TEACHING PROFESSIONAL ETHICS IN PSYCHOANALYTIC INSTITUTES: Engaging the Inner Ethicist Merle Molofsky Teaching professional ethics in psychoanalytic institutes begins with two assumptions: (1) Students learn not only a code of ethics, they learn to develop their inner ethicist. (2) Institutes do not “train” students to become versed in a professional discipline, institutes educate, so students acquire a complex range of knowledge, developing intellectually and emotionally. Studying professional ethics begins with questions concerning freedom, free will, and responsibility, allowing students to contemplate emotionally charged topics: power politics, collegial relationships, organizational malfeasance, and boundary violations. Another area of concern involves the ability to observe and manage countertransference. Another related theme is trust: trust in supervisors, training analysts, instructors, and one’s own ability to process countertransference. Processing countertransference is a necessary ethical obligation. Instructors need to be aware of the emotional stresses involved in studying professional ethics, particularly in discussions of sexual boundary violations. Students developing an ethical stance can enhance creativity in psychoanalytic work.

O what of that, O what of that, What is there left to say? —W. B. Yeats, “The Curse of Cromwell”

I have taught courses in professional ethics in psychoanalysis at two psychoanalytic institutes, and at the first class of each semester I begin by saying that I do not know more about ethics than anyone else in the room. I say it because I believe it, and because I think it is the ethical thing to do. I may know more about the history of ethics in psychoanalysis, I may be more familiar with Psychoanalytic Review, 101(2), April 2014

© 2014 N.P.A.P.

198

MERLE MOLOFSKY

psychoanalytic codes of ethics, I may have read more books and articles about ethics in psychoanalysis or ethics in general than most students in the course, but I don’t know more about what is ethical. We study professional ethics in a psychoanalytic institute for many reasons. At the most pragmatic, we study because many institutes, in order to maintain a state charter, or comply with legislation, must offer a required course in professional ethics. We study to uphold the ethics and standards of our profession, our psychoanalytic community, and any psychoanalytic organizations with which we may be affiliated. We study to uphold the “prime directive,”—“first, do no harm.” We study to protect our analysands, our profession, our professional community and organizations, our colleagues, our students and supervisees, and ourselves. The time is always right to do the right thing. —Martin Luther King, “The Future of Integration” Relativity applies to physics, not ethics.

—Albert Einstein

To study professional ethics in a psychoanalytic institute begins with the semantics of study. Psychoanalytic institutes are called “training institutes.” Why? We use the term “training” when we are referring to the study of a particular discipline. We “train” to be a (fill in the blank). We use the term “education” when we are referring to the acquisition of knowledge, of further developing our mind, becoming conversant with ideas. “Training” has a narrower goal, “education” a broader goal. We seem to be stuck with a term that applies to mastering skills associated with a profession, when psychoanalysis, our profession, is much more than a skill set or even knowledge that can truly be manifested by passing a state licensing exam. Psychoanalysis is a multilayered discipline, a complex body of knowledge that might prove to be an amalgam of a broad range of ideas drawn from philosophy, psychology, mythology, folklore, literature, sociology, anthropology, and more. Psychoanalysis is an education not only of the intellect, but of the heart and soul, the emotional core of the always-­becoming, going-­ on-­being psychoanalyst. A psychoanalyst is always a psychoanalytic student.

TEACHING PROFESSIONAL ETHICS199

When we cut through duality . . . we develop a natural ethical stance because there is less division and alienation between self and object, self and other. —P. C. Cooper, personal communication

