At its meeting last December, the Executive Council turned to a major discussion of issues raised by the national debate on health care, especially as these bear on the practice of psychoanalysis.
Foremost on discussants' minds was whether it is possible to practice psychoanalysis under a system requiring disclosure of patient confidences. Some felt that any disclosures to third parties would create an atmosphere in which patients would consider confidentiality so breached as to preclude the conduct of an analysis. Another concern was that the plans now on the table so discriminate against psychiatric coverage that reimbursement schedules would make practices unsustainable.
A major debate occurred over the direction to be taken by the Committee on Government Relations and Insurance. There appeared to be consensus that the committee should do everything it can to ensure, under any plan, that psychoanalytic practice remains viable.
Two distinct groups pushed for maintaining the right of patients and analysts to contract privately, beyond the constraints of any health plan, as there was great concern that the legislative package might mandate that all mental health care be mediated through health plans. Despite official assurances that private practice will continue, the economics spelled out so far would severely erode it. In advance of the meeting, the Coalition for Patients' Rights, a group of members led by Robert Pyles, Sam Rubin, Jean Greenspan-Margolis, and Harvey Rich, circulated an appeal to the membership for funds to pay an influential Washington attorney now working to ensure that any plan finally passed will allow the private contracting of analysis. The attorney in question, who has impressed the group with his contacts, abilities, and dedication, had been pursuing this goal even before the group met and retained him. Pyles and Rich spoke with the Executive Committee about bringing their efforts under the aegis of The American, but because they could not agree to report to the Committee and receive direction in a mutually satisfactory manner, the Committee felt it could not commit money collected from dues. The group is continuing to solicit funds on its own.
Representatives of the Southern California Society again raised their proposal that The American strive to ensure that psychoanalysts may practice apart from any plan. As discussion advanced, the difference between the Southern California position and that of CCRI seemed not as wide as it initially appeared. The Southern Californians no longer seemed to be asking The American to withdraw from the national debate, and discussion narrowed to issues of tactics and priorities. Some wanted CGRI to make the right to contract privately its first priority, while the committee prefers to make this only one of a number of goals, thereby enhancing its negotiating position. CGRI believes that many younger candidates and members, as well as their patients, may be depending on the health care plan, when enacted, to pay psychiatric fees. For this reason, CGRI prefers to fight for acceptance of psychoanalysis as a compensable treatment, as well as for the right to contract privately. By a vote, the Council ultimately supported that position.
What seems likely to follow is the mounting of a two-pronged attack. The Pyles-Rich group will work through their attorney, using funds raised voluntarily to finance its efforts. Meanwhile, The American too will ask for voluntary contributions so that CGRI may hire a consultant to survey current contacts, evaluate legislative trends, and raise the additional money needed to intervene more actively as the spring and summer “markup” period unfolds. These are critical times, and mapping the best strategy is the game. Disagreement arose over the best moment to influence legislation, but it would seem the two approaches will complement each other.
Treasurer Stephen Firestein presented a budget, explaining that the information was still incomplete. Although conversion to a computerized system is a great help, a year of experience is required to create a base from which to project a budget. Categories of income and expenditures are in need of further refinement, but the data on hand afforded the Council a far better view of The American's finances than was possible in the past.
The Treasurer also reported that dues-paying membership has sagged, partly as a result of a decline in new applicants, but mainly through the graying of the membership, which shifts dues-paying active members into the life member category. To make up for lost revenue, a dues increase has been considered, but a decision has been held off for fear that an increase might in fact lower revenues by making membership less attractive.
In the discussion that followed, suggestions were made that a more detailed budget be presented at the next meeting, and that life members who remain in active practice might continue paying dues. The Treasurer thought asking life members to pay dues would violate a long-standing trust, but added that a “step-down” formula for those entering life member status is being considered. The policy has become standard practice in some local societies and in organizations such as the American Psychiatric Association.
