Principles and Standards of Ethics for Psychoanalysts (2007)

Psychoanalysis is a method of treating children, adolescents and adults with emotional and mental disorders that attempts to reduce suffering and disability and enhance growth and autonomy. While the psychoanalytic relationship is predicated on respecting human dignity, it necessarily involves a power differential between psychoanalyst, patient and, particularly in the case of children, the family that, if ignored, trivialized or misused, can compromise or derail treatment and inflict significant damage on both parties to treatment*. Constant self examination and reflection by the psychoanalyst and liberal use of formal consultation are obvious safeguards for the patient, as well as the treating psychoanalyst.

 

No code of ethics can be encyclopedic in providing answers to all ethical questions that may arise in the practice of the profession of psychoanalysis. Sound judgment and integrity of character are indispensable in applying ethical principles to particular situations and individuals. The major goal of this code is to facilitate the psychoanalyst's best efforts in all areas of analytic work and to encourage early and full discussion of ethical questions with colleagues and members of local and national ethics committees. These revised Principles presuppose a psychoanalyst's life-long commitment to act ethically and to encourage similar ethical behavior in colleagues and students. It is expected that over time all psychoanalysts will enrich and add cumulatively to the guidance provided by the Principles with their own experience and values, and that the Principles will evolve, based on the profession's insights and experience.

 

General Principles of Ethics for Psychoanalysts

 

Introduction:

The American Psychoanalytic Association has adopted the following Principles of Ethics and associated Standards to guide members in their professional conduct toward their patients and, in the case of minors, toward their parent(s) or guardian(s) as well as supervisees, students, colleagues and the public. These Principles and Standards substantially revise and update the ethical principles contained in the previous Principles of Ethics published by the American Psychoanalytic Association in December 1975, and revised in 1983. The revisions take account of evolving moral sensibilities and observed deficiencies in the earlier codes. As ethical standards change, behaviors that were acceptable in the past may no longer be considered ethical. In this regard, however, these evolving standards should not be used to punish individuals retroactively. These revised principles emphasize constraints on behaviors that are likely to misuse the power differential of the transference-countertransference relationship to the detriment of patients and, in the case of minors, their parent (s) or guardian (s) as well.

 

The new code seeks to identify the parameters of the high standard of care expected of psychoanalysts in treatment, teaching, and research. By specifying standards of expected conduct, the code is intended to inform all psychoanalysts in considering and arriving at ethical courses of action and to alert members and candidates to departures from the wide range of acceptable practices. When doubts about the ethics of a psychoanalyst's conduct arise, early intervention is encouraged. Experience indicates that when ethical violations are thought to have occurred, prompt consultation and mediation tend to serve the best interests of all parties concerned. When indicated, procedures for filing, investigating and resolving complaints of unethical conduct are addressed in the Provisions for Implementation of the Principles and Standards of Ethics for Psychoanalysts.

 

There are times when ethical principles conflict, making a choice of action difficult. In ordering ethical obligations, one's duty is to the patient directly, or indirectly through supervision or consultation with the treating psychoanalyst. In the case of patients who are minors there are also ethical obligations to parent(s) or guardian(s) which change as the patient becomes older and more mature. Thereafter, ethical obligations are to the profession, to students and colleagues, and to society. The ethical practice of psychoanalysis requires the psychoanalyst to be familiar with these Principles and Standards; to conduct regular self-examination; to seek consultation promptly when ethical questions arise; and to reach just sanctions when judging the actions of a colleague.

 

Guiding General Principles:

I. Professional Competence. The psychoanalyst is committed to provide competent professional service. The psychoanalyst should continually strive to improve his or her knowledge and practical skills. Illnesses and personal problems that significantly impair the psychoanalyst's performance of professional responsibilities should be acknowledged and addressed in appropriate fashion as soon as recognized.

 

II. Respect for Persons. The psychoanalyst is expected to treat patients and their families, students and colleagues with respect and care. Discrimination on the basis of age, disability, ethnicity, gender, race, religion, sexual orientation or socioeconomic status is ethically unacceptable.

 

III. Mutuality and Informed Consent. The treatment relationship between the patient and the psychoanalyst is founded upon trust and informed mutual agreement or consent. At the outset of treatment, the patient should be made aware of the nature of psychoanalysis and relevant alternative therapies. The psychoanalyst should make agreements pertaining to scheduling, fees, and other rules and obligations of treatment tactfully and humanely, with adequate regard for the realistic and therapeutic aspects of the relationship. Promises made should be honored.

When the patient is a minor these same general principles pertain but the patient's age and stage of development should guide how specific arrangements will be handled and with whom.

