I recently attended the annual meeting of the Association of American Physicians and Surgeons in Denver. I was a little concerned about whether this would be worthwhile as this group has sometimes taken positions that are a bit too much to the right for my taste. To my surprise and relief, it turned out to be what may very well have been the best professional conference I have ever attended. Every speaker was intelligent, well informed, and thoughtful. Each one presented a unique point of view that was informative, creative, and thought provoking. Very few of the speakers or attendees were psychiatrists. Most were surgeons, general medical doctors, or emergency room physicians.
Several messages came through. One was that they were unambivalently devoted to their patients and to providing quality medical care, living up to their motto Omnia Pro Aegroto (everything for the patient). Nearly all of them were entirely in private practice, accepting no insurance. Then they took it a step further, entering into private agreements with medical laboratories and pharmaceutical companies so they were able to offer patients medical tests and medications at nearly one-tenth of the cost that would have been the case under an insurance plan. Overhead costs were dramatically reduced (compared to a more common practice which accepts third-party payment or managed care) because there was no need to budget for administrative and bureaucratic costs imposed by insurers. This is critical because it debunks the myth of equating private practice with concierge medicine, only affordable by the wealthy patient.
For them, the doctor-patient relationship was central and paramount. For example, one internist in a rural area of Texas said that when any of her patients develop cancer, she treats them at no cost. Another message that came through, over and over again, was the danger of centralized government control, which, in their view, drove up costs dramatically and drove down quality equally dramatically. They referred to it as “Soviet style” medicine. To a person, they all seemed exuberant about their independence and freedom, having left behind managed care practices to go entirely into private practice.
Another speaker reported on the experience of her husband's family with the Dutch medical system. Both his parents suffered strokes at different times and were hospitalized. Apparently the protocol in Holland is to allow elderly stroke victims three days to recover, and if they do not, the routine procedure is to treat them with morphine and starvation. I was familiar with some aspects of the Dutch system because of the analytic institutes there, which were initially pleased to have the government cover the cost of psychoanalytic training. However, once the government was firmly in control, it then refused to pay for either psychoanalytic training or psychoanalytic treatment, resulting in the Dutch group being reduced to a bare minimum.
I was very struck that these practitioners had come back to, and discovered, what we have never left. Once again, we are the canary in the coal mine, and other canaries seem to be flocking to the cause.
I also attended a meeting of their board of directors that was equally remarkable. They were struggling over whether to participate in an amicus brief about a matter in which they were almost equally and intensively divided. They were clearly anguished over the decision. The striking thing to me was the earnestness with which they stated their positions, but more dramatically, the consideration and even affection, they felt for each other. They felt strongly about not alienating and hurting each other, despite their differences. In the end, they decided they needed more time to process the issue so they could come to a unified decision that would not result in predictable splits and resignations.
At the conclusion of this topic, the president stated with deep emotion that he felt that he would have to look into his own heart to see in what way he might have contributed to the conflict, and in what way he might be able to bring about the healing of the group in the future. I thought, “Amazing, what he's talking about is being self-reflective!” And this was a surgeon.
These are people who are not specially trained or sophisticated psychologically, as we are and yet, instinctively, they seem to operate on a much more effective level in terms of group function than we do. What an embarrassing contrast to our own way of trying to deal with a divisive issue. Instead of being able to discuss the PPP proposal and the training analyst system, the BOPS leaders leapt to legalistic and adversarial positions. The first move was to establish a committee to determine in what ways the proposal was illegal, according to the rules of our Association and the IPA. The charge to the committee was to look into the legality of the PPP proposal rather than its substance.
The second move was to file a lawsuit. Unlike general medical doctors who treasure their relationships and common goals, we leapt immediately to a demonization of colleagues and ad hominem attacks.
When I was a candidate, there was a split in the Boston Institute and a new institute, PINE, was formed as a result. As candidates,
Bob Pyles, M.D., is president of the American Psychoanalytic Association.
we were treated to the disturbing vision of our mentors (senior analysts) treating each other like enemies. I had to conclude that either psychoanalysis did not work or something else was going on. It was at that point that I studied Bion and the behavior of “Basic Assumption” groups.
So what are the underlying assumptions behind our current controversies? One seems to be that the mere discussion of an idea is destructive and must be avoided at all costs. Another is that any major alteration in the training analyst system would be tantamount to the destruction of psychoanalysis itself. This, in spite of the fact that two out of the three educational models in the IPA do not have a training analyst system, and those groups seem to be getting along quite nicely.
