The taboo we analysts have that makes it difficult to talk about the storms of our personal lives often keeps us in a posture of denial of dysfunction or impairment. Many analysts go on as if there were no ill, stressed out, demented, or otherwise functionally impaired practitioners. We have our share of impaired persons, just like every other segment of society, and like everyone else, we engage in denial and even outright deception to avoid dealing with the resultant difficulties. This climate of avoidance helps no one and can lead to many problems that not only affect us, but also our colleagues, students, supervisees, and patients. When this denial breaks down and there is a scandal, the image of our profession in the larger world suffers considerable damage.
Patients often develop such intense positive transferences that they perceive us as invulnerable to the usual vicissitudes of life, never aging nor losing our capacities. Our unrealistic self-protective defenses can lead to egregious errors and serious consequences.
We have been exaggerating to make the point that psychoanalysts individually or collectively cannot be in a state of denial regarding impairment of our professional functioning.
Consider the tale of this psychoanalyst. He discovers a lump and consults a doctor. He is told that he has a medical problem that can be expected to get worse. He starts treatment, scheduling it for hours when he is not in his office. He continues to work and tells no one. When friends ask about his persistent fatigue he blows them off with a lascivious or self-aggrandizing joke about why he is so tired. When patients comment, he interprets their aggressive feelings towards him. He does not want to burden anyone else with his problem. He has a generally downhill course over an extended period of time but continues to work and to see new patients. He notices that referrals are not so plentiful and he wonders if anyone suspects that he has a problem. He becomes morose and distrustful. He feels increasingly isolated.
He has told a few close friends but has sworn them to secrecy, and they respect his wish to keep his medical problems to himself. They try to be supportive and optimistic. No one has the heart to suggest that he had better think more realistically about his future and make some kind of plan. What kind of plan could he possibly make and who could help him decide what to do? When he tries to imagine what he could do, he comes up with a black hole in which there is no one he can trust to help him. Besides, he might defy the odds and miraculously recover, but if people knew about his problem the damage to his practice would be irreparable.
He does think about his patients but decides that continuing with him for as long as he is able to see them is preferable to any other option. He, of course, is the only one who can decide when he becomes impaired. He does not want to stop working, and he knows that his patients would be devastated if he tried to get rid of them. He feels that he could not cope with the outpouring of grief and other emotions that would erupt should they know his situation. It would distract them from the true business of their hours with him, their own problems.
Eventually he dies, working until the end. His family has to put a sign on his door notifying patients that he has passed away. The family refers a few patients who call persistently to analyst friends who agree to this onerous duty. Some patients feel abandoned and one consults a lawyer. A dead analyst's estate can be sued for damages!
If he had called a member of the Psychoanalyst Assistance Committee (PAC) of his society and/or institute and arranged for a confidential consultation, the story would be different. A small subcommittee would be designated to help him deal with the many ramifications of his diagnosis and prognosis, in an atmosphere of confidentiality. He might be able to work for some time, but not take on new cases except for consultations and brief psychotherapeutic situations. As the illness progresses, he would begin to inform his patients, with the confidential consultation and assistance of his committee. All kinds of feelings would pour out. With help and support from the committee, gradually things might well fall into place as patients are dealt with individually. As the practice dwindles, in a planned way and to fill in his time and provide some compensatory income, other remunerative activities that seem appropriate to the PAC might come his way. He may be helped to get into supportive treatment outside of the PAC.
After he dies, his family and friends do not have to deal with suddenly deprived patients who are suffering an acute loss. They can cope with their own loss without the additional burden and disruption of having to concern themselves with unprepared patients. Although loss of a psychoanalyst presents many difficult problems for patients and colleagues, in this climate of open dealing and disclosure, the complexities can be more appropriately handled with beneficial results. And, no one sues.
The Joint Psychoanalyst Assistance Committee (JPAC) of the American Psychoanalytic Association was established in January 2005 to facilitate the establishment and functioning of local PACs. In many communities, referrals to local PACs remain far below their capacity to help. Some societies and a few institutes still struggle to establish PACs, although they were mandated by both Board and Council some years ago. Hopefully this article will motivate analysts to think about how to alleviate this situation either by joining a local PAC or by referring a colleague in need of help. At best, impaired analysts can be restored to full functional capacity. When this is not possible, they can be aided in transition to retirement with their dignity intact.
Rita W. Clark, M.D., is a member of both APsaA's Ethics and Joint Psychoanalyst Assistance Committees (JPAC) and co-editor of The Ethics Casebook. She is also the chair of the PAC at the Psychoanalytic Association of New York.
Jerome Winer, M.D., founded JPAC and continues as its chair. He has served as chair of the International Psychoanalytical Association Ethics Committee and director of the Chicago Institute for Psychoanalysis.