Health care reform issues intruded Hinto the usual deliberations on psychoanalytic education at the December 15 meeting of the Board on Professional Standards. BOPS chair Marvin Margolis opened the meeting by announcing that a considerable amount of the Board's time had been set aside to discuss health care reform, in acknowledgment of current concerns about the possible detrimental effect of the Clinton health care proposals on the practice of psychoanalysis. Margolis also stressed the need for The American to develop innovative programs to reverse statistics showing slight declines in both membership and private practice.
Three speakers were scheduled to present their positions to BOPS. Norman Clemens, co-chair with Arthur Farley of the Committee on Government Relations and Insurance, summarized The American's official position on health care reform as set forth in last year's Action Plan. Clemens emphasized the goals of providing the best possible benefits for psychoanalysis, appropriate utilization review, and freedom of patient and analyst to contract outside the system. Harvey Rich, representing the Coalition for Patients' Rights, a newly formed group independent of The American, announced that the coalition was established because of the urgent need to deal with health care legislation. The group's purpose is to preserve the ability of patient and analyst to contract outside of any health care system. James Pyles, a noted Washington lawyer with expertise in heath care issues, has been retained to promote that goal as the health care bill takes final form. The coalition is requesting private donations to support its efforts. The third scheduled speaker was Robert Cummings, who presented the Southern California Psychoanalytic Society's proposal in opposition to the Action Plan's goal of government health coverage for psychoanalysis. The proposal recommends that The American work aggressively to opt out of any coverage of psychoanalysis. (See the accompanying article on the meeting of the Executive Council for additional details on the three positions.)
Before discussion of these issues, Horacio Etchegoyen, president of the International Psychoanalytical Association, greeted the assembly. He was followed by Peter Fonagy, IPA treasurer and member of the British Psychoanalytical Society, and Elfriede “Suzanne” Lustig de Ferrer, an IPA vice president and member of the Argentine Psychoanalytic Association, who summarized the effects of health care policies in their respective regions. In Europe the systems vary greatly from country to country, but in all countries the system is compatible with the identity of psychoanalysis. However, Fonagy warned, “There was always a price to pay; there is no free lunch.” He cautioned that when abrupt changes occur in health care systems, problems with psychoanalysis can occur. In Latin America, Lustig de Ferrer reported, there is also a wide variety of systems; in Argentina psychoanalysis flourishes not within the government heath care system but in the private sector.
The thrust of the discussion that followed was that the fellows of BOPS unequivocally desire the option of freedom to contract outside of any government system. Although financial concern was mentioned, other concerns were more evident. The worst case scenario considered was that psychoanalysis might not be allowed within the new system while being made unlawful outside it. On occasion, the phrase “the death of psychoanalysis” was heard. More prevalent concerns were those mentioned in the Southern California proposal: that a new system of health care involving bottomline managed care would distort psychoanalysis, that confidentiality would be compromised, and that abrupt cancellation could be anticipated.
Clemens responded that in California CHAMPUS had contracted out to a group that was unreasonable. However, in a different CHAMPUS area, an analyst, Alan Zients, is a director of Health Management Strategies, and 75 cases are currently in psychoanalysis. Clemens cautioned that opting out might be difficult because the Clinton administration is opposed to a two-tier system. The general sense among BOPS was that since the form and requirements of the new system are not yet known, it is too early to attempt to opt out; it is, however, a possible future strategy if current apprehensions prove founded. Clemens suggested that a referendum be held among the membership before any decision is made to opt out. Margolis commented in conclusion that not all is “doom and gloom”; he noted that in some areas of the country analysis has increased by 4% a year.
Among other issues discussed at the meeting was the “slippery slope” concern that as The American attempts to become more inclusive internally, and more political externally, standards of training and practice will be eroded.
Arthur Rosenbaum, chair of the Committee on Certification, reported that the committee reviewed 38 applications and certified 22 members. Eight of 22 new applications were approved and 14 of 16 continued applications passed. Upon reviewing recent data on members applying for certification, the committeé discovered that applicants who were more than seven years past graduation had a 73% success rate, three times that of recent graduates. A probable reason is that competence increases with analytic experience. Because of this, a five-year trial was proposed in which applicants for certification who are more than seven years past graduation would have the option to submit reports of only two cases (one of each sex, with one terminated).
The proposal occasioned extensive discussion, centering on the issue of whether this policy would lower standards or at least be perceived as lowering them. There was some concern that if it was passed, graduates would delay applying for certification. It was emphasized that the standard for graduation would remain three cases, and that only the committee's method of evaluation would be altered. In the vote, only six Fellows opposed the proposal.
Phyllis Tyson, chair of the Committee on Non-Medical Clinical Training (CNMCT), announced that since the committees inception 81 persons applied for a waiver, 45 being deferred. Of that group, 30 were eventually granted waivers (one also became eligible for training without one). Since 1989, only two applications for waivers were finally denied. Waivers are now required only for applicants who are not psychiatrists or psychologists with a doctorate in clinical psychology. Currently there are 47 M.S.W.s in training at twelve institutes. In regard to past concerns about accepting poorly qualified individuals for training, Tyson noted that in general the group in training have excellent credentials.
The committee provides consultation with institutes prior to submission of the waiver application, and this has proved helpful. The new policy of “rolling admissions” (i.e., obtaining a provisional waiver prior to the meeting of CNMCT in December so that the applicant may begin classes in September) has proved generally successful, but occasional problems occur. Tyson underscored that CNMCT needs waiver applications no later than July 1 in order to allow time for a thoughtful review. In a few cases, institutes have allowed a candidate to begin classes before submitting a waiver application.