In his statement, Paul C. Cooper gives us a model for empathy based on integration, the healing of splits. Perhaps this empathic understanding is the basis for ethical treatment of others. Using this possibility as a base, we can ask the question, how do we understand the education of both mind and heart? The Chinese word xin does not have a correlative word in English. The best translation might be a compound word, “heart–mind.” In Chinese philosophy, heart and mind are one, and there is no difference between affective and cognitive states. They exist in a braid of experience. Perception is both felt and understood. The Chinese term Tao means Path or Way. We are guided by Tao, and when xin allies with Tao, we are in harmony with Nature. If, following Cooper’s insight, we heal dualities within ourselves, and develop an integration of heart and mind, feeling and thought, we are on a path toward further developing our ethical perspective. Perhaps then an intrinsic goal of studying psychoanalysis in a psychoanalytic institute is the same as the anticipated outcome of a successful psychoanalysis—authenticity and integration—resulting in what I would term a “natural ethical stance,” as dualities are set aside. Psychoanalytic education is an education of xin, heart– mind. Ideally, we learn to work as psychoanalysts with our full selves, our fully developed, fully integrated, fully authentic heart– minds. The obvious path in teaching professional ethics in psychoanalysis is to begin with the received wisdom: codes of ethics of the psychoanalytic institute, local and national organizations, and other “mental health” organizations. These codes often are thorough, detailed, meaningful, and even wise, yet to begin with established codes, received wisdom, is to place the emphasis on ethics from the outside, rather than from within the self. In the face of the words of Cooper that I cited, am I setting up a duality, a split? Yes. Ultimately, I think the split can be bridged, and healed. But initially, the split exists, the split between

200

MERLE MOLOFSKY

inner world and outer authority. By definition, a psychoanalytic institute establishes authority. People come to an institute to learn, to become proficient in a discipline. They assume, naturally, that institute faculty know more than the students do. And so they should—except . . . except when it comes to a sense of ethics. As the “authority” in the room, the instructor may need to challenge that very authority, may cede the authority to each and every person in the room. We may consider it natural that students at a psychoanalytic institute would identify with the perspectives of the perceived authorities, the instructors and members of the institute, the code of ethics recommended by the institute. We also have to consider their transferences, which may cause them to suspend their own judgments and values in deference to authority. Therefore the instructor has an ethical obligation to encourage students to consider their own understanding of ethical concerns, because those students eventually will be relying on their own ego functions in their clinical work. FREEDOM

Underlying every discussion of ethical conduct in the psychoanalytic situation and every other situation is the concept of freedom. Do we have free will? And, if so, what does that imply? When we postulate free will, we are engaged in an act of imagination in which we conceive of a human being with internal freedom to guide her or his own actions. How do we imagine such a human being? What constraints and limitations to personal freedom does a human being encounter? Physical constraints, either by virtue of innate or acquired physical limitations, such as illness or disabilities, or by external restraints, such as prison walls or leg irons and the like. Innate, “given” limitations of intelligence and intellectual understanding. Neurological impairment, such as Tourette’s syndrome. Brainwashing and extreme trauma, with the results of trauma manifesting in posttraumatic stress disorder. The manifold complexities of emotional considerations, both conscious and unconscious, with concomitant complexities regarding beliefs and morality. Unconscious process—aye, there’s the rub, unconscious conflict, emotional turmoil, thoughts and

TEACHING PROFESSIONAL ETHICS201

feelings and fantasies. If so much internal human experience is unconscious, how possible is free will for human beings? And for what can a human being be held responsible? I begin my Professional Ethics course with a discussion of freedom, a fast-­forward speed review of key concepts of freedom in Western philosophy, essentially drawing from Aristotle, Spinoza, and Kant. The first reading I assign is the Grand Inquisitor chapter from The Brothers Karamazov by Fyodor Dostoevsky, published in 1880, not a “standard psychoanalytic text.” Sigmund Freud called The Brothers Karamazov “the most magnificent novel ever written,” and wrote a paper “Dostoevsky and Parricide” (Freud, 1928; revision, 1945). I offer a thumbnail outline of the characters in the novel, as follows: Fyodor Karamazov, a rich, dissolute, hedonistic, aging landowner, has sired three legitimate sons by two women, both now dead. The three sons are symbolic representations of three aspects of the self: Dmitiri, the eldest son, is physical, sensual, emotional, and impulsive; Ivan, the middle son, is intellectual, rational, and an atheist; Alyosha, the youngest, is spiritual and highly moral. Ivan and Alyosha have the same mother. A fourth son, Smerdnyakov, is illegitimate, fathered by Fyodor on the “village idiot,” whom he most likely raped, and who died in childbirth. Smerdnyakov serves in his father’s household as a servant, disenfranchised, envious, and resentful. He does not share the Karamazov name; his last name means “son of the smelly stinking one,” referring to his mother’s status as poor and debased. I do not offer a plot summary, but I do offer some key information. Ivan, intellectual and atheist, has published an article that says that if there is no God, then anything is permissible—a concept that essentially translates as, if there is no outside authority, then people can do anything they want: They are free. This is a key issue in the novel. Instant thumbnail sketch: The father and his son Dmitri, both sensualists, are infatuated with the same woman—a loaded oedipal situation. Money is at stake. Someone murders the father and steals the money. Dmitri is the likely suspect. Spoiler alert: Dmitri is not the culprit. Smerdnyakov is. He has taken Ivan’s concept that if there is no God then anything is