 

IV. Confidentiality. Confidentiality of the patient's communications is a basic patient's right and an essential condition for effective psychoanalytic treatment and research. A psychoanalyst must take all measures necessary to not reveal present or former patient confidences without permission, nor discuss the particularities observed or inferred about patients outside consultative, educational or scientific contexts. If a psychoanalyst uses case material in exchanges with colleagues for consultative, educational or scientific purposes, the identity of the patient must be sufficiently disguised to prevent identification of the individual, or the patient's authorization must be obtained after frank discussion of the purpose(s) of the presentation, other options, the probable risks and benefits to the patient, and the patient's right to refuse or withdraw consent.

 

V. Truthfulness. The psychoanalytic treatment relationship is founded on thoroughgoing truthfulness. The psychoanalyst should deal honestly and forthrightly with patients, patient's families in the case of those who are minors, students, and colleagues. Being aware of the ambiguities and complexities of human relationships and communications, the psychoanalyst should engage in an active process of self-monitoring in pursuit of truthful therapeutic and professional exchanges.

 

VI. Avoidance of Exploitation. In light of the vulnerability of patients and the inequality of the psychoanalyst-analysand dyad, the psychoanalyst should scrupulously avoid any and all forms of exploitation of patients and their families, current or former, and limit, as much as possible the role of self-interest and personal desires. Sexual relations between psychoanalyst and patient or family member, current or former, are potentially harmful to both parties, and unethical. Financial dealings other than reimbursement for therapy are unethical.

 

VII. Scientific Responsibility. The psychoanalyst is expected to be committed to advancing scientific knowledge and to the education of colleagues and students. Psychoanalytic research should conform to generally accepted scientific principles and research integrity and should be based on a thorough knowledge of relevant scientific literature. Every precaution should be taken in research with human subjects, and in using clinical material, to respect the patient's rights especially the right to confidentiality, and to minimize potentially harmful effects.

 

VIII. Protection of the Public and the Profession. The psychoanalyst should strive to protect the patients of colleagues and persons seeking treatment from psychoanalysts observed to be deficient in competence or known to be engaged in behavior with the potential of affecting such patients adversely. S/he should urge such colleagues to seek help. Information about unethical or impaired conduct by any member of the profession should be reported to the appropriate committee at local or national levels.

 

IX. Social Responsibility. A psychoanalyst should comply with the law and with social policies that serve the interests of patients and the public. The Principles recognize that there are times when conscientious refusal to obey a law or policy constitutes the most ethical action. If a third-party or patient or in the case of minor patients, the parent(s) or guardian(s) demands actions contrary to ethical principles or scientific knowledge, the psychoanalyst should refuse. A psychoanalyst is encouraged to contribute a portion of his or her time and talents to activities that serve the interests of patients and the public good.

 

X. Personal Integrity. The psychoanalyst should be thoughtful, considerate, and fair in all professional relationships, uphold the dignity and honor of the profession, and accept its self-imposed disciplines. He or she should accord members of allied professions the respect due their competence.

 

Standards Applicable to the Principles of Ethics for Psychoanalysts

The American Psychoanalytic Association is aware of the complicated nature of the psychoanalyst-patient relationship and the conflicting expectations of therapists and patients in contemporary society. In addition, the Association recognizes that this complexity is increased when the patient is a minor and parent(s) and guardian(s) are a natural, if changing, part of the therapeutic picture. The following ethical standards are offered as a more specific and practical guide for putting into practice the Guiding Principles. The Standards represent practices that psychoanalysts have found over time to be generally conducive to morally appropriate professional conduct. A discussion of situation-dependent guidelines and dilemmas will be presented in a separate document, a Casebook on Ethics.

 

I. Competence

1. Psychoanalysts are expected to work within the range of their professional competence and to refuse to assume responsibilities for which they are untrained.

2. Psychoanalysts should strive to keep up to date with changes in theories and techniques and to make appropriate use of professional consultations both psychoanalytic and in allied psychotherapeutic fields such as psychopharmacology.

3. Psychoanalysts should seek to avoid making claims in public presentations that exceed the scope of their competence.

4. Psychoanalysts should take steps to correct any impairment in his or her analyzing capacities and do whatever is necessary to protect patients from such impairment.

 

II. Respect for Persons and Nondiscrimination

1. Psychoanalysts should try to eliminate from their work the effects of biases based on age, disability, ethnicity, gender, race, religion, sexual orientation or socioeconomic status.

2. The psychoanalyst should refuse to observe organizational policies that discriminate with regard to age, disability, ethnicity, gender, race, religion, sexual orientation, or socioeconomic status.

