Progress in Ethics Code Revision

The Committee to Revise the Code of Ethics of the American Psychoanalytic Association has nearly completed its assignment. The committee was appointed by Board Chairman Marvin Margolis and President Judith Schachter in 1994. The committee is now ready to present a recommended draft of the “Principles of Ethics and the Provisions for Implementation” of the code to the Council for feedback and ultimate approval in May 1998. The draft will then be submitted to the membership at large for discussion and ultimate ratification.

A Guide to Using the Code

The committee's major remaining project is the development of a Casebook in Ethics, which will translate ethical concepts into clinical examples, make the code more user-friendly, and render the code understandable and alive for both students and practitioners. The editors of the casebook include committee members Katherine A. Brunkow, Murray T. Charlson, Paul A. Dewald, Glen O. Gabbard, Margaret Keenan, Katherine MacVicar, and Ernest Wallwork. The casebook will present an ethical situation in psychoanalytic practice, a discussion of which ethical principles apply, and competing interpretations and differences of opinion. It will also include possible questions to serve as a teaching guide.

To this end, the committee solicits from the membership at large appropriately disguised vignettes illustrating ethical questions, situations, or experiences typical of problems encountered. The committee seeks contributions from the individual psychoanalyst or faculty member involved in clinical work, supervision, or class teaching, as well as administrators of institutes and societies. Vignettes should be sent to the central headquarters of the Association, c/o the Subcommittee for Ethics Revision.

To illustrate the format of such vignettes, here are two examples.

Vignette: Impaired Ability vs. Confidentiality

As ombudsman of your local psychoanalytic society, you are approached by a psychoanalytic candidate who is in training analysis with a senior and well-respected training analyst. Over the past months, the analysand has noticed that his analyst is losing weight, appears increasingly pale and feeble, has a chronic and persistent hacking cough and, from time to time, has labored breathing. He has mentioned these observations during the course of his analytic associations and is concerned about the welfare of his analyst.

The analyst's response has been to interpret his observations and concerns as a manifestation of negative transference and a death wish related to the death of the analysand's father when he was an adolescent. The analysand has consulted with several institute faculty members about the situation and has been told that his concerns are matters for his analysis and that he should go back and “take it up there as part of your treatment.”

You inquire of the institute director as to the health status of the training analyst. You learn that many are aware the analyst is significantly and terminally ill with a progressive cancer, but he has expressed the wish to maintain the knowledge of his illness in confidence and to continue to practice as long as possible.

Is this an ethical violation? If so, which principles are involved? If not, what is the justification for maintaining the current situation? What options does the ombudsman have in this situation? What should the institute directors and officials do?

The newly revised Principles of Ethics provide three guiding statements that clearly apply to this situation. The code suggests that

if impairment within the psychoanalyst, however evidenced, is threatening or disturbing to the quality of work, he/she should seek remedial measures so as to avoid any compromise of the ethical care of the patient. (Section C, Preamble)

Further,

A psychoanalyst is not ethically obliged to reveal or deny an illness or disability, the existence of which could affect others. If an analyst is officially notified by a representative of his institute or society that a possible impairment of his/her clinical judgment or ability exists, the analyst should seek consultation from no less than two colleagues, which can include medical specialists acceptable to the notifying body, and release their recommendations

to it. If such impairment is found to exist, remedial measures should be followed in order to prevent a degradation of ethical standards of care. (Section C-4)

During direct or indirect consultation, a psychoanalyst can ethically intervene on behalf of the colleague's patient if the analyst believes the colleague to be conducting him or herself unethically toward the patient or to be impaired in a way that threatens the patient's welfare. (Section D-3)

Vignette: Questions of Boundaries

In the course of her analysis, an analysand is disturbed to hear that a friend is profoundly troubled and confused by what is happening in her own analysis. There are stories of boundary violations that are not being analyzed. The analysand doesn't know what to do to help her friend. What should the analyst, the analysand, and the friend do?

First, the situation cannot be ignored. Assuming that the situation receives whatever analytic attention is useful, it is also necessary for the analyst to exemplify in analytic practice the principle that “psychoanalysts should strive to protect against any practice of psychoanalysis … that demonstrates an absence of professional competence or the compromise of ethical standards” (Principle D.) It is ethical for the analyst to give advice to the analysand about whom to consult about assisting her friend.

Second, if the friend is able to discuss the situation with her own analyst, consultation needs to be arranged to determine if the analysis can be re-established with boundaries and analytic

frame such that an analytic process can address the friend's needs and analyze the boundary violation. “When the analytic frame is threatened … the psychoanalyst should … seek consultation and/or terminate the treatment with referral” (Section C-3).

Third, in whatever way it can be arranged, the friend should promptly seek consultation with or without the knowledge of the analyst. “A psychoanalyst can ethically consult with a patient of a colleague without giving notice to the colleague” (Section D-1).

