Analysts throughout the United States have seen what we are now calling “ethical boundary violations” by their colleagues and friends. Articles appear with some frequency in our journals and even in the local and national papers. Our institutes offer ethics courses; discuss and revise guidelines; and struggle with policing, teaching, and adjudicating cases against analysts. Our relationship with our own colleagues, as well as with the public, has been called into question. The complex issues inherent in the ethical difficulties appearing all too regularly in our national and international psychoanalytic societies contributed to the urgent need for the recent revisions of the ethics guidelines of the American Psychoanalytic Association and the publication of the Ethics Case Book.
The recent changes to the guidelines are the third such revision, updating the 1975 and 1983 versions. The new revisions attempt to reflect the shift and evolution of our moral sensibilities as well as deficiencies in the previous editions of the code. Ethics and morality are neither constant nor static over time. The early history of analysts' behavior is replete with what we now view as transgressions: treatment of their own children and involvement in their patients' lives financially, personally, and sexually. Such activity, well beyond the scope of the therapeutic analysis, has a history including Freud, Jung, Klein, and Kahn.
After the latest revision of our ethics code, a subcommittee of the joint ethics committee was established to develop the new Ethics Case Book that has now been sent to all members of the Association. Edited by Paul Dewald and Rita Clark with the help of a committee of sixteen other members, this case book is intended to supplement the development and the implementation of the new code.
The case book work group, headed by Dewald, began in 1994 to develop more formal ethics classes to be taught at our different institutes. The subcommittee's intent was to formalize, at different levels of teaching intensity, curricula for ethics classes that might last anywhere from five to fifteen sessions. Such classes could be supplemented further by workshops at the APsaA national meetings. As a result of this effort, says Dewald, twenty-seven institutes now teach formal courses on ethics.
Dewald's subcommittee hopes that the case book will encourage in-depth discussions of ethical issues as they might arise within psychoanalytic institutions. For this reason, many of the cases used as illustrations in the case book lack explanations or detailed discussions. Dewald and his subcommittee intended the case book's examples to encourage analysts and candidates to struggle with these problems in vitro before they arose in their own institutes and societies. The codes detailed and examples given in the case book are specific for psychoanalysts, and as such may be in conflict with ethical guidelines of some of our component professions, such as psychologists.
Abbot A. Bronstein, Ph.D., is a member of the TAP editorial board. He is on the faculty of the San Francisco Psychoanalytic Institute and chairs its Special Programs Committee.
Problems within our institutions involve the ethics both of the individual analyst or candidate and of the individual institute and society. In recent cases, institutes' by-laws have been challenged. They have had to form new structures to cope with the increasing dilemmas posed by ethical and boundary violations and charges brought against members.
BOPS has required that each institute have a standing ethics committee, and also recommends a standing Patient and Analyst Assistance Committee. The assistance committees attempt to address and resolve concerns in a confidential manner before a formal ethics complaint would need to be filed.
Dewald suggests that such committees comprise training analysts, other analysts within an institute, and candidates. He hopes for an “evolution of ideas and ethics to protect both the public and the profession” in an era when the “loss of normal and ethical judgment is shocking at times.”
Whether or not analysts are behaving unethically more frequently today, we certainly need to be aware, vigilant, and thoughtful about the pernicious effects of our own and our colleagues' behaviors. Douglas Kirsner, in his book Unfree Associations, writes of ethical misbehavior that was individually and institutionally sanctioned in many of our well-established institutes and from many of our most respected colleagues. Such handling of ethical problems damaged our field under the guise of maintaining standards and a kind of analytic purity.
Generally, our efforts to keep standards of behavior and standards of training high seem well motivated. Yet when analysts or institutes know of violations or suspect ethical breaches and do not act, the effect is dangerous and destructive for us, our patients, and our analytic communities. These problems of ethical misbehavior and institutional mishandling are not unique to APsaA. In France, Great Britain, and South America, such problems are no less prominent and no less destructive. Each institute seems to have its stories of unethical behavior and destructive consequences for patient, analyst, and analytic society.
Photo by Michael Coleman
The gross as well as the subtle dangers of “enactments” in ethical boundary violations with our patients have become a focus of courses on ethics in England as well as in San Francisco. Betty Joseph, who teaches a portion of the ethics course at the British Psychoanalytical Institute and Society, described psychoanalysis as a profession with certain occupational hazards.
We ask our patients implicitly to bring their problems into the room with us, says Joseph. This, however, influences the analyst to act in certain ways, which at times draw the analyst into behaviors that are anti-analytic and may create ethical problems. Here the emphasis is not on the analyst whose character may lead him to exploit patients sexually, financially, or in other ways. It is on the gray area between “technical errors which are getting dangerous and things which are actual dangerous acting out,” said Joseph. We must help ourselves and our students understand these gray areas and where the boundaries lie.
Members of institutes across the country agree it is necessary to monitor the entire ethics process carefully. Nevertheless, fear of reporting, fear of lawsuits, and fear of the stigma have interfered with protecting our profession and our patients. To this end, Dewald hopes the Ethics Case Book can be an aid in the living, organic evolution of ethics at our psychoanalytic institutes and will help us to expose and discuss our work truthfully and thoughtfully to colleagues throughout our careers.