 

III. Mutuality and Informed Consent

1. Psychoanalytic treatment exists by virtue of an informed choice leading to a mutually accepted agreement between a psychoanalyst and a patient or the parent(s) or guardian(s) of a minor patient.

2. It is not ethical for a psychoanalyst to take advantage of the power of the transference relationship to aggressively solicit patients, students or supervisees into treatment or to prompt testimonials from current or former patients. Neither is it ethical to take such advantage in relation to parent(s) or guardian(s) of current or former minor patients.

3. It is unethical for a psychoanalyst to use his/her position of power in analytic organization, professional status or special relationship with a potential patient or parent or guardian of a minor patient to coerce or manipulate the person into treatment.

4. Careful attention should be given to the process of referral to avoid conflicts of interest with other patients and colleagues. Referrals between members of the same family, including spouses, and significant others, should be especially scrutinized and disclosure should be made to patients about the relationship in the initial stages of the referral so that preferable alternatives may be considered.

5. All aspects of the treatment contract which are applicable should be discussed with the patient during the initial consultation process. The psychoanalyst's policy of charging for missed sessions should be understood in advance of such a charge. The applications of this policy to third party payment for services should be discussed and agreed upon by the patient. In the case of patients who are minors, these matters should be discussed early on with the parent(s) or guardian(s) as well as with the patient as age and capability dictate.

6. A reduced fee does not limit any of the ethical responsibilities of the treating psychoanalyst.

7. The psychoanalyst should not unilaterally discontinue treating a patient without adequate notification discussion with the patient and, if a minor, with the parent (s) or guardian (s) and an offer of referral for further treatment. Consultation should be considered.

 

IV. Confidentiality

1. All information about the specifics of a patient's life is confidential, including the name of the patient and the fact of treatment. The psychoanalyst should resist disclosing confidential information to the full extent permitted by law. Furthermore, it is ethical, though not required, for a psychoanalyst to refuse legal, civil or administrative demands for such confidential information even in the face of the patient's informed consent and accept instead the legal consequences of such a refusal.[1]

2. The psychoanalyst should never share confidential information about a patient with nonclinical third-parties (e.g., insurance companies) without the patient's or, in the case of a minor patient, the parent's or guardian's informed consent. For the purpose of claims review or utilization management, it is not a violation of confidentiality for a psychoanalyst to disclose confidential information to a consultant psychoanalyst, provided the consultant is also bound by the confidentiality standards of these Principles and the informed consent of the patient or parent or guardian of a minor patient has first been obtained. If a third-party payer or a patient or parent or guardian of a minor patient demands that the psychoanalyst act contrary to these Principles, it is ethical for the psychoanalyst to refuse such demands, even with the patient's or, in the case of a minor patient, the parent's or guardian's informed consent.[2]

3. The psychoanalyst of a minor patient must seek to preserve the patient's confidentiality, while keeping parents or guardians informed of the course of treatment in ways appropriate to the age and stage of development of the patient, the clinical situation and these Principles.

4. The psychoanalyst should take particular care that patient records and other documents are handled so as to protect patient confidentiality. A psychoanalyst may direct an executor to destroy such records and documents after his or her death.

5. It is not a violation of confidentiality for a psychoanalyst to disclose confidential information about a patient in a formal consultation or supervision in which the consultant or supervisor is also bound by the confidentiality requirements of these Principles. On seeking consultation, the psychoanalyst should first ascertain that the consultant or supervisor is aware of and accepts the requirements of the Confidentiality standard.

6. If the psychoanalyst uses confidential case material in clinical presentations or in scientific or educational exchanges with colleagues, either the case material must be disguised sufficiently to prevent identification of the patient, or the patient's informed consent must first be obtained. If the latter, the psychoanalyst should discuss the purpose(s) of such presentations, the possible risks and benefits to the patient's treatment and the patient's right to withhold or withdraw consent. In the case of a minor patient, parent(s) or guardian(s) should be consulted and, depending on the age and developmental stage, the matter may be discussed with the patient as well.

7. Supervisors, peer consultants and participants in clinical and educational exchanges have an ethical duty to maintain the confidentiality of patient information conveyed for purposes of consultative or case presentations or scientific discussions.

8. Candidate psychoanalysts-in-training are strongly urged to consider obtaining the patient's informed consent before beginning treatment, pertaining to disclosures of confidential information in groups or written reports required by the candidate's training. Where the patient is a minor, the candidate is strongly urged to consider obtaining informed consent from the parent(s) or guardian(s); age and stage of development will assist the candidate in determining if the patient should also be informed.

