Twenty-two years ago the American Psychoanalytic Association formulated the Principles of Ethics as a guide for psychoanalysts in the treatment of patients and in relationships with colleagues. Provisions for Implementation were promulgated at the same time. Over the past two decades, modifications have been made in both documents, but the issues, which are of increasing importance to members and to the profession generally, have received nowhere near the attention they deserve. Consequently, in 1994 president Bernard Pacella and BOPS chair Marvin Margolis created, under the Joint Ethics Committee, a Subcommittee on Ethics Revision. This new body, supported subsequently by Judith Schachter and Lawrence Chalfin (successors to Pacella and Margolis), was given several charges: (1) to evaluate the usefulness and limitations of the current Principles and Provisions by reviewing the experience of societies, institutes, study groups, and new training facilities; (2) to evaluate the experience of The American's Joint Committee on Ethics over the previous two decades; (3) to consider to what extent and in what situations nonadversarial processes may be used to promote understanding and extend therapeutic processes interrupted by ethics violations; and (4) to consider how The American can aid local groups in developing their ethics procedures.
The subcommittee was chosen to represent diverse groups within The American. The members, all of whom have had experience in dealing with individual and organizational ethics issues, are Katherine Brunkow (Washington), Murray Charlson (Pittsburgh), Paul Dewald (St. Louis), Glen Gabbard (Topeka), Jacob Jacobson (Denver), Margaret Keenan (Minnesota), Paulina Kernberg (Columbia), Maria Lymberis (Los Angeles), Malkah Notman (Boston), James Robinson (Houston), Bernard Rubin (Chicago), Evangeline Spindler (Michigan), and Ernest Wallwork (Washington).
The subcommittee began meeting in May 1994. A survey of the ethics experience of the societies and institutes was devised and carried out in the fall of 1994. The survey sought to elicit responses in three general areas of ethics experience, asking the following questions:
How are ethics matters dealt with? Does the society/institute have a standing ethics committee with codified procedures, or does it appoint an ad hoc committee? What is your experience with the Principles and Procedures?
Have you considered nonadversarial processes? Do you have an early warning system? What do you do about rumors?
Do you teach ethics to candidates? Do members have opportunities to learn about ethics?
Of the forty societies and twenty-eight institutes, just over half responded to the questionnaire in writing. Telephone follow-up brought the response rate to 100 percent, so that this report reflects the collective experience of all societies and institutes of The American. The results:
Just over half of the societies and institutes have standing ethics committees. Of the rest, most have ad hoc committees, with only a few having no arrangements at all.
Experience with the Principles was in general satisfactory, but a number of society/institutes found the wording vague and not specific enough.
The major concerns were about implementation. Many small groups felt they were too closely knit to carry out ethics procedures in an objective manner. Confidentiality is a major concern, as are legal costs and the threat of lawsuits. Another concern is the drawn-out nature of ethics procedures.
Only eight groups reported experience with nonadversarial processes such as mediation, and only a few reported the use of an early warning system or a way of conveying rumors to render them useful in the ethics process.
Regarding education, only six institutes reported offering a course on ethics. Many view the teaching of ethics as part of training candidates in technique. Only a few groups make ethics issues part of their members' postgraduate education.
The survey showed that most society/institutes want an active link with the Joint Committee on Ethics, and almost all favor an ongoing ethics workshop at meetings of The American.
The subcommittees survey of the work of the Joint Ethics Committee included a review of the fifty-four cases brought before the committee for review, as mandated in the Provisions for Implementation. The vast majority of these cases, 81 percent, were the result of boundary violations, mostly sexual, between analyst and patient, with 37 percent involving sexual intercourse between a male analyst and a female patient. The remaining 19 percent included situations in which the patient felt injured by psychoanalytic treatment but no ethical violation was found (11 percent); one case in which the analyst failed to obtain consultation in a difficult treatment (2 percent); and three complaints unrelated to treatment of patients (6 percent). The subcommittee concluded from its review that both patients and the psychoanalytic community focus on boundary violations and the sexual abuse of patients, almost to the extent of viewing them as exhaustive of ethics violations. In consequence, other ethical issues are diminished in importance. The relatively small number of cases reported overall suggests that they are but a subset of all violations, and that the saliency of sexual and other boundary issues marks a case as more likely to come to light.
