The past 25 years have led to a sea change in the way our institutes and societies handle ethical issues. Ethics and assistance committees have been mandated by APsaA. Our ethics code has been revised; we have published an Ethics Case Book, and made significant advances in candidate and faculty ethics education. As a result there seems to be a decrease in the most egregious boundary violations. We cannot be as proud of our efforts to establish rehabilitation programs for ethics violators. Our ethics code is essentially silent about rehabilitation. There are no procedures recommended by our Ethics Committee. In most of our sites there have been at best only preliminary discussions regarding rehabilitation. Nevertheless, rehabilitation efforts are under way in a small number of our sites. The challenge for our Association in the next decade is the establishment of guidelines for rehabilitation.
To further this process, the Committee on Psychoanalytic Education (COPE) established a new study group on “Boundary Violations and Rehabilitation,” which began meeting biannually in 2007. The members of the committee, which I chair, have been active in both local and national ethics committees. The members include: Sydney Arkowitz, Rita Clark, Suzanne Gassner, Prudy Gourguechon, Rion Hart, John Hall, Frederic Levine, and Vaia Tsolas. We began by reviewing the existing literature and interviewing former patients and their analysts as well as colleagues involved in rehabilitation where that is in place. We are indebted to them for their courage to revisit these painful issues so that others could profit from their experience and hard-won insights.
As analysts we might be curious about the disparity between our vigorous attention to sanctions and our relative neglect of rehabilitation. Clearly, we have been profoundly disturbed by the unethical conduct of our colleagues. It is even understandable that we would want to deny our commonality with such behavior by extruding them from our midst. Therefore, we may tend to view such colleagues as being unworthy of remedial action. However, as analysts we are also committed to a belief in the potential for change that can arise from a treatment that aims at explicating and resolving unconscious conflicts. This is the tension we work with that undergirds our ambivalence towards rehabilitation.
It has become painfully clear that the sequellae of severe boundary violations are so widespread that rehabilitation programs must encompass our entire analytic community and oftentimes our larger community of support. Of course the highest priority should be given to patient-victims as well as to the analysts who have transgressed. Our rehabilitation focus in the past has often been too narrowly directed at the impaired colleague. Clearly the rehabilitative effort for most situations will take place over a period of years.
Where a broad spectrum of efforts has been mobilized, some communities have responded positively. Where a comprehensive strategy was not undertaken, the residual damages have been deep and of long duration. A demoralized, divisive, depressed psychoanalytic community interferes with the growth of practice, candidate recruitment and education, and even undermines the progression of colleagues towards certification and training analyst opportunities. The psychoanalytic culture of these communities that contributes to the ethical morass must be changed. Our study group is collecting narratives of community healing to learn what they did to achieve their success. Trauma can lead to growth. A psychoanalytic community that experiences ethics crises can emerge from such a calamity with greater understanding of its problems and adopt creative efforts to reaffirm its psychoanalytic identity. The same applies to the individuals involved directly in these problems.
Some feel that outside analysts by virtue of their greater objectivity ought to be in charge of the transgressors' rehabilitation efforts. They claim that local colleagues are too familiar with the erring analyst and are less likely to be objective. Protagonists of local efforts note that their knowledge of and ongoing contacts with these colleagues is more comprehensive. Most would stipulate that a return to treatment and supervision would be central to any rehabilitation plan. Many would also include restitution of analytic fees. All seem to agree that remorse and a personal apology would be desirable but difficult to assess in regard to its sincerity.
Colleagues who will monitor the transgressors' rehabilitation need to report their findings to an oversight committee distinct from the group that originally decided on the sanctions. The period of rehabilitation is very difficult for the sanctioned colleagues as well as the involved patients. Both therapist and patient often suffer ostracism. They are frequently treated as toxic, damaged goods. All parties deserve our support and encouragement during this difficult period.
Clearly it is very difficult to determine an end point to this process. The damage lives on for years. Yet, the oversight committee must ultimately suggest a phased-in reentry for the full restoration of member privileges and responsibilities. As in clinical practice, we look for a good enough result, not a perfect rehabilitation.
Some of our ethics committees are overly severe in their sanctions. This can be as unfortunate as the earlier period in which ethical
Marvin Margolis, M.D., Ph.D., is a training and supervising analyst at the Michigan Psychoanalytic Institute, past president and chairman of the Board on Professional Standards of the American Psychoanalytic Association.
problems were neglected. Knowledge of the potential for professional ruination can therefore lead some colleagues to bypass our institutions to create their own rehabilitation program. We need to study the problem of overkill as an impediment to improving the ethical climate. Our goal is to create a respected, fair system that all will seek out for help. Finally, it must be recognized that some colleagues may not be capable of rehabilitation. This determination is a difficult one and may require a long period of time.
We are at the very beginning of a long period of evaluation of these recent rehabilitative efforts. We are all indebted to the groundbreaking efforts of Glen Gabbard and Andrea Celenza who have written about our organization's efforts to create pathways of rehabilitation. Many models of rehabilitation need to be studied. Long term follow-up of results is necessary. Our study group would welcome information of any rehabilitation programs ongoing or completed, formal or informal; complete confidentiality will be followed. We would hope to present a report based on aggregate data so that no institute, society, or individual can be recognized.
While much progress has occurred in recent years, we all recognize that there will always be a few who become involved in unethical behavior. Our group feels that most colleagues can slip into unethical practices at times of uncommon stress and vulnerability. They, along with their patients and communities, merit our best effort at rehabilitation.
In closing, we can acknowledge that the ethical climate in our institutes and societies has improved. APsaA has a deserved worldwide reputation for developing strategies to deal with these problems. The development of a comprehensive approach to rehabilitation is our next challenge.