202

MERLE MOLOFSKY

permissible to heart: He can do anything. Anything he wants. And he does. From a psychoanalytic perspective, we could surmise that his background of childhood abuse and trauma leave him with a powerful desire for revenge, and Ivan’s ideas become the basis for his rationalization of his murderous desires. The problem, of course, is, that if there is no ultimate outside authority, no God, to offer not only moral guidance, but judgment and punishment— or reward, of course—then people may take that as complete license, and may not develop their own “inner ethicist.” In the Grand Inquisitor chapter, Ivan tells Alyosha the story of a dramatic poem he is writing. Ivan’s story, thumbnail sketch: During the Spanish Inquisition, Jesus returns to earth: the long awaited Second Coming. He wanders through the streets, through the marketplace, in complete silence—but he performs miracles. The people recognize him, with awe and wonder and joy. The Grand Inquisitor is notified, immediately has Jesus arrested, and intends to burn him at the stake. The Grand Inquisitor challenges Jesus, telling him that when he refused to be tempted by Satan, and instead chose freedom, and offered freedom to humankind, he misjudged human nature. The Grand Inquisitor asserts that human beings cannot cope with freedom; they need to follow, to be led by powerful authority figures, by the Church. Jesus never answers him, but kisses him on the lips, and the Grand Inquisitor sets him free, telling him never to come back to earth again. And what is the Grand Inquisitor to psychoanalytic ethics, or psychoanalytic ethics to the Grand Inquisitor? Everything: freedom. Psychoanalysts have been told to follow a number of codes of ethics created by “higher authorities”—or, at least, authorities: professional organizations, membership associations, training institutes. During their training, psychoanalytic candidates are required to discuss their clinical work with supervisors. Upon graduation, certification, licensing, and they of course may continue to discuss their clinical work with supervisors, or peer groups. But as candidates and as independent professionals, they always are alone in their consulting rooms with their analysands. Big Brother is not watching. Is God? Certainly no one else is. Within the

TEACHING PROFESSIONAL ETHICS203

privacy of their own consulting rooms, they are “free” to conduct an analysis as they see fit. And they are “free” to transgress against the code if they so desire. Acknowledging this freedom is the essence of teaching professional ethics in psychoanalysis. Since deep psychoanalytic work involves unconscious symbolic process, the use of “The Grand Inquisitor” chapter serves to mobilize students’ awareness of symbolic process in analytic work, in the analytic dyad, and the freedom that the clinician encounters in working without being observed by anyone else. Rather than learning only through didactic texts, the students have an opportunity to learn from their response to the symbolism inherent in the drama of the chapter. Analytic candidates need to be aware of the extent of their own freedom, and the responsibility of being free, as they learn about and discuss the code(s) of ethics that they are told by “authorities” that they are expected to follow. They may dutifully “study” the code(s), acknowledge them, assume that they will “follow” them, but if they do not “inquire within” and pay attention to their own unconscious process, their countertransferences, their conflicts, they will not have adequately formulated an ethical stance that they can turn to when needed. In the brief review of essential ideas about ethics discussed by three major philosophers of Western civilization—Aristotle, Spinoza, and Kant—I point out that none of them tells people what is right and wrong, what people should do. They ask people to think. Freud is heir to the Western tradition of thinking, and the psychoanalytic method exemplifies this tradition, as Freud’s work encompasses making the unconscious conscious, embodying the Socratic dictum “Know thyself” in the statement “where id was, there ego will be” (Freud, 1933). I ask students to consider and discuss Aristotle’s notion that when a person remains true to her or his nature and self, that person will live ethically. I do not take a stance about the concept. Rather, I leave it up to the students to evaluate the idea that the person must mature in order to live up to her or his potential and that to achieve this, a person’s choices must be rational. I compare this concept to the concept of self-­realization, the desire to

