Ethics Case Book of the American Psychoanalytic Association

This book courageously tackles a complex and compelling topic—ethical problems in the practice of psychoanalysis and in psychoanalytic education. Published by the American Psychoanalytic Association, it is written especially for its members. However, I believe it will be of great interest to all psychiatrists and other mental health professionals. Its authorship appears a bit murky. Although Dewald and Clark are listed as editors “with the help of the Subcommittee on Ethics Revision,” whose members are also listed, no author or authors are identified. Having just finished the book, I am tempted to add, echoing a refrain that occurs throughout this excellent book, “Is this an ethical or a technical issue?” Less facetiously, I suspect it is an artifact of self-publication, as are the horrendous number of typographical errors in the book. But these are minor criticisms of a book that takes on the formidable challenge of addressing some of the most nuanced and seemingly insoluble of ethical dilemmas.

The introduction explains the book’s rationale. In the process of preparing a revised ethics code for the American Psychoanalytic Association (which is included in this book), the Subcommittee on Ethics Revision found that group discussion of specific vignettes enhanced participants’ sensitivity to ethical issues and also helped achieve a consensus about ethical guidelines. They then wrote this book to provide a wide range of hypothetical and disguised actual cases to stimulate group discussions. Keep this in mind, or you will wonder why the book abounds in such extraordinarily thorny ethical conundrums, often without offering the authors’ help in resolving them. Only a minority of these vignettes include “discussion” sections, in italics, which suggeststhe Subcommittee’s opinion on the extremely provocative questions they have raised.

Although the reader might reasonably wish that every single question had been answered, the book’s format serves to remind us that many ethical dilemmas have no clear-cut and absolute answers. This is especially true of the vignettes in this book, since they include a preponderance of dilemmas that evoke conflicting ethical precepts, not to mention conflicting legal, moral, theoretical, personal, economic, societal, and public relations considerations. Short of adding King Solomon to the Subcommittee, it is probably impossible to offer definitive answers to all ethical quandaries. The book is modest in acknowledging its limitations:

Perhaps the book should come with a warning label—“Danger! Contents may be hazardous to readers with harsh superegos!” Such readers may suffer toxic sequelae from overdosing on a bolus of just about everything that can possibly go wrong in analytic practice, no matter how well-intentioned the analyst is. As Glen Gabbard (1) has documented, the psychoanalytic profession needs to come to terms with its sad history of serious boundary violations, including those perpetrated by some of its most respected figures. Gabbard has often taken the leadership in asking that we acknowledge these ethical violations and that we do all we can to prevent future violations or to impose appropriate sanctions when they occur (e.g., reference 2). Given our current need to compensate for our past history of group blind spots and inaction, we have to be cautious that we not overcompensate, swinging the proverbial pendulum too far in the other direction.

The book asks that analysts follow the code of ethics even when this means the analyst might be punished for breaking the law (pp. vi, xxx). Should an analyst follow his or her own conscience, even when it conflicts with this code of ethics? Gutheil and Gabbard (3) have warned against the misapplication of the concept of boundary violations to boundary “crossings” and other less ethically loaded issues. Even such seemingly innocuous behavior as addressing a patient by his or her first name, seeing a patient during one’s last appointment of the day, or charging the patient a reduced fee have raised eyebrows when hypervigilance about boundaries condemns these actions on the grounds that they will lead to a “slippery slope,” with seriously unethical behavior unavoidably at the bottom of the hill.

The Subcommittee that wrote this book solicited input from all members of the American Psychoanalytic Association early in their endeavor. I was invited to attend one of their meetings, apparently because I was the only member who sent them detailed feedback. One point I made was that the slippery slope argument should not be misused. The Chinese proverb does not assert that each single step invariably leads to a long journey. As Gabbard has shown (1, 2), heightened awareness of good professional boundaries does not reduce analysts to cold, emotionally distant automatons. On the contrary, it allows us to be optimally engaged with the patient, as both we and the patient are reassured that important professional boundaries will always be respected.

As enthusiastic as I am about how well this book succeeds in its goals, I hope it will be greatly expanded in subsequent editions. There are so many issues it could not take up in its current limited format. For example, it is silent on the important question of similarities and differences between psychoanalysis and other professional activities of psychoanalysts and other mental health professionals. Few analysts restrict their practice solely to classical psychoanalysis, and analysts are vastly outnumbered by other mental health professionals, who are themselves rightly concerned with professional ethics. I am aware of cases where the technical principles of classical analysis are misapplied as ethical imperatives in treatments where those principles are completely inappropriate. For example, I heard that someone was reprimanded by a state licensing board for discussing a mutual interest in classical music with a chronically psychotic patient she was treating in supportive psychotherapy. Self-disclosure, when clearly in the service of building an alliance and offering oneself as an auxiliary ego, may be entirely appropriate and therapeutic in supportive therapy. (An excellent resource on supportive therapy was written, in fact, by one of this book’s editors [4].)

