For many years it was assumed that psychoanalysts adhered universally to a high standard of ethical behavior, both professional and personal. Ethical professional conduct was considered a given, and any deviations that came to light were considered anomalies, aberrations attributed to sociopathic bad apples. Only the grossest of conduct disturbances seemed to count as violations.
In response to a number of nationally publicized cases in which psychoanalysts were accused of violating ethical standards — similar violations had occurred locally—the St. Louis Institute undertook to evaluate its curriculum with regard to ethical issues. This decision was influenced by the fact that a senior faculty member had been appointed to The American's Subcommittee on Ethics Revision. Recognizing that analysts are inherently neither more nor less ethical than other professionals, and that ethical issues may involve subtle behavior patterns as well as more obvious ones, we decided it was appropriate to introduce psychoanalytic candidates to these issues as part of their formal training.
In reviewing the institute's curriculum, we became aware that the topic had never systematically been addressed. The expectation, probably naive, had been that ethical problems of a characterological nature would be recognized during the candidate selection process and that more specific ethical issues would be dealt with and resolved during the training analysis. There was a tacit assumption that ethical questions were being addressed piecemeal, in technical or clinical seminars, clinical case conferences, and individual supervision. It was clear, however, that the topic of ethical conduct and the code of ethical behavior for psychoanalysts was being addressed only minimally, if at all.
Several articles in the psychiatric and psychoanalytic literature survey the incidence of ethical violations (particularly the sexual abuse of patients) and indicate that incidence to be far greater than generally acknowledged. An element of denial seems operative in analytic and psychiatric circles that is analogous to the attitude that once prevailed with regard to the physical and sexual abuse of children. It is also clear from the literature that only a small percentage of cases of major patient abuse ever reach public awareness. It is notable also that many ethical questions are scarcely mentioned in the literature.
In the St Louis community, instances of flagrant violations of ethical standards were widely known, but it had taken years of expensive legal maneuvering to correct individual cases. In some instances, no adequate resolution was ever reached. It was decided, therefore, that prevention through education would be more effective than dealing with violations once they occur.
Because we did not wish in any way to diminish the importance of psychoanalytic ethics, it was decided to teach the subject not as an elective but as a course required for graduation. Initially the course was given as an eight-week seminar in the fourth year. Organized and run by a senior analytic instructor, the course took the form of a relatively informal discussion group. Although a list of suggested topics and a bibliography were circulated in advance, the readings served primarily as a takeoff for group discussion rather than as texts for intensive study. Discussion topics included sexual and nonsexual boundary violations; fees and other financial matters; confidentiality; records and record keeping; knowledge of a colleague's violation of ethical standards; reports to others of abuse or criminal action either by the patient or directed toward the patient; the analyst's values and biases; the analyst's countertransference in the face of objectionable behavior by the patient; the analyst's implied promises; informed consent; consultation (sought by either analyst or patient); personal events in the life of the analyst; illness and disability in the analyst or in a colleague; the writing up and publishing of case material; the handling of gifts; and posttermination contacts.
The initial task of the seminar was to establish a comfort and openness that would allow participants to reveal honestly their questions, doubts, and concerns about ethical values. To foster this sense of openness, the seminar leader had to be willing to share personal countertransference responses to patients and to describe ethical dilemmas actually encountered in clinical practice.
That certain situations admit relative rather than absolute responses and that no one has a monopoly on “correct” behavior was repeatedly acknowledged. Attention was also focused on the difference between countertransference responses and fantasies, on the one hand, and, on the other, behavior that violates ethical standards. The former are ubiquitous but, if not recognized and acknowledged, may become a slippery slope leading to the latter.
The eschewal of moral absolutism did not preclude the recognition that valid common guidelines do exist. Although the strict limits to behavior may vary in different situations, the important point is to recognize the significance of what the analyst does or does not do and the implications for the analytic situation, regardless of the details of a particular set of behaviors or attitudes.
Although few moral and ethical absolutes were accepted universally by the group, the seminar had a consciousness-raising effect on candidates, particularly regarding topics that had never before been considered ethical issues or that evoked widely varying attitudes. Among the more difficult questions considered was determining what action is required in response to an analysand's report of unethical behavior, particularly when it involves a colleague or friend. Equally difficult is deciding whose responsibility it is to correct situations involving a chronically ill or impaired analyst, faculty member, or training analyst.
In implementing a code of ethical conduct, it is important to distinguish a punitive and controlling approach from an empathic and therapeutically helpful attempt to deal with the offending analyst. This is a particularly difficult issue when the analyst in question is significantly impaired and problems of friendship or collegiality compound the situation. Managing such situations with minimal psychic trauma to the person in question, and minimal damage to friendships and collegial relations, takes an extremely delicate hand.
There was a general sense among faculty and candidates that the establishment of a required ethics course communicated the institute's sense of the importance of these issues and its serious concern that analysts maintain high ethical standards. Because professional learning involves identification with the teacher, to have senior faculty members indicate these concerns was felt to be important in the development of candidates. The sharing of personal experiences by a senior faculty member tended to make candidates less defensive or ashamed in revealing their own questions and experiences. It promoted both the establishment of a psychoanalytic superego and a willingness to engage in self-observation and self-analysis.
A consensus developed that it might be preferable to introduce the topic earlier in the curriculum. The next time the course was offered, it was introduced at the beginning of the second year of the program, though the number of class sessions devoted to the topic was for logistical reasons reduced from eight to three. The participants generally agreed that this arrangement did not allow sufficient time for a comfortable group process to evolve and a genuine and deep discussion of the issues to occur. Three sessions
were sufficient only to alert candidates cognitively to the multitude of ethical issues, but not to deal with them substantially.
The subject of ethics and ethical standards is only now receiving the attention it deserves. As analysts emerge from a pattern of denial, The American is at work revising and explicating its code of ethics, and plans are afoot to offer model curricula for consideration by the various institutes. With regard to the latter venture, long overdue, the experience of the St. Louis Institute will be of great help.