 

V. Truthfulness

1. Candidate psychoanalysts-in-training are strongly urged to inform psychoanalytic training patients and prospective psychoanalytic training patients that they are in training and supervised. Where the patient is a minor, the parent(s) or guardian(s) should also be informed. If asked, candidate psychoanalysts-in-training should not deny that they are being supervised as a requirement of their training.

2. The psychoanalyst should speak candidly with prospective patients or the parent(s) or guardian(s) if the patient is a minor about the benefits and burdens of psychoanalytic treatment.

3. The psychoanalyst should avoid misleading patients or parents or guardians of minor patients or the public with statements that are knowingly false, deceptive or misleading.

 

VI. Avoiding Exploitation

1. Sexual relationships involving any kind of sexual activity between the psychoanalyst and a current or former patient, or a parent or guardian of a current or former patient, or any member of the patient's immediate family whether initiated by the patient, the parent or guardian or family member or by the treating psychoanalyst, are unethical. Physical touching is not ordinarily regarded as a technique of value in psychoanalytic treatment. If touching occurs, whether of the patient by the psychoanalyst or the psychoanalyst by the patient, such an event should alert the psychoanalyst to the potential for misunderstanding of the event by the patient or the psychoanalyst. and consequent harm to the future course of treatment and consultation should be considered. Consultation should be considered if there is concern about the future course of treatment.

With children before the age of puberty touching between the patient and the psychoanalyst is likely to occur as in helping or during a patient's exuberant play. Also, a disruptive or out of control child may need to be restrained. The psychoanalyst needs to be alert to the multiple meanings for both parties of such touching. Keeping parent(s) or guardian(s) informed when this occurs may be useful. Consultation should be considered if the touching causes the psychoanalyst concern.

2. Marriage between a psychoanalyst and a current or former patient, or between a psychoanalyst and the parent or guardian of a patient or former patient is unethical, notwithstanding the absence of a complaint from the spouse and the legal rights of the parties.

3. It is not ethical for a psychoanalyst to engage in financial dealings with a patient, or in the case of a minor patient, the parent(s) or guardian(s) beyond reimbursement for treatment; or to use information shared by a patient or parent(s) or guardian(s) for the psychoanalyst's financial gain.

4. It is not ethical for a psychoanalyst to solicit financial contributions from a current or former patient or the parent/guardian of a current or former patient for any purpose; nor should a psychoanalyst give the names of current or former patients or their parents/guardians for purposes of financial solicitation by others.

5. If a patient or parent or guardian of a minor patient brings up the idea of a financial gift to a psychoanalytic organization or cause during treatment, it should be handled psychoanalytically and, if necessary, the patient should be informed that his or her confidentiality might be breached by the treating psychoanalyst's obligation to recuse him/herself from involvement in decisions governing use of the gift. If a gift is given nevertheless, the psychoanalyst is ethically obliged to refrain from any decision regarding its use by the recipient organization or cause.

6. If a current or former patient or the parent/guardian of a current or former patient, gives an unsolicited financial gift, or establishes a trust or foundation or other entity for the benefit of his/her psychoanalyst, or for the benefit of the professional or scientific work of said psychoanalyst, or for the benefit of the psychoanalyst's family, or the gift is placed under the control of the psychoanalyst, even if not directly beneficial to the psychoanalyst or his/her family, it is not ethical for the psychoanalyst to accept any financial benefit or to control its disposition.

7. It is ethical for a psychoanalyst to accept a bequest from the estate of a former patient, provided that it is promptly donated to an organization or cause from which the psychoanalyst or his/her family do not personally benefit and over which the psychoanalyst has no direct control.

8. It is unethical for a psychoanalyst to use his or her professional status, special relationship, or position of power in an analytic organization to solicit gifts or funds, sexual favors, special relationships, or other tangible benefit from patients, the parent(s) or guardian(s) of minor patients, members of the patient's immediate family, psychoanalysts-in-training or supervisees. Sexual relationships between current supervisors and supervisees are unethical.

9. Concurrent supervision of candidates by the spouse, significant other or other relative of their analysts should be avoided whenever possible in the interest of maintaining the independence and objectivity of both the supervisory and analytic processes.

 

VII. Scientific Responsibility

1. The psychoanalyst should take every precaution in using clinical material to respect the patient's rights and to minimize the impact of its use on the patient's privacy and dignity. In the case of minor patients the impact on parent(s) or guardian(s) needs to be considered. Particular care should be exercised in using material from a patient who is still undergoing treatment.

2. It is unethical for a psychoanalyst to make public presentations or submit for publication in scientific journals falsified material that does not refer to actual observations drawn from the clinical situation. Such clinical material must be disguised sufficiently to protect identification of the patient.