Finally, Firestein had intended to ask, in another portion of the meeting, for authorization to form
a foundation, legally separate from The American and incorporated outside of New York State, as a means of raising funds for educational and research projects. The health care issue eventually overtook the agenda, so authorization is being sought through a mail vote.
Allan Rosenblatt, chair of the Joint Committee on External Credentialing, reminded the Council that the committee was set up in response to NAAP's application for recognition as a national certifying body for psychoanalysis, and that the committee encourages discussion about creating a certifying body external to The American. The issue is one that touches sensitivities, as was evident in the discussion that followed. Stephen Firestein offered an historical note, reminding the meeting that when Burness Moore introduced the certification process, he did so as an intended first step toward external certification. (Firestein may have been referring to earlier, failed attempts to develop certification in psychoanalysis as a subspecialty of the American Board of Psychiatry and Neurology.) Current discussions have, as their poles, the recommendation to proceed slowly, because many members and local organizations do not favor the idea, and, on the other side, specific proposals that the necessary corporations be formed and procedures developed for the external credentialing of institutes and certification of members.
Past President George Allison spoke in favor of the latter course. President Bernard Pacella pointed out that the organization can retain the option of defining psychoanalysis as it likes, for example as a four-times-weekly procedure, but that it might have to join forces with groups that define the process differently. Henri Parens and Rebecca Solomon supported Allisons position, but Marvin
Margolis, chair of the Board on Professional Standards, urged caution and a step-by-step approach. Lawrence Chalfin, who will succeed Margolis, expressed uncertainty, urging the committee simply to explore, and not to negotiate or develop anything definite. The Council again concurred, voting to continue explorations.
Helen Fischer, dubbed “Miss American” by President Bernard Pacella, announced at the meeting that she will retire. Pacella told the Council how Helen has shaped the progress of The American, how time and again she has steered the Executive Committee onto the right path. She will stay on board as Consulting Administrative Director until the May meetings, and has been offered an undefined position as Special Consultant for a limited time thereafter.
Her successor, Doris L. Eder, who has degrees and experience in education, administration, and fund raising, was introduced and briefly addressed the Council.
In an effort to better inform and coordinate the Council and the societies, the Executive Committee has established two new bodies. The Steering Committee of the Council, a coordinating body comprising the chairs of Council committees, is comparable to the Coordinating Committee of BOPS. The other new group, the Committee on Societies, chaired jointly by Allan Rosenblatt and Ralph Engle, is charged with sending information on crucial issues to the societies, and pressing for active local discussion so that councilors may better represent their societies. The committee has begun its work by surveying the societies and will soon be preparing reports.
The “Quad” committees—Government Relations and Insurance, Practice Issues, Peer Review, and Public Information—have a new coordinator. Claire Coyne, appointed last May, reported on the changes taking place in the communications environment in which thoughtful processes, including psychoanalysis, take place.
Roger MacKinnon reported on our relationship with medical schools and students. If we are to interest medical students in psychoanalysis, he remarked, we need to show that we offer treatment other than classical four-to-five-times-a-week analysis. We need to speak to the broader applications of psychoanalysis and psychoanalytic education. Marvin Margolis commented that we are belatedly waking up to our neglect of medical education and have, for example, no strategy for psychiatric residencies. He reminded the gathering of The American's history of recruitment and training of nonmedical candidates and remarked that standards were not lowered to admit them.
Sheila Hafter Gray, chair of the Committee on Peer Review, presented a report, available to members, that should be read in the light of the current health care debate. She feels that many of our past insistences have created serious problems for practicing psychoanalysts. She was commended and applauded for her long-term efforts, as well as for the power and clarity of her presentation.
The survey of societies revealed a strong preference for establishing a Candidates Council.
The recurrent debate was joined regarding the siting of meetings. While a more equitable geographic distribution is the goal of many, others believe the meetings should continue in New York, as meetings there have historically been the most heavily attended.