An earlier draft of the Subcommittee’s guidelines would have prohibited bartering with patients as always unethical. I wrote to the committee about a psychiatrist I knew in a small community who accepted produce from indigent farmers in lieu of monetary payment. Although this may not be standard practice in large cities, I was troubled by the implication that guidelines suitable for one setting would be applied across the board. In its current form, the book includes one vignette involving a more questionable use of barter (pp. 51–52) but does not state the Subcommittee’s opinion on its use in general.

The book does not address cases of false accusations against practitioners. This omission creates the misleading impression that every allegation of unethical conduct is valid, as long as the patient seems like “a credible individual” (p. 91). In an earlier era, all children’s allegations of sexual abuse by adults were similarly assumed to be valid. In both cases, the pendulum inevitably swings too far from one extreme to the other—from excessive disbelief to excessive credulity. I heard of a highly ethical psychiatrist who made a serious suicide attempt when he realized his professional society believed his patient’s false allegation of sexual misconduct. The patient later admitted she concocted the story to get back at him for refusing to have a sexual relationship with her. In addition, Gabbard (5) has identified a group of depressed practitioners who react with “masochistic surrender” to patients’ efforts to violate boundaries and go on to interact self-destructively with ethics committees, allowing themselves to be punished far in excess of their wrongdoing.

The book repeatedly urges us to seek consultation early on whenever we face ethical uncertainties. This is eminently sound advice, since reluctance to share a dilemma with a trusted colleague may in itself be a warning sign that we are trying to conceal potential wrongdoing. Having said this, I believe the book overlooks many of the complications that consultation can create. It wisely urges that we use a consultant who can be objective rather than turn to a friend who is likely to approve of whatever we are doing. But it does not address the dilemma we may be in if we disagree with the consultant’s advice. Should we ignore our own judgment? Seek a second consultant? What do we do if two or more consultants disagree with each other? One analyst is criticized for his “uncritical willingness to accept” a consultant’s advice (p. 70). And what about the consultant’s duty to report? In one humdinger of a vignette (pp. 46–49), a woman reports to a consultant that her analyst is trying to engage her in a sexual relationship. But she asks the consultant to keep confidential what she has told him. I believe this is the only example in the book that acknowledges disagreement among the co-authors as to how the consultant should resolve his conflicting duties to maintain the patient’s confidentiality and also to protect her and other patients from unethical conduct. The book hints at a clever option: that the consultant himself should seek consultation, and lots of it, from so many colleagues that eventually the patient’s secret would be a rather open one.

What about the toll that ethics work can take on consultants, ethics committees, and professional societies? The book in no way minimizes the many financial and emotional costs of adjudicating allegations of unethical conduct. In one vignette, the local society lacks the financial resources needed to conduct an ethics investigation. I am aware of an instance where the legal fees for a local society were $40,000 for a single case that did not even involve a lawsuit. As past chair of my local psychoanalytic society’s ethics committee and former member of an ethics appeal committee of the American Psychoanalytic Association, I can also attest to the psychological strain of handling complaints against respected friends and colleagues. In fact, I have thought that an appropriate punishment for milder ethical misdeeds might be the “community service” of being a member of an ethics committee!

What impact will this book have on psychiatrists? How will it influence their opinion of psychoanalysis? One psychiatrist told me after reading it that she had decided against seeking analytic training, since the book left her with the impression that unresolvable ethical dilemmas are almost daily fare in analytic practice. I feel certain that this is not the impact the American Psychoanalytic Association wants the book to have. I wonder if one unconscious motive that led the association to publish it is to engage in a sort of public mea culpa—acknowledging past lapses and making reparation by showing just how seriously the profession is addressing unethical conduct now. This is a reasonable goal. However, if the book inadvertently implies that all psychoanalysts are either sociopathic predators or sanctimonious prigs, or both, the book does not reach its more adaptive goals.

Further, it is unfortunate that recent efforts to root out unethical colleagues and strip them of their professional licenses happen to coincide with an era of apparent oversupply of mental health professionals, creating the appearance of a conflict of interest for ethics committees (perhaps they could be constituted by respected retired colleagues who are still performing their community service). Although the book was subsidized by the company that provides malpractice insurance to members of the American Psychoanalytic Association, I am concerned that unscrupulous trial lawyers will misuse it to bring unjustified malpractice suits against analysts and, possibly, against other mental health professionals.

Although King Solomon would have been too wise to step into the morass of ethics work today, we can turn to Nathaniel Hawthorne for the psychological acumen of great literature. Many critics consider The Scarlet Letter to be the United States’ best novel. It is an extraordinary case study of the psychology of sin—its impact not only on the sinners but also on those who sit in judgment. The townspeople’s gradual capacity to forgive Hester Prynne for her adultery and to admire her for her many virtues was constrained by their need to use her as a target of projection, which Hawthorne characterizes as “the propensity of human nature to tell the very worst of itself, when embodied in the person of another” (6, p. 135). Hester’s estranged husband becomes obsessed with Hester’s infidelity and in tracking down and destroying her lover. Toward the end of the novel, Hawthorne describes the self-destructiveness of this obsession with the sins of others:

So Hawthorne can serve as an astute consultant to all of us, warning us of some of the risks inherent in the nonetheless necessary work of enhancing professional ethics.

I hope this book will enjoy the wide readership it deserves.