The Ethics Committee of the Psychoanalytic Consortium sponsored a panel on “The Role of Consultations in the Prevention of Boundary Violations” which was presented with notable success on both coasts: at the Division 39 meetings during the American Psychological Association Convention in San Francisco on August 14, 1998, and at the Fourth International Conference on Sexual Misconduct, hosted by the Boston Psychoanalytic Society and Institute in Boston, on October 3, 1998.
The Psychoanalytic Consortium is a forum where delegates from the four major psychoanalytic associations in this country can meet regularly and address issues of common interest, such as managed care, healthcare legislation, or accreditation. Under the assumption that ethical practice is an issue that does, or ought to, unite all of us, Marvin Margolis and I founded an ethics committee of the Consortium in 1996. Within the committee, the American Psychoanalytic Association has been represented by Ralph Engle; The American Academy of Psychoanalysis by Sylvia Olarte and Josef Weissberg; The National Membership Committee on Psychoanalysis in Clinical Social Work by David Phillips; and Division 39 by Jody Messler Davies and myself.
The committee sees its mission as educational rather than regulatory. Rather than receive complaints or impose rules, we seek to offer information and to maintain an ongoing, consciousness-raising conversation about ethical issues in psychoanalytic practice. We have identified areas of concern:
Boundary violations.
Managed care issues such as confidentiality, gag rules, or abandonment.
Confidentiality issues involved in published case study reports or in the maintenance of patient records.
Impaired analysts, how they are identified, and what actions may be taken.
Issues related to the recruitment of former patients by foundations and lobbying groups.
The role of routine or mandatory consultation in clinical practice.
The Ethics Committee has examined the ethical principles and standards of the four component professional organizations of the Consortium. We have drafted a statement on confidentiality, which has been endorsed by the Consortium's board. We are developing a list of essential readings to recommend on the issues of boundaries and boundary violations. Thus far, our major effort, in order to promote a preventive approach to the issue of maintaining ethically sound clinical conduct, has been sponsoring an initiative to establish regular consultation as a voluntary standard practice. The members of the Board of the Psychoanalytic Consortium are personally committed to undertake two consultations on their clinical work in the next year.
Mindful how the privacy and intensity of the analytic process challenges every analyst to manage highly evocative, destabilizing, or enticing moments in the treatment relationship, we believe that the establishment of a regular practice of consultation — perhaps two or three a year — by all analysts (and ultimately all professional psychotherapists) would support the individual practitioner in maintaining a check on personal vulnerabilities, blind spots, or interactive lapses in clinical work.
Aside from extreme cases of predatory clinicians, we assume that most ethical violations could be prevented by the early detection of proto-ethical dilemmas arising and intensifying in the course of a treatment relationship. We hope, and would predict, that a clinician's regular practice of consulting with a colleague would serve as a check against (transient or persisting) states of denial or dissociation that can blind an analyst to a “slippery slope.” Such a normative practice of regular consultation, by clinicians of all levels, could be a wholesome opportunity for self-reflection, self-renewal, the sharing and building of ideas out of otherwise isolated clinical experiences, and a responsible ounce of prevention for patients, providers, and the professions who share a common interest in a prophylactic approach to ethical lapses.
We do not regard such a program of consultation in the spirit of policing. Although not necessarily corrections of conspicuous error, consultations may correct the course of a clinical voyage — serving as a check on our vital instrumentation, especially apt as analysts recognize and employ more relational and interactive elements of therapeutic action.
We do not intend to establish a cadre of special experts in ethics, or a new echelon of training analysts, who would conduct consultations. Rather — except in cases in which complex ethical conflicts or egregious ethical breaches are already evident — we have in mind the value of each of us (whatever our age, experience, or seniority) consulting whomever we respect and trust as a colleague in our community. We advocate consultation in the spirit of times set aside regularly, and with high seriousness, for this specific purpose.
The Fall 1998 panel on boundary violations included papers by Barbara Pizer and Glen Gabbard and a discussion by Jody Messler Davies. Pizer's paper focused on the state of mind of the analyst, the impact of a history of trauma on the mind of the analyst during clinical work, and the subjective signs (affects, defensive affects, and defenses such as “cognitive flummoxing”) that a self-monitoring analyst may read as signals to seek consultation. Gabbard addressed the more extreme cases of therapists or treatments that have already gone awry, and the various ways in which consultations may be resisted or subverted by the consultee. He further developed themes of the consultant as both superego and support and identified the merits of various forms of consultation. Davies' discussion focused on our identification with a normative practice of consultation. She offered a rich clinical example of how consultation may serve not only as a check on the analyst but also as a liberating and reassuring connection in the midst of challenging clinical work, when the slippery slope is more like the point of an inverted cone and any clinical choice in any direction feels to the analyst like a potential downhill slide.
Stuart A. Pizer, Ph.D., ABPP, chairs the Psychoanalytic Consortium's Ethics Committee. He is a supervising analyst and faculty member of the Massachusetts Institute for Psychoanalysis and a member of the New York Freudian Society. He is also a clinical instructor in psychology at Harvard Medical School and a member of the editorial boards of several psychoanalytic publications.
The panel presentation was received enthusiastically in San Francisco and Boston. Now the Ethics Committee of the Consortium urges members of each association to consider in earnest the value of routine consultation as an enhancement of clinical work, a source of personal comfort or growth, and an analyst's act of responsibility toward self-care and the care of patients.