204

MERLE MOLOFSKY

fulfill one’s potential, as elaborated by Maslow (1943) in his development of the idea of the hierarchy of needs, and with concepts of what the goal of psychoanalysis is. “To thine own self be true, / And it must follow, as the night the day, /Thou canst not then be false to any man” (Polonius in Hamlet, 1.3.539–541; Shakespeare, 1936). Spinoza also emphasizes rational choice, that reason is the foundation for ethical behavior. He claims that without reason, we are enslaved by our emotions. A psychoanalytic corollary to this might be that when we uncover unconscious affect and fantasy, when we understand the unconscious narrative, the “back story,” of our emotional response to the world, we have more choice. We are not subject to unconscious forces of which we are not aware. To endeavor to understand is the first and only basis of virtue —Baruch Spinoza, Ethics If you want the present to be different from the past, study the past. —Baruch Spinoza, Ethics

Spinoza’s ideas could be seen as contributing to an understanding of psychoanalytic process, and from that, psychoanalytic ­ethics, in that they emphasize the “endeavor to understand” and recognize the importance of understanding the past, which psychoanalysis addresses in uncovering crucial aspects of the past that have remained unknown, unconscious. I also introduce Kant’s idea of the categorical imperative, a concept that stirs up interest, concern, conflict, confusion, as it is a concept that challenges what we think we think. Kant’s concept of the categorical imperative states that for an ethical precept to be true, it must always be true, without exception, and must be universally applicable. As college sophomores taking their first philosophy course generally discover, the categorical imperative is baffling, because we face a dilemma: What if two categorical imperatives are in conflict with each other? “Always tell the truth” and “prevent murder” are two categorical imperatives that wind up in conflict. A classic example, which I recall from my own college philosophy course, involves someone, perhaps your own broth-

TEACHING PROFESSIONAL ETHICS205

er, coming to your door, begging, “Hide me, hide me, assassins are chasing me, they want to kill me.” And so you hide him. Moments later, along come the assassins (or the Gestapo, the rival gang, or the police—we shape the story to fit our cultural frame of reference) and the leader demands, “Is your brother here?” Conflict! It is wrong to lie! But if you say “Yes,” your brother will be killed, unjustly. What a dilemma. How do we resolve our moral dilemma? Yes, there is an out, an escape hatch. Caught on the horns of the categorical imperative dilemma, choose the moral command that has greater moral value. How do we apply this to psychoanalytic ethics? This is where the fun begins. The instructor can describe possible conflictual situations, and can invite the class members to imagine and invent their own conflictual situations, and discussion begins in earnest. The best discussions in earnest are discussions that engage the heart and mind and soul of the nascent psychoanalyst. Novels and philosophy are an excellent jumping off point for class discussions of psychoanalytic ethics. But psychoanalytic training institutes do not live by novels and philosophy alone. Fortunately, there is an excellent psychoanalytic literature to draw from, books and articles that address and illuminate the somewhat dry professional codes of ethics. One well-­known source is The Ethics Case Book, by Dewald and Clark (2007), published by the American Psychoanalytic Association. AWAKENING IMAGINATION

The Ethics Case Book contains the Code of Ethics of the American Psychoanalytic Association, and is organized into areas that address the concerns of the Code. When I teach, I emphasize that professional ethics do not apply to clinical situations alone, although our ethical obligation to the people with whom we work in our practice indeed is the centerpiece of psychoanalytic professional ethics. Yet to develop a sense of ethical responsibility in clinical practice, we have to understand the far-­reaching ethical issues of our profession. We need to understand our ethical responsibility to our colleagues and our profession. We need to re-

