One of the major changes in our Association in the past decade is our approach to ethical issues in clinical practice, training, and research. In the past, too frequently, ethical breaches were not reported and were even covered up to protect colleagues. At times, when complaints did surface we lacked provisions in our code to cover even some very egregious ethical breaches.
When analysts had sexual relations with patients or financially exploited them, the situations were often not adequately addressed at the local or national level. The scandals associated with these events played a significant role in discrediting our science and profession among local communities. Despite the steady progress made in the American to promote ethical conduct (especially since the publication of our first ethics code in 1974), there was still far too much denial, secrecy, and even cavalier indifference toward ethics in our ranks.
Many factors led finally to our decision in the 1990s to deal with unethical issues in a more open, comprehensive manner. There was a growing public awareness, as well as awareness among our members, of the ubiquity of abuse of children, women, and the elderly in our country. This included the painful acknowledgement that there were psychoanalysts among the abusers. An increased interest in the analyst's countertransference also focused our attention on the contribution of personality issues to boundary violations. The arrival of large numbers of female candidates in our midst helped us confront this problem. Most victims of analytic boundary violations were female mental health professionals, and our female candidates were in the vanguard of protest. Finally, we overcame our morbid fear of litigation and devised new legal strategies that were more oriented to help patients.
In 1994 a large subcommittee of the Ethics Committee was appointed to thoroughly review and revise the existing ethics code. The group included colleagues and candidates and was chaired by Ralph Engle, the newly appointed chair of the Ethics Committee. The subcommittee consisted of Katherine Brunkow, Murray Charlson, Rita Clark, Paul Dewald, Glen Gabbard, Dorothy Holmes, Irving Humphrey, Jacob Jacobson, Margaret Keenan, Paulina Kernberg, Katherine MacVickar, Malkah Notman, James Robinson, Cynthia Rose, Bernard Rubin, Evangeline Spindler, and Ernest Wallwork.
The subcommittee undertook the creation of a casebook of clinical vignettes with discussion to illustrate the possible application of the code. It also conducted a survey, which revealed that only six out of twenty-nine institutes offered an ethics class for candidates. Many institutes did not even have an ethics committee. The subcommittee assumed the responsibility of creating model curricula for ethics courses and fostering the establishment of ethics committees.
As a result of these efforts, every institute in the American today has an ethics course. Currently the revised Code of Ethics is receiving its final local discussions prior to vote at Board and Council. Special thanks are due to Bernard Rubin and Ernest Wallwork for the final rewrite and editing of the code.
The Ethics Casebook will be published in the spring of 2001. It is the first such casebook published by any psychoanalytical organization. Editors Paul Dewald and Rita Clark applied their vision and commitment to the completion of this project. Both the code and the Casebook will be issued in looseleaf binders so these works in progress can be periodically updated.
Gradually the public is becoming aware of the very substantial steps that we have undertaken to establish our profession and science on an increasingly ethical basis. And what of our future? Ethics must remain a high priority in the concerns of our Association and our local components. We can never again retreat to denial and avoidance of our responsibility when patients and students are being abused by our own colleagues. The colleagues who err are frequently old friends; yet we must overcome our natural reluctance to report them to the appropriate committees that deal with boundary violations.
The American's Ethics Committee will continue its enlarged range of activities. Central to its mission, it will review ethics complaints, which first are adjudicated at the local level. The committee will continue to advocate the establishment of joint society/institute ethics committees in every one of our forty-three centers. Separate committees are wasteful of our limited resources. Smaller centers may require supplementary personnel from larger nearby centers; perhaps financial support may also be required. We cannot allow financial considerations or lack of personnel to provide an excuse for not dealing directly and promptly with ethical concerns.
It is tempting at times to shunt this kind of problem off to the ethics committees of other mental health professions. Unfortunately that strategy prevents our local groups from having the difficult but beneficial experience of facing and dealing with their own ethical problems.
Finally, analytic understandings may be required to fully work with the havoc created by major boundary violations. The Ethics Committee will encourage the establishment of ethics courses in both initial and advanced seminars of candidates. The committee will make itself available by telephone and visits to help local ethics committees improve their effectiveness. National workshops will continue to be available at every meeting.
Despite this array of initiatives, we are left with the painful reality that only a small fraction of ethics infractions are ever brought forward for discussion at either the local or national levels. In fact, the cases that do come to our attention are predominantly the most egregious sexual boundary violations. By the time ethics complaints are brought to committees, grievous harm has often been caused to patients and even to the analysts. The majority of sexual boundary violations are still not being reported. Meanwhile a vast array of other ethical problems are not being adequately dealt with, e.g. boundary violations in the supervisory situation, financial exploitation of patients, and abandonment of patients. Ethics committees' legalistic protection of the rights of colleagues and need for adversarial procedures discourage complainants. They are necessary, but hardly sufficient to address the problem of boundary violations.