3. The psychoanalyst should exercise caution in disguising patient material to avoid misleading colleagues as to the source and significance of his or her scientific conclusions.

 

VIII. Safeguarding the Public and the Profession

1. The psychoanalyst should seek consultation when, in the course of treating a patient, the work becomes continuously confusing or seriously disturbing to either the psychoanalyst or the patient, or both. On occasion in the treatment of a minor, the relationship between the psychoanalyst and parental figure may cause sustained disturbance or confusion for the psychoanalyst. In such a situation consultation is indicated.

2. A psychoanalyst who undergoes a serious illness and extended convalescence, or whose analyzing capacities are impaired, must consult with a colleague and/or medical specialist to clarify the significance of his or her condition for continuing to work.

3. A request by a patient, a parent/guardian of a minor patient, or a colleague that the psychoanalyst seek consultation should receive respectful and reflective consideration.

4. If a psychoanalyst is officially notified by a representative of an institute or society that a possible impairment of his/her clinical judgment or analyzing ability exists, the psychoanalyst must consult with no less than two colleagues, one of whom may be a non-analyst medical specialist, each acceptable to the notifying body. If impairment is found, remedial measures be followed by the psychoanalyst in order to protect patients from harm and to prevent degradation of the standards of care in the profession.

5. It is ethical for a psychoanalyst to consult with the patient of a colleague without giving notice to the colleague, if the consultation has been requested by the patient.

6. It is ethical for a psychoanalyst to intervene on behalf of a colleague's patient if he or she has evidence from a direct or indirect consultation with the colleague's patient or from supervision of the colleague's work with the patient that the colleague may be conducting him/herself unethically toward the patient or may be so impaired as to threaten the patient's welfare.

7. It is ethical for a psychoanalyst to accept for treatment the current patient of a colleague if consultation with a third colleague indicates that it is in the best interest of the patient to do so.

8. In the event that a credible threat of imminent bodily harm to a third party by a patient becomes evident, the psychoanalyst should take reasonable appropriate steps to protect the third-party from bodily harm, and may breach patient confidentiality if necessary only to the extent necessary to prevent imminent harm from occurring. The same applies to a credible threat of suicide.

9. In the case of a minor where the psychoanalyst is concerned that a credible threat of serious self injury or suicide is imminent, the psychoanalyst should take appropriate steps. This would include the notification of parent(s) or guardian(s) even if a breach of confidentiality is required. Under these circumstances, any breach of confidentiality should be restricted to the minimum necessary to prevent harm of the minor child.

10. When a psychoanalyst becomes convinced that abuse is occurring the psychoanalyst may report adult or child abuse of a patient or by a patient to the appropriate governmental agency in keeping with local laws. Should the patient be a minor, informing parent(s) or guardian(s) needs to be considered. In these circumstances, confidentiality may be breached to the minimum extent necessary. However, in keeping with General Principle IX, a psychoanalyst may also refuse to comply with local reporting laws if that psychoanalyst believes that to do so would seriously undermine the treatment or damage the patient. Given the complexities of these matters, a psychoanalyst who is concerned that abuse of an adult or child is occurring is encouraged to continue to explore the situation and to consider utilizing consultation to determine what course of action would be most helpful.[3]

11. Local psychoanalytic societies and institutes have an obligation to promote the competence of their members and to initiate confidential inquiries in response to ethics complaints.

 

IX. Social Responsibility

1. The psychoanalyst should make use of all legal, civil, and administrative means to safeguard patients' rights to confidentiality, to ensure the protection of patient treatment records from third party access, and to utilize any other ethical measures to ensure and maintain the privacy essential to the conduct of psychoanalytic treatment.

2. The psychoanalyst is urged to support laws and social policies that promote the best interests of patients and the ethical practice of psychoanalysis.

3. The psychoanalyst is encouraged to contribute his or her time and talents, if necessary without monetary compensation, to consultative and educational activities intended to improve public welfare and enhance the quality of life for the mentally ill and economically deprived members of the community.

 

X. Integrity

1. Psychoanalysts and candidate psychoanalysts-in-training should be familiar with the Principles of Ethics and Standards, other applicable professional ethics codes, and their application to psychoanalysis.

2. Psychoanalysts should strive to be aware of their own beliefs, values, needs and limitations and to monitor how these personal interests impact their work.

3. Psychoanalysts should cooperate with ethics investigations and proceedings conducted in accordance with the Provision for Implementation of the Principles and Standards of Ethics for Psychoanalysts. Failure to cooperate is itself an ethics violation.