206

MERLE MOLOFSKY

alize that the organizations to which we belong, including the educational institute we are affiliated with, where we study, have an ethical obligation to us, and that we, as affiliates of those organizations, have an ethical obligation to the organizations as well. The Ethics Case Book offers lively vignettes in all the major ­areas of psychoanalytic ethics. An advantage of using these vignettes is that they bring to life what otherwise might be dry directives. Students have an opportunity to imagine, along with the book’s authors, various scenarios that might occur. Beyond the book itself, other possibilities arise Students and instructor might bring in their own vignettes, of actual events or acknowledged imagined events, actual problems encountered, and a host of what-­ifs. The advantage of using The Ethics Case Book as a springboard for other vignettes is that once the book itself brings possibilities to life, recounting actual circumstances or making up possible scenarios brings the issues even closer to home. Each organization has its own variations and nuances of organizational culture and style. Once students are able to imagine events happening in surroundings and circumstances that feel familiar, their potential for understanding increases. Of course discussing actual situations that arise in people’s practices, or other aspects of their psychoanalytic professional lives, ensures that the depth of experience continues to inform their understanding. In order to make the course feel even more alive, and to convey a sense of safety to the students, I also offer examples of ethical conflict from my own practice. If I can discuss my own dilemmas, then perhaps students would be encouraged to present their own. And they do. I generally provide simple, yet charged, examples. For instance, when I tell people in my practice that I am going on vacation, several ask to schedule extra sessions. I do use a sliding scale, so that I can work with people who cannot afford my full fee. In scheduling extra sessions, should I consider my income, or should I consider the needs of the individuals? Should I give a coveted hour to someone who pays a low fee, or someone who pays a high fee? They both have time constraints. I could rationalize a decision to choose based on fee by telling myself that if I protect my income, I can continue to take lower fee referrals. I

TEACHING PROFESSIONAL ETHICS207

need to recognize the rationalization for what it is, and make an ethical choice based on the individual’s needs. COUNTERTRANSFERENCE: A CENTRAL CONCERN OF PSYCHOANALYSIS, AND PSYCHOANALYTIC ETHICS

Because the transference/countertransference matrix is central to the understanding of psychoanalytic process, and attentiveness to processing countertransference is so personal an undertaking, students are eager to discuss this topic, and can be both shy about self-­revelation and pleased with discovering the safety of community in doing so. I have found that by providing a few necessary preliminary areas of discussion, students begin to offer their own experiences for discussion. Once again, The Ethics Case Book provides a lively and engrossing set of vignettes and poses a number of questions that students respond to and willingly address. Furthermore, I have found that when I begin to describe my own clinical experiences, including a gamut of countertransference responses—some that easily become consciously available, some that result in minor enactments—which are not ethical violations and which provide insight into the analysand’s dynamics as well as the analyst’s unconscious process, students gain confidence and trust, and offer their own experiences for discussion. I believe that the commitment to observing and processing our countertransference is a major ethical obligation in psychoanalytic practice. In emphasizing that commitment, I am careful to differentiate unethical enactments from the ordinary run-­of-­ the-­mill unavoidable enactments that have become an important focus in psychoanalytic literature. I point out that we learn from our enactments, and that the more aware of our countertransferences we become, the better analysts we become. Our ethical obligation, of course, is to become the best analyst we are each capable of becoming. I describe my awakening, during the early years of my analytic education, to the wonders of valuing my own emotional response to everything. Both in my “training” analysis, which of course was a deeply personal analysis, and in my supervision, I discovered the power of using my emotional response in the service of the analytic encounter. The benefit, of course, is

208

MERLE MOLOFSKY

that when we learn the value of using our emotional response in the analytic setting for the benefit of others, we also gain access to a core aspect of ourselves. Therefore, teaching the importance of attentiveness to countertransference as an ethical obligation also offers students an appreciation of how important it is to themselves, personally, as well. ORGANIZATIONAL RESPONSIBILITY