In view of the above considerations, the Ethics Committee has embarked on a program to encourage local societies and institutes to deal with boundary violations in a new, additional way by the establishment of committees to assist colleagues and patients. Such committees are already functioning in St. Louis and Michigan; many others are in the planning stage. These committees are being established
Ralph Engle, M.D., chaired the Ethics Committee from 1994 to 2000. Marvin Margolis, M.D., Ph.D., past president of the American, is the current chair of the Ethics Committee.
as peer review groups for the purpose of early consultation and mediation in a confidential setting. No lawyers will be used. The emphasis is on finding cases early. This service will be widely publicized in the community. We suggest that patients be told that if they have questions about the propriety of their treatment, they should first speak to their analyst. If this is not satisfactory, patients should turn to their local institute's Colleague and Patient Assistance Committee for a confidential consultation and possible remedial help. (Colleagues are also encouraged to report possible unethical situations or even to seek consultation about their own behavior.) Many professional groups provide cards with this information to be placed in waiting rooms. The same announcement can be annually published in our newsletters.
For the sake of enhanced objectivity, we suggest that complaints be heard by a team of two colleagues. The team will speak to both analyst and patient. Sometimes spouses or close friends are involved directly in the mediation process to great advantage; patients are often in need of their support to make a complaint.
If the complaint is corroborated, a plan for remediation will be proposed. The plan would often involve recommending a new analyst for the patient and a return to analysis for the analyst. It might involve apologies and financial restitution. The plan might also place limitations on the analyst's educational responsibilities. It is therefore recommended that all complaints be reviewed by the institute's central elected official, such as the education committee chair, who would participate in forming the remediation plan.
The team will monitor the rehabilitation program and recommend restoration of privileges for the analyst, if such restrictions had been initially recommended. The team will stay in touch with the complainant to provide whatever follow-up help might be indicated.
Sometimes mediation/consultation efforts are unsuccessful. The analyst may withdraw prematurely. The analyst may attempt to minimize the damage done while admitting the sexual boundary violation. In these cases we may advise the patient to pursue her/his complaint through our Ethics Committee. Many complainants of course may seek further redress through malpractice suits and/or complaints to professional licensing boards. This is more likely to occur if the mediation/consultation route proves insufficient to the patient's grievances.
The new direction of the Ethics Committee not only emphasizes continuing concern and care for the aggrieved patient, but also embraces the notion that ethical violations affect not only patients but their spouses and children as well. The fallout is even wider. The analysts' patients not involved in the ethics infractions, the community of analysts, mental health patients, even the general community may be affected. As an analytic community, we have only taken the first steps toward dealing with the devastating effect of ethics breaches in our communities. In the case of sexual boundary violations, spouses and children are often badly damaged. Some marriages have been destroyed. Spouses and children can feel confused, guilt-ridden, betrayed, and very angry. They frequently appreciate an opportunity to have consultation to help them deal with the painful reality and aftermath. Many will require continuing psychotherapeutic interventions.
“Ethics must remain a high priority in the concerns of our Association and our local components. We can never again retreat to denial and avoidance of our responsibility when patients and students are being abused by our own colleagues.”
Current and past analyst patients of proven unethical colleagues who have not been themselves abused also are upset by the scandalous revelations that first circulate as rumors but eventually become public. Many initially do not want to believe the allegations. In fact, many colleagues keep the information from them in order to “protect their analyses.” Other colleagues, who conclude that the unethical colleague was a very poor analyst, insinuate that all of the analyses of the unethical colleague were severely flawed as a result of their faulty treatment. The analyst's patients and ex-patients frequently are treated as “damaged goods” by the analytic community, or they feel this way themselves without too much external assistance.
Ethics committees have arranged meetings in some cities where analyst ex-patients can discuss these issues. Some of these report that they have heard such rumors but never discussed them with anyone. Such colleagues overwhelmingly report relief and frequently demonstrate that they have overcome the professional deficiencies of their analysts through further analysis or the normal continuing self-development of analysts.
Finally, there is the plight of our unethical colleagues. Most colleagues commit ethics breaches at times of special vulnerability. They may be remorseful and prepared to withdraw voluntarily from central educational functions during their monitored rehabilitation. They deserve our support. We need to learn how to differentiate such colleagues from the very chronic destructive boundary violators who lie, distort, bully, and even try to fool the monitoring teams. We have much to learn in this new area of institutional activity.
Since a few complaints may be frivolous or unduly vindictive, we need to protect the civil rights of colleagues. Our experience, however, is that most complaints have some basis in fact. We have to recognize that our responsibility is to protect patients, families, and psychoanalysis itself from those few colleagues who would betray patients and damage our credibility in the community.
While boundary crossings are inevitable and ubiquitous, ultimately we all have much to learn about psychoanalysis by studying these egregious issues. We can mitigate the amount and severity of damage by making this issue a priority. Through education and research we can help patients and colleagues identify the early warning signals of developing ethical breaches. Hopefully we can improve selection, enhance education, and deal with the challenging task of conducting an effective, good enough, ethical analysis.