The committee distributed its data on CNMCT applicants to the Board, which voted to broaden this study to include data on non-CNMCT applicants in order to provide more basic information on selection. All seven applicants for waivers were approved.
Allan Rosenblatt, chair of the Committee on External Credentialing, reported that the National Association for the Advancement of Psychoanalysis (NAAP) through its subsidiary, the American Board for Accreditation in Psychoanalysis (ABAP), continues to press the Committee on Recognition of Postsecondary Accreditation (CORPA)—formerly the Council on Postsecondary Accreditation (COPA)—for recognition as the sole accrediting agency for psychoanalytic training institutes. Their application is being reconsidered by CORPA and will move into the second phase of evaluation for
approval in January. The American, joined by the four independent IPA societies in the United States and as part of the Psychoanalytic Consortium (which includes Division 39 of the American Psychological Association, the Academy of Psychoanalysis, and the Committee on Psychoanalysis of the National Association of Social Workers), will testify against ABAP/NAAP's bid for recognition. Since an organization can reapply indefinitely, Rosenblatt noted, the only way to permanently block the group is to have CORPA approve a different accrediting body, as it generally recognizes only one accrediting agency per profession. The committee is exploring this option with various groups, including the IPA institutes and the Consortium.
Lawrence Chalfin, incoming chair of BOPS, raised various questions to be considered before further action is taken. He noted first that what was originally conceived as a voluntary external credentialing for members who need it to qualify for third-party payment is now being conceived of as mandatory external accreditation of institutes. He also voiced concern that various threats and pressures are being exerted on the committee by groups outside it. He doubted the wisdom of rushing to make changes in response to, or anticipation of, external pressure. If a united Psychoanalytic Consortium approached CORPA, the standards of training it supported would have to be acceptable to all the partners, who at present have very different standards. The question of standards is of great concern, because the Clinton health reform approach might incline toward accepting the minimal as the psychoanalytic practice standard.
Chalfins remarks sparked a lively interchange, and the resulting discussion revealed that many Fellows of BOPS were confused by the issue. Rosenblatt attempted to clarify the matter, noting that though CORPA is a private entity, not a government agency, the government recognizes its decisions. CORPA's decision could therefore become a determining factor in health care reimbursement. If The American attempted to become the CORPA- approved accrediting body, it would be opposed not only by ABAP/NAAP but by current allies in the Consortium. If the unlikely happened and The American were approved by CORPA, the probability of a legal battle with the other groups would be great.
In regard to the possibility of obtaining certification from the American Board of Psychiatry and Neurology, that body's latest position is that it “does not have an interest in credentialing non-M.D.s.” Margolis felt there was consensus to work with other analytic groups only to fight ABAP/NAAP and to deal with health care reform issues. BOPS instructed the committee to continue to explore, but not negotiate, external credentialing with the Psychoanalytic Consortium and the four independent IPA institutes.
Richard Fox, chair of the Boards Committee on Membership, reported a small but significant decline from a total of 3,043 in May 1993 to the current 3,011. He proposed and it was passed that the committee take steps to encourage eligible affiliate members—those who have graduated from their institutes—to seek active membership. He reported that for recent members the average age at graduation is 45 and length of training 9.6 years. However, wide variations exist. Training showed a range from 4 to 20 years. The number of control cases varied from 3 to 9, and hours of supervision from 150 to 700. Some institutes have graduated a few candidates who did not meet minimal standards. In one instance, for example, the submission of reports on three female cases and no male case was deemed acceptable. On a few occasions there was no overlap of supervision of cases with the training analysis. These exceptions raised questions about the institutes' use of the tripartite model of education, and the committee will study this further. Fox asked permission for the committee to gather anonymous data on all institute graduates, not just those currently applying for graduation, and BOPS voted overwhelmingly in favor of his request.
The Board voted unanimously to approve the appointment, by incoming chair Lawrence Chalfin, of Donald Rosenblitt (UNC-Duke) to the position of secretary of BOPS.
The following members were appointed training and supervising analysts: James S. Dalsimer and Jonathan Kolb at Boston, Norman A. Clemens at Cleveland, Elizabeth Auchincloss and John Munder Ross at Columbia, Daniel M. Brener and Stephen M. Sonnenberg at Houston-Galveston, Fred Busch at Michigan, Salman Akhtar at Philadelphia Psychoanalytic Institute, Axel Hoffer at PINE, Eric Nuetzel at St. Louis, Stephen D. Purcell at San Francisco, Robert L. Bergman at Seattle, and Becquer Benalcazar at Topeka. Kenneth R. King was appointed child/adolescent supervising analyst at Seattle.
Harvey Rich, chair of the Joint Committee on Foundations, announced that there are now eighteen institutes and societies in various stages of foundation development. He mentioned that the committee would hold a weekend workshop in California in late February. The general feeling among institutes and societies with ongoing foundations is that they result in increased practice.
David Carlson, chair of the Committee on New Training Facilities, announced that the Florida Psychoanalytic Training Program has made great progress. The Board voted unanimously to accept Florida as a provisional institute. Peggy Hutson of Florida thanked their sponsor, the Baltimore-Washington Psychoanalytic Institute, and CNFT for their help.
Because of the amount of time devoted to discussing practice issues, a planned discussion of two bylaw proposals was postponed until the May meeting. These proposals came from the Joint Task Force on Board-Council Structure and Functions and from the Joint Ad Hoc Committee to Consider Membership for IPA Members.