The obligation of psychoanalytic institutes and other psychoanalytic organizations to behave ethically and responsibly in relation to students enrolled at the institute or members of institutes and other organizations is not a neglected issue, but neither is it an issue that commands attention—unless attention is drawn to it. When professional organizations, and particularly educational organizations, fail in their ethical obligations, a major risk is that students will not only not learn how to consult their own inner ethicists and conduct themselves ethically in their practice and in their professional relationships, but that they may even learn unethical behaviors. The most pernicious, corrupt, unethical indoctrination occurs through identifications. Students exposed to an unethical professional culture may form identifications with those who create their culture, and hence, the students become part of the problem, and perpetuate the culture. Because I am aware of this risk, I assign two readings addressing issues of organizational responsibility early in my syllabus. One addresses an organizational failure embedded within a repressive political situation, and one addresses a cultlike indoctrination. In 2005, The Psychoanalytic Review published an article by Lucia Villela, “The Chalice of Silence and the Case That Refuses to Go Away.” This was the first time that an English-­language psychoanalytic journal published an account of a situation that arose in Brazil. The title of the article has a hidden depth of meaning, which Villela explains. Calice in Portuguese means chalice, and it also is homophonic with a Portuguese phrase meaning “keep silent.” Villela tells us that in the 1970s a well-­known Brazilian singer/composer, Chico Buarque, wrote a politically charged song

TEACHING PROFESSIONAL ETHICS209

with a refrain Calese, meaning keep silent, during a highly repressive, even dangerous, era. Thus her title is suited to her description of a shocking situation of the era, in which a Brazilian physician, who was a candidate at a psychoanalytic institute, and an analysand of the president of the institute, was working with the Brazilian army in a torture unit that tortured political prisoners. Another analytic candidate became aware of the situation, and notified someone who published a newsletter, and the physician/ analytic candidate working with the torture unit was identified in the newsletter. The person who anonymously identified him was named when her handwritten note identifying him was obtained and compared with all the handwritten material on file in the psychoanalytic institute. She was prevented from advancing further in the psychoanalytic institute’s hierarchy. The case became controversial; there were severe schisms in the psychoanalytic community; and eventually, after democracy was restored to Brazil in 1985, the International Psychoanalytic Association investigated the situation. I chose this article because the corruption in the psychoanalytic institution involved, in conjunction with the dangerous political situation in Brazil and the absolute depravity of a physician about to qualify as a psychoanalyst involving himself in torture, shows the ethical concerns of professional organizations at its most extreme. Villela (2005) comments, “This unavoidable interaction between the contingencies of a specific culture and the universality of being human poses a problem for all types of society” (p. 824). She says further, “When we are dealing with honorable men and things still keep getting muddled, Shakespeare ­notwithstanding, it is time to investigate not individuals but institutional structures” (p. 826). When and how better to take this lesson to heart, and to learn this essential truth, then during psychoanalytic training? The second article I use in approaching this topic is “Forced Discipline: Indoctrination Masquerading as Training in Psychotherapy,” by Richard Raubolt (2006), included in a book that he edited, Power Games. The article is autobiographical, and tells of a cultlike training Raubolt became enmeshed with, in an organization from which he had to tear himself away. The training focused

210

MERLE MOLOFSKY

on experiential group encounters, including mandatory attendance at such groups by spouses and significant others of the people involved in the training. The training program claimed to be psychodynamic. Raubolt describes the organization as coercive, using shaming methods, and essentially using brainwashing methods. The theme that tends to emerge in discussing Raubolt’s experience is best expressed by a book title, a 1935 novel by Sinclair Lewis, It Can’t Happen Here. Philip Roth’s 2004 novel, The Plot Against America, also hints at the same theme, a “what if” quality: What if it happened here? Could it happen here? Obviously it is highly unlikely that a manipulative cultlike experience could happen in a well-­established, reputable psychoanalytic institute. However, given the fact that reprehensible things did happen in a respected Brazilian psychoanalytic institute in the 1970s into the 1980s, should serve as a warning, should give us pause, and hence, should be safe-­guarded against. How? If we discuss these issues, these situations that seem so unlikely to come up, in a professional ethics class, then we are building a bulwark against any similar unethical occurrences. Since it is possible that initial warning signs might go unremarked, once awareness is established early in the psychoanalytic professional development of students, perhaps those warning signs will become immediately recognizable, and unfortunate situations will be forestalled. COLLEGIAL RESPONSIBILITY