During a direct or indirect consultation, a psychoanalyst can ethically intervene on behalf of a colleague's patient if the analyst believes the colleague to be conducting him/herself unethically toward the patient or to be so impaired as to threaten the patient's welfare. (Section D-3)

While there are other issues involved, such as assistance to the friend's analyst, the four principles quoted all pertain to providing help for the analysand and her friend, and these are the first order of business.

Four Years of Progress

Under the chairmanship of Ralph Engle, the committee began its work in the spring of 1994 by dividing into three subgroups to address the need to vastly revise the “Principles of Ethics” and “The Procedures for Implementation” of the code and, most important, to educate analysts about ethical considerations.

At the time of the committee's beginning deliberation, only six institutes in the Association had a formal course of ethics on their analytic curriculum. Currently, 26 of the 29 institutes have formal course instruction to raise consciousness and develop awareness of the importance of ethics in the practice of analysis. This sustained attempt to raise consciousness on the importance of ethical issues included the development of eight arguments as to why each psychoanalytic group needs to address the importance of ethics:

1. People are becoming aware that ethical violations occur more frequently than was previously acknowledged.

2. Consciousness-raising and prevention of ethical conflicts are easier and less expensive to accomplish than dealing with a violation after it has occurred.

3. Awareness and concepts of professional ethical issues have become more sophisticated and less limited to “bad behavior” than previously.

4. The role of the analyst and the analyst's behavior in the development and working through of an analytic process have received increased recognition, along with the importance and ubiquitousness of the analyst's countertransference and continuing need for self-observation.

5. The importance given these issues by the organization in question—whether it be a society, an institute, a study group, The American as a whole, or even in consultation situations — must be demonstrated to colleagues and the public in general.

6. Society in general has become more litigious.

7. Awareness of ethical violations affects the identity of analysis and analysts in the eyes of the public and those of students and colleagues.

8. An open forum and group process is important in the professional sharing of ethical concerns and differences of opinion.

The committee has presented consciousness-raising workshops and study groups at the meetings of The American. Additionally, it has developed models of curricular teaching, accompanied by an appropriate bibliography, for three levels of intensity: minimal, moderate, and maximal.

The eight statements and three teaching programs were circulated to individuals at every institute and society and served to enhance interest in the issues and recognition that they were important. Individual members of the committee made themselves available for consultation with any person or group who asked for help. The topics proposed, and the references listed, represent tentative suggestions from the Subcommittee for Ethics Revision. It is assumed that the institute teacher of the course will add or delete topics in keeping with his/her preference and will select from the suggested readings those that best suit his/her course plans. Where books are listed, it is assumed the course teacher will select the specific chapters or page references that best deal with the course topics.

Principles and Procedures

The Subcommittee to Develop the Principles of Ethics, chaired first by James S. Robinson and subsequently by Bernard Rubin, devised an expanded, more specific, and more appropriately complex statement of principles, which are not to be thought of as rigid rules but as guidelines. These principles can be used by analysts to observe their own as well as colleagues' performance and activities. The statement includes an elaborated preamble and introduction to the importance and implications of the code and a general sense of how it can be helpful to the individual psychoanalyst.

The ethics code now recognizes a hierarchy of relative importance of its different sections. First is an analyst's responsibility to patients. Second is responsibility for issues of confidentiality and potential conflicts of interest. Third is the need to uphold the dignity and honor of the profession and accept its self-imposed disciplines. Fourth is responsibility to students and colleagues and to the professional community. Fifth is the relationship between the analyst and the community at large. Each of these sections has an explanatory preamble as well as specific individual recommended standards. The spelling out of these standards is meant to encourage excellence of action and to increase professional freedom for the individual.

Implementation

The Subcommittee on Implementation of Ethical Standards, chaired by Ralph Engle, has expanded the description of procedures both at the local and national level. This description emphasizes the need for a standing, rather than ad hoc, ethics committee to deal with these issues. The document includes an expanded discussion of the issues of due process in handling of ethical complaints. The committee has made an effort to spell out the procedures that are considered optimal and to develop a code with appropriate legal safeguards. To this end, The American's attorney, JoAnn Macbeth, was a consultant throughout the process of developing the standards.

The implementation document also discusses non-legal procedures and encourages the development of local processes of mediation and non-adversarial management in hopes of avoiding expensive and time-consuming legal tangles and complexities.

Drafts of both the principles document and the implementation document have been circulated to the institutes and societies and will be presented at the meeting of The American in Toronto for discussion and approval. The last revision of the Ethics Code occurred in 1984. The current effort represents a significant advance for The American. In this effort the ethical codes of other mental health groups have also been consulted and, to the extent appropriate, incorporated into the current version.