Yet, what is it that creates this mortal fear of any discussion of the core belief in the training analyst system? Many BOPS supporters seem to respond with annihilatory anxiety. Otto Kernberg pointed out that such deep anxieties suggest that these central belief systems really are religious in nature, rather than educational or analytic. Freud himself, in his article “Group Psychology,” theorized about what would happen if the body of Christ were discovered unresurrected in his tomb. How would this challenge to the central belief of the Christian Church affect the organizational cohesiveness of that group?
Judge Schlesinger, in her decision, cited our bylaws in arguing that BOPS has sole authority over educational matters, and owes no allegiance to the membership or to the Board of Directors. This strict interpretation of the bylaws cuts both ways. For example, the bylaws state that the only two areas of responsibility allotted to BOPS are the setting of standards and the carrying out of certification. In fact, BOPS has taken on many other areas of responsibility, most recently setting up outreach to help individual institutes restore effective functioning. In fact, according to the bylaws, none of these things are technically the purview of BOPS. One could argue that there has been considerable “mission creep,” as BOPS has steadily taken on activities that are not designated in the bylaws.
After many years of dealing with analytic organizations, I have come to feel that there is something about psychoanalysts that does not lend itself easily to well-functioning groups or organizations. When there are serious differences of opinion, analysts almost always jump to either a split or an ongoing civil war, as characterized by Douglas Kirsner in his landmark book, appropriately titled, Unfree Associations, describing splits in analytic organizations, including Boston.
What seems to be operating here is a kind of an organizational character disorder, which is defined by an unconscious and unrecognized value system that perceives any challenge as a threat to the survival of the group, as Kirsner describes. But the idea of being able to put aside one's own personal and narcissistic interests for the good of the group does not seem very common in analytic organizations.
One could reasonably ask why are communications from some BOPS supporters so filled with rage and so focused on personal attacks? For example, some BOPS supporters feel it is perfectly acceptable, and even admirable, to file a lawsuit against our Association, but it was a betrayal of the highest order for the Executive Committee to decide to appeal that lawsuit. I have chosen not to reply to these very personal attacks, but the best reply I have seen was made in a post by Paul Mosher. After discussing the legal issues in which he felt that an appeal was entirely justified, Paul said, “I hope that before swallowing the distortions in Dr. xxx's note, APsaA members will read the Sworn Affidavit submitted to the court by Dr. Pyles, APsaA's president, which lays out in painful detail the narrative of ‘stonewalling’ and serial rebuffs the attempts of the APsaA leadership received from the BOPS chair and secretary, which then led up to the Council action, and finally to the flinging in the membership's faces this lawsuit of the BOPS leaders and their five co-complainants” (reprinted with permission).
One could well wonder why such bitterness and divisiveness seem so characteristic of psychoanalytic groups. I have many thoughts about it but no real answer One is that very few of our members have had extensive experience in group activities where one has to put aside one's own interest for the good of the whole. Secondly, although we are trained intensively in individual psychology, we have very little training in groups. And lastly, our profession is a solitary one and we operate mostly without feedback from our peers.
Such an intense value system would seem to be the result of 60 years of operating without oversight, checks and balances, or feedback from the membership and Board of Directors.
In reviewing our 2011 practice survey, the message from our members is loud and clear It is their primary wish for us to preserve private practice and their autonomy. Psychoanalysis and psychoanalytic practice can only survive and flourish in an atmosphere of truly “Free Associations.”
The Litigation Committee of the Executive Committee has put forth a plan that Mark Smaller and I described previously. This is a four-pronged approach. The first is to file an appeal to the lawsuit, which has been done, and is expected to take between two to eight months to resolve. Again, let me reiterate that the legal costs of the original lawsuit and the appeal are covered by insurance. The second point is to follow Judge Schlesingers recommendation that if we want to change our dysfunctional structure, which has crippled us for 20 plus years, we have to change the bylaws. This we are doing, and the results will be submitted for discussion and vote by the membership. Thirdly, Mark and I are engaging in discussions with the BOPS leaders, Lee Ascherman and Betsy Brett, hoping to deal with some of the issues, or at least tone down some of the rhetoric. And lastly, we want to continue to focus on practice and recruitment, which is the reason I have chosen to reflect on the meeting I described in the beginning of this column.