Wednesday, December 30, 2009

Commentary on Opinions of APA Ethics Committee

The American Psychiatric Association recently published a long overdue compilation of opinions on the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry (2009 edition). While some opinions may reflect some needed reality testing and updating the committee has regrettably retained many archaic opinions (some more than 30 years old), and has omitted at least a few that might have added to the document.

The Opinions of the Ethics Committee on The Principles of Medical Ethics

Getting off on the wrong foot, the Forward explains that the document includes responses to questions about the seven Principles where I count nine "sections." I think we might do well to jettison the last two anyway. More on that later.

The ethics committee seems to have missed two facts about psychiatry and psychotherapy: First, many psychiatrists no longer do psychotherapy. Second, many of those who do psychotherapy do not claim to do psychoanalytic psychotherapy or to believe in psychoanalytic theory (Oh, sacrilege). This makes references to psychoanalytic terms like "counter-transference" and "transference" (I counted 6) quaint but archaic and inappropriate. These concepts serve no purpose in medication management, magnetic stimulation, or even CBT, becoming little more than euphemisms. Any attempt to impose an ethical principle based on these unproven constructs upon a psychiatrist outside the context of analytic/dynamic psychotherapy would itself be unethical and must be avoided. Psychiatrists should only be subjected to ethical principles relating to psychiatric practice in general.

Let me attempt to translate some of these references to transference. Take the answer to A.1.a. (page 5) for example: "procedures do not activate transference distortions that preclude effective treatment" appears in a 1989 opinion about whether a psychiatrist can ethically perform vaginal exams or "lead" his (We were all men back then.) patients into sexual fantasies. I would like to advance the theory that transference distortions will not likely make olanzapine or paroxetine any less effective. But could it be that by "treatment" the committee really meant psychotherapy? And I must admit I would not know a transference distortion if one bit me in the superego.

Can we not address this question without invoking mythical concepts like transference? A psychiatrist who routinely attends to the general medical needs of her patients can ethically, with the patient's consent, perform any aspect of a physical examination indicated. However, regardless of whether treatment includes psychotherapy and regardless of the type of psychotherapy, if the psychiatrist uses genital examination for his or her own sexual gratification, we should consider it unethical. We need not refer to or even believe in the existence of "transference distortions."

On page 6 we see a question about the ethical implications of a psychiatrist dating a former patient. The opinion refers to the possibility the patient has developed a "positive transference" in arguing such a relationship would not be ethical. "Positive transference" here, I believe, means not just that the patient likes the psychiatrist, but also that the "liking" is just an illusion, an artifact of treatment, that it is not real. Once again, we need not invoke psychoanalytic hokus pokus. It behooves us as a profession for our patients to know they are entitled to expect that we will provide treatment we believe to be in their best interest, free of any concern that we may want something other than money from them in return.

On page 8  the question is whether the role of the psychiatrist (really as psychotherapist -- no question of medication here) can ethically switch from that of treater to that of psychotherapy supervisor. Once again the initial opinion (circa 1988) "probably not" is spot on, but then from the fog of psychoanalytic theory emerges a possible exception: "unless there is consultation for both you and the social worker that indicates no transference-countertransference issues that might harm the patient or lead you to misuse the supervisory role." I see one analyst passing a consultation form to another. At the top it reads, "Rule out transference-counter... etc". How would one do this? How many months on the couch(es)? But aside from the "issues" issue this opinion raises the question of the extent to which the problem might be specific to the particular method of psychotherapy provided. If the treatment had involved CBT or systemic psychotherapy, might the answer be different? Does the committee really expect that the psychiatrist and social worker might consult a psychoanalyst on such a matter when the treatment and supervision involve family systems psychotherapy?

