Every member of the American Psychoanalytic Association has had experience with a functionally impaired faculty psychoanalyst — an analyst whose ability to do analytic work and/or teach is impaired by illness. Few, however, can report a compassionate and effective intervention on the part of their institute. Exposure to the problem occurs indirectly through reports from a patient, colleague, or friend, or directly when one is a patient, supervisee, or student of an impaired analyst. Frequently the exposure comes through observation of a colleague struggling to carry on his or her career despite serious illness.
The consequences of functional impairment are often grim. Training analyses have to be interrupted — or even worse, should be interrupted but never are, leaving analyst, analysand, or both despairing in silence. Supervision fails because the supervisor cannot pay sufficient attention to the supervisee's needs. Classes do not escape this sad phenomenon, despite their more public nature. Learning objectives give way to anger or pity and a sense of having been tragically cheated. In whatever setting, few want to “blow the whistle” on an already suffering human being.
When someone does bring the condition to the attention of the appropriate people, usually no one knows what to do. It is not uncommon for chairs of education committees or institute directors to employ seemingly benign neglect, hoping that the situation will somehow take care of itself or at least hold until a new administrator inherits the problem. Students are sometime queried but often feel that their progression might be hindered by getting involved. They deny or suppress their observations or feel, quite justifiably, that they are not the ones who should have to take care of such a problem.
Even when action is taken to confront an apparently impaired analyst, it frequently is in the form of informal intervention behind the scenes. Personal friends, former students, or even former analysands are asked to confront or monitor the sick person, with the idea that it would be cruel to bring in analysts who are not close to the allegedly impaired person. Some institutes are so small that there is no choice but to ask closely related analysts to be the ones to investigate. Frequently they return to report that they found nothing amiss or that they have turned things over to family or to someone else. These designees are usually unable to do anything.
There are several reasons for this situation in most of our institutes and societies. First, almost no institutes have a standing committee trained and prepared to assist impaired colleagues. Second, institute administrators feel that they are poorly equipped (or poorly indemnified) to begin a process that might lead to retaliatory legal action on the part of someone who is a colleague and possibly also a personal friend. They believe that anything from restraint of trade to defamation will be claimed. What the person intervening sees as an act of kindness, taken on reluctantly on behalf of others, becomes a nightmare in this fantasy. The glib phrase “No good deed remains unpunished” never seemed more true.
Although no accurate statistics exist, this scenario may never have progressed to the point that people fear, although there is no question that it is plausible. On the contrary, in some states there is a duty to report impaired physicians; such states grant immunity from lawsuits for doing so, and in a few states there is even a penalty for not doing so. (I know less about the case of impaired psychologists and social workers.)
A third reason is that where problems of aging or degenerative physical disease are involved, denial and disavowal defend against the feeling that “there but for the grace of God go I.” Fourth, analysts are concerned that they may get involved where there is a duty to report to state regulatory or licensing authorities, and they do not want to become involved in such matters. Fifth, the fact that the analyst may already be hard pressed financially deters action that might worsen his or her financial situation. Sixth, some of the impaired faculty analysts still maintain high positions in their institutes, and no safe and accepted means of challenging their authority exists. There are other reasons as well.
In December of 1993, Sandy Abend, chair of the Committee on Psychoanalytic Education, asked me as a member of that committee to form a study group to look into this widely acknowledged but little discussed problem. I invited eleven senior training analysts with administrative experience to join me, and to my surprise every one of these very busy people agreed to help: William Bernstein, Paul Dewald, Ralph Engle, Newell Fischer, Rhoda Frenkel, Eugene Goldberg, Eugene Kaplan, Morris Peltz, Paul Roberts, Lorraine Siggins, and Robert Tyson. Our group established a liaison between each institute of the American and one of our study group members. We then assessed what existed in the way of policies and procedures or modi operandi at all of these institutes.
We learned that most institutes have no systematic procedures to deal with impaired faculty. Virtually all institutes that have required re-appointment of training and supervising analysts rubber-stamp the re-appointment. When it is recommended that an impaired faculty analyst seek help or retire, compliance is almost always on a voluntary basis, and frequently there is no compliance. Outside resources, such as physician assistance programs, legal consultation, or consulting with the American, are seldom used, but when they are it is usually a positive experience. Several institutes had worked out elaborate procedures but balked at the prospect of appearing too legalistic. Some institutes refer their impairment cases directly to their ethics committees, which seems an unkind conflation of two distinct entities. A few institutes involve candidate representatives in procedures involving impairment.
We collected anecdotal material from around the country and learned little that was positive. Most cases ended in stalemate until the analyst became so impaired that things took care of themselves. The impaired analyst's practice terminated suddenly, with no advance mechanism in place to assist the stranded candidates.
Politics often interfered with carefully thought out plans to assist impaired senior analysts. Analysts who did cooperate with assistance and regained their health were shunned subsequently. Where a training analyst appropriately lost that status because of impairment, candidates became enraged. In other cases they were enraged because no one did anything about an impaired training or supervising analyst.
Soon after I launched the study group, I became active in a new Chicago Society ad hoc committee, appointed by then-president Harvey Strauss and chaired by Ronald Krasner, to study and make recommendations concerning this problem. Nathan Schlessinger also served in the group. The Chicago committee developed a model for a Standing Impairment Committee (The Chicago Model) with twice-yearly input from the APsaA study group.
Jerome A. Winer, M.D., is director of the Chicago Institute for Psychoanalysis, where he is a training and supervising analyst. He is a professor of psychiatry at the College of Medicine of the University of Illinois at Chicago. He is also editor of The Annual of Psychoanalysis.
The final version of that plan was adopted as an amendment to the by-laws by the Chicago Psychoanalytic Society last November. The society had considerable legal consultation, and the document's tone is admittedly legalistic and “watchdog” sounding, but the amendment is systematically clear and widely applicable.
At the December 13, 1998, meeting of the Board on Professional Standards, I proposed that:
The American require each institute to establish a standing Psychoanalyst Assistance Committee in accordance with the laws of its state governing the practice of medicine, clinical psychology, and clinical social work.
The Board on Professional Standards establish a standing Psychoanalyst Assistance Committee (PAC) to advise institutes in matters concerning the establishment of such impairment committees and to assist institutes in seeking the help of other institutes when the local institute's PAC can not function because of special conditions. This may be particularly applicable to small institutes that can arrange a consortium to help one another. It will not be the responsibility of the American's PAC to deal with individual impaired psychoanalysts but to serve in an advisory capacity to the local groups.
The American's PAC will collect and disseminate information about advances in techniques and approaches for dealing with problems of functional impairment and will promulgate information about successful ancillary organizations and services that may exist.
Response was very positive. The issue is scheduled for further discussion and vote at the May BOPS meeting.