Related to organizational responsibility is the awareness that we have an obligation to each other, as colleagues. How do we communicate this responsibility in teaching professional ethics? Perhaps an emotionally loaded topic is trust—trust that analytic candidates may or may not feel in their relationships with key people in their psychoanalytic education: their own psychoanalysts, and their supervisors. By beginning a discussion of professional obligations by discussing the role of the “training analyst” and the supervisor, students discover just how meaningful ethics is in professional relationships. Fewer and fewer institutes have “reporting analysts” today. “Training analysts” no longer report students’ “progress” in their

TEACHING PROFESSIONAL ETHICS211

analysis. Indeed, in discussion of the issue in ethics courses, often enough students are shocked by the concept. It has fallen by the wayside. Nevertheless, as it once was important in major American institutes, it still is a relevant topic. Can, and should, a student trust that her or his own analyst will put the student’s well-­being before the well-­being of the institute, or the profession? Indeed, is it in the student’s best interest to continue in an institute’s training program if the student has serious character flaws and is not suitable for psychoanalytic education? Who decides? Certainly, the student’s analyst most likely knows much more about the student than the student’s supervisor, instructors, or fellow candidates, may know. However, if a student knows that the analyst is reporting on “suitability,” will the candidate hold back, and have an inauthentic analysis, and perpetuate inauthenticity? These topics may not be of immediate relevance anymore, but they still lead to meaningful considerations. A particular “meaningful consideration,” a related concern, is trusting the supervisor. Supervisors indeed do file evaluations of analytic candidates with the institute. An important aspect of supervision involves candidate countertransference in a clinical situation. If the candidate is experiencing strong countertransference, and has to learn to identify and process countertransference, can the candidate trust the supervisor with such personal information? Is supervision the proper venue for doing so, or should all countertransference processing be confined to the candidate’s personal analysis? Yes? No? Why? Often, candidates have rich areas of personal life to discuss in their own analysis. Therefore, if they cannot discuss their countertransferences comfortably in a supervisory setting, will the countertransference issues fall by the wayside? Or, if they choose to discuss them in their own analysis, will the other personal issues fall by the wayside? By discussing trust issues in the supervisory session, students in a psychoanalytic ethics class gain a sense of the importance of trust in professional relationships, and the uses of supervision for their growth as analysts. Recognizing the ethical issues, and the trust issues, leads to students being able to assess their own needs and even their supervisors’ capabilities.

212

MERLE MOLOFSKY

BOUNDARY VIOLATIONS

A major area of concern in psychoanalytic ethics, reflected in all professional codes of ethics and commanding the attention of students, involves boundary crossings, transgressions, and violations. While some subject matter in professional ethics may take some students by surprise, every student I have encountered has been well aware of, and concerned about, the necessity of addressing boundary violations. Gabbard and Lester (2005) address both sexual and nonsexual boundary violations, and their book is of great value in teaching professional ethics in a psychoanalytic institute, both for the content and the readability. The subject matter understandably stirs up anxiety when it is discussed in an ethics class. Indeed, the subject matter does, and should, stir up anxiety in any discussion, for psychoanalysts and candidates. In teaching boundary violations, I decided to devote two full classes in a twelve-­week course to the subject, and found myself faced with a challenging choice: Should I begin with sexual or nonsexual boundary violations? Choosing to begin with sexual boundary violations meant bringing the underlying anxiety directly to the foreground, in a sense “getting it out of the way,” acknowledging what was on everyone’s mind. Choosing to begin with nonsexual boundary violations meant easing into the subject gently, like slowly wading into a swimming pool, rather than jumping in. I found myself guided by Gabbard and Lester’s (1995) arrangement of chapters in their book devoted to the subject of boundary violations. Chapter 6 addresses sexual boundary violations, and Chapter 7, nonsexual violations. Earlier chapters introduce the overall subject, providing a transition, before the authors get to the specifics of specific boundary violations, “main events” on which a psychoanalytic ethics course must focus. Ideally, it would be truly informative and meaningful for students to read and discuss the entire book, and, were the course to be offered as a full year, two-­term course, sixteen weeks a term, that would be feasible. However, since that is not the case, I do not teach the entire book, although I recommend that the stu-