Much of the work of the Joint Ethics Committee can be traced to ambiguities in the Provisions for Implementation, as both local society/institutes and the committee have the authority to investigate and adjudicate ethics complaints. Quite simply, jurisdiction is unclear. In practice, the committee has referred almost all complaints to the local group, where these problems have vast repercussions. In the few situations in which the committee has itself undertaken the investigation and adjudication of a complaint, the results have been problematic. The subcommittee concluded that the committee functions best in an advisory and reviewing capacity, a function that has in fact eclipsed the committee's investigative and adjudicative role, which has virtually ceased. What remains is to amend the Provisions for Implementation to reflect this change. More important, however, is the need to increase the committee's availability to society/institutes forming their own standing ethics committees; local groups often need help in spelling out procedures for handling complaints.
Ralph P. Engle, M.D., chairs both the Joint Ethics Committee and the Subcommittee on Ethics Revision.
Ethics awareness is heightened only in those society/institutes where problems have surfaced. The subcommittee assumes that many more problems exist, and that sooner or later all society/institutes will face them. Indeed, a salutary trend finds psychoanalytic communities shifting away from denial; ethical problems today are far less likely to be swept under the rug. This new openness can be furthered through certain institutional changes. One such change is to make ethics a required course in all institutes of The American. The subcommittee's survey found that optional courses are not well attended and that the catch-as-catch-can approach to ethics training is inadequate — candidates can simply not be expected to absorb all they need to know in this regard from their supervision and from courses on technique. The leadership of the society/institutes must be convinced that ethics is at the very heart of training standards. One way to achieve this is by “teaching the teachers,” as most faculty members have themselves received no formal instruction in ethics. To help effect this, Paul Dewald will lead several ethics minicourses at the Los Angeles meeting. Dewald's Education Sub-subcommittee has drawn on the experience of those institutes that teach ethics to outline a number of ethics courses that institutes may adapt to their purposes.
Another goal of the revision was to strengthen the Provisions for Implementation and to make them more explicit and to the point. In large measure, this has been achieved. Revisions have gone through many drafts and have been reviewed by legal counsel. The latest draft is currently under discussion by Board and Council. The changes formalize the consultation, advisory, and review function of the Joint Committee on Ethics and emphasize the responsibility of each society/institute to adjudicate complaints. Members' responses to these projected changes will assure The American the best and most workable document possible.
Finally, bringing the Principles of Ethics into conformity with the Principles of Ethics of psychiatry, psychology, and social work, as well as rendering them useful to psychoanalysts, is a goal within sight. With the guidance of the Committee on Foundations, the subcommittee has drafted clear ethical guidelines on gift giving and the solicitation of gifts from patients. While most ethics complaints occur as a result of boundary violations, the subcommittee has noted the relative absence of complaints about impairment, together with an alarming lack of institutional response when indeed an analyst is impaired. These problems, widespread, are addressed by not a single society/institute. Although the question of whether impairment is in fact an ethics issue has not definitively been answered, the Principles clearly include it as one. This is an area that needs to be addressed in current discussions.
Revising and improving the Principles of Ethics and the Provisions for Implementation has taken work and will require more, but it is not the hardest part of the task at hand. Unless candidates, faculty, and the membership generally can be made more aware of ethics issues through effective teaching, this effort at ethics revision will not flourish. Consequently, the Subcommittee on Ethics Revision has dedicated itself to remaining in existence until solid evidence appears that its work has taken root and is flowering. Meanwhile, the members of the subcommittee, particularly Paul Dewald and James Robinson (who head the Education and Principles Sub-subcommittees, respectively) can take pride in having prepared the ground so well.