A.2.e. (page 11):
I am doubly interested in this question since it also touches on media use of patient information by the psychiatrist as author. The answer seems to contain a contradiction: "Their consent while "freely" given is likely to be heavily influenced by their transference feelings, the need to please you." How can consent be "freely" given when it is also "heavily influenced?" This case may not even involve psychotherapy, much less psychoanalytically oriented psychotherapy. How can the committee invoke "transference" in formulating the response? Fortunately, even in 1989, someone got to the real point which is that the whole project smacks of exploitation of patient by psychiatrist for the personal gain of the psychiatrist and is therefor probably unethical.

K.2.h. (page 49):
A quarter century ago, analytic theory, misapplied, obfuscates a straight forward problem. The financially challenged patient pays only part of the fee; unbeknownst to her, Mom pays the rest. According to the Principles, "A physician shall deal honestly with patients...", but this will only be considered dishonest from a psychoanalytic perspective if a "consultation" reveals that the associated "transference distortions [are] significant enough."

R.2.a. (page 78)
22 years ago the committee invoked psychoanalytic concepts to probe the ethical depths when a male resident accepted a ride from a female patient. Not just any patient, mind you, but one with "an eroticized transference toward him." Perhaps there would be no need to question the ethics here but for that nasty transference problem. The recommendation might have been (but was not): If a patient offers you a ride, only accept if you have previously determined the transference (assuming there is one) is not eroticized. Once again it is not clear whether the psychiatrist was providing  psychoanalytic treatment.

We could debate whether evidence supports use of any psychotherapy based on psychoanalytic theory for treatment of any mental disorder, but my point here is that we should no longer consider psychoanalytic theory to be at the core of psychiatry. It is only one of many treatment modalities that psychiatrists and other professionals may elect to provide. Despite their age the opinions cited above remain instructive and deserve inclusion in the document, but the ethics committee should have either removed references to peculiarly psychoanalytic concepts or added an explanation with an updated basis or translation into non-analytic terminology. Furthermore, and perhaps of greatest concern, inclusion of analytic concepts raises suspicion that some committee members might be unable to fairly consider ethics questions or complaints where the case involves no psychoanalytic treatment. The committee should no longer assume that all treatment involves psychotherapy of any kind. Opinions should not contain obscure and often ambiguous jargon, like "transference distortion," unless accompanied by a definition. When we refer to a patient's feelings as transference we also imply, at least to some degree, as noted in at least one example above, that the feelings are an unreal artifact of treatment. Even in the context of psychoanalytic treatment this notion risks conflict with Section 1 of the Principles to the extent that it fails to provide for "respect for human dignity" in the patient-physician relationship.

Commentary on Opinions of APA Ethics Committee II


  1. I have some comments from an internist's perspective.

    If a psychiatrist (MD after the name) regularly practices primary care for patients, a practice that does not seem common, but, none-the-less if the psychiatrist does regularly do this for most of his/her patients a gynecologic exam, with a third party female attendant present for male psychiatrists, does not seem unreasonable on the surface.

    Regarding A.1.e. if a psychiatrist and a patient want to strike up a personal/romantic relationship the AMA has recommended formally ending the clinical relationship, waiting 6 months, then setting out on a personal relationship. In psychiatry this perhaps should be a strict guideline.

    Using patient information for media publication is difficult. I would be inclined to exclude anything attributing patient identification in any media disclosure. But if there is a need to disclose personal information about the patient under the guise of "his/her consent" it may be reasonable to have third party evaluate the patient's "capacity" to be clear and uninfluenced by the patient/doctor relationship. This is a murky situation though.

    Finally, regarding a psychiatrist's willingness to accept gifts, like a ride home from a patient, would fall into the realm of motivation. A gift as an expression of pure gratitude, beyond financial payment to the psychiatrist, seems less murky than a gift that leads to secondary gain for the patient, such as the possibility of starting a relationship between patient and psychiatrist. A young, attractive patient offering a ride home could seem suspect as compared to a geriatric patient bringing in a fruit basket.

    J O'B.

  2. Thanks for the comments. In psychiatry, instead of 6 months before starting a non-professional relationship, we generally say never. I tend to agree.