TEACHING PROFESSIONAL ETHICS213

dents read it at leisure as they are able to, over time, perhaps as summer reading, as part of their commitment to the ethics of psychoanalytic work. As an instructor, I also have to consider that a course such as this, like every other course in a psychoanalytic education program, should offer multiple perspectives, and thus, readings chosen from multiple authors. The topic of sexual boundary violations in psychoanalysis discussed in class elicits gasps, tsk-­tsks, and other audible nonverbal responses, as well as facial expressions of shocked disbelief, anger, turmoil. And rightly so. Sexuality and psychoanalysis are intricately linked. Contemporary psychoanalytic education addresses Freud’s move from his theory that hysterical neurosis was caused by early sexual trauma to an elaborate theory of infantile sexuality, including unconscious sexual fantasy; sexual wishes; conflict; and fear of punishment, including genital mutilation, fixation, and more. Of course, Freud continued to consider trauma as a factor in psychic disturbance, and the psychoanalytic literature is rich in considering trauma in light of the strength of ego defenses and the fragility of the self. Psychoanalytic theory delves deeply into transference and countertransference fantasies, and offers an elaborated theory about trauma. Our contemporary culture is open to discussion of sexual abuse and sexual trauma, and the several recent decades of television shows such as Oprah and Doctor Phil encouraged a public openness to, and sympathy for, personal revelations. The most powerful factors of psychoanalytic theory that affect the response of students to discussions of sexual boundary violations are the necessary pervasive emphasis in psychoanalytic education on transference and countertransference, and the powerful emergence of contemporary psychoanalytic theory that addresses awareness of countertransference enactments by the analyst as a useful clinical tool. As a community, psychoanalysts and psychoanalytic candidates are deeply aware that the clinical situation can evoke early repressed unconscious wishes and fantasies of early childhood, and that analysands can yearn for the fulfillment of denied, repressed, and unresolved romantic desires for parental erotic response. Whether or not these wishes become

214

MERLE MOLOFSKY

the basis for acting-­out seductive behavior or any other form of a repetition compulsion, any reciprocity on the part of the analyst is countertherapeutic, and, if the analyst’s behavior escalates into seductive erotic activity of any sort, is patently destructive. In exploring other forms of counterindicated behavior on the part of the analyst, that is, unethical behaviors, students can and do express surprise, outrage, anger, bewilderment—a gamut of responses. Yet nothing else evokes the extreme distress that the crossing of sexual boundaries in clinical situations does in class discussions. Our understanding of the intensity of transference fantasy is magnified by our awareness of our own, personal vulnerability, our own wrestling with our fantasies, in our roles of both analysand and analyst. Every analyst, every analytic candidate, is or has been an analysand. It is precisely our vulnerability that helps us fully comprehend the necessity to avoid sexual boundary violations. In a psychoanalytic ethics course, once we establish a language of ethical discourse, as we discuss various difficult and disturbing scenarios, the instructor can create an atmosphere that helps students feel increasing confidence and trust. Thus, exploring these highly sensitive issues involves a shift from shock and fear, to relief. Teaching a course in psychoanalytic ethics therefore means that the instructor has to be highly sensitive to the sensibilities of the students and their emotional responses to highly charged subjects. By initially exploring other difficult topics, such as institutional violations, with all their myriad scenarios, the students can more easily tolerate the plunge into the cold water that the topic of sexual boundary violations feels like. Eventually discussion can focus on the characterological problems of clinicians who violate sexual boundaries. Students easily recognize the psychopathic or antisocial character of a predatory analyst. Seeing such analysts as deeply unprincipled people helps students cope with their anger and outrage. When they begin to contemplate other characterological issues, such as the lovesick or emotionally vulnerable analyst, they are faced with a test of their own capacity for empathy. The shift from a stance that proclaims, “I would never do that!” to an attitude that says, “I would never do that, but I can understand

TEACHING PROFESSIONAL ETHICS215

the suffering of someone who would, even if that suffering person causes even worse suffering,” is itself an advance in an ethical therapeutic attