin Mandel will chair a search committee to fill that post.
Claire Coyne has been retained as Practice and Public Education Coordinator. She will work closely with the “Quad”: the Committees on Peer Review, Psychoanalytic Practice, Public Information, and Government Relations and Insurance. This is a result of the Council's vote last December to establish a Coordinator of Psychoanalytic Practice Activities. The Executive Committee, deciding it was impossible for one person to perform all of the functions outlined in the December proposal, felt it necessary to rewrite the job description.
Recent intense and protracted ethics deliberations have revealed a need to review The American's code of ethics. William O'Brien, chair of the Committee on Ethics, is moving forward on this problem.
The National Association for the Advancement of Psychoanalysis (NAAP) is moving to phase two in its continuing efforts to be named the accrediting body for psychoanalysis by the Council on Postsecondary Accreditation (COPA). If NAAP is granted this power, The American might have to resort to legal action.
The possibility of a North American Federation of IPA groups (similar to FEPAL in Latin America) is being explored.
Two new affiliate societies were approved: the San Antonio/Austin Psychoanalytic Society and the Tampa/Southwest Florida Psychoanalytic Society.
Of 26 applications for certification, 14 were accepted.
Elise Snyder, chair of the Fellowship Subcommittee on University and Medical Education, announced the selection of ten new fellows for 1993.
Jerome Beigler, chair of the Committee on Confidentiality, discussed problems with managed care. Hearings will soon be held on a federal confidentiality law.
At the suggestion of Homer Curtis, chair of the Committee on Soviet Education Exchange, the Council gave a vote of thanks to International Universities Press for their efforts in shipping analytic books to Russia.
A proposal to form a National Candidates Council was discussed and will be further explored. The council would be part of the structure of The American and would permit the greater involvement of candidates in the organization.
Minutes of the meeting will be sent to Councilors of all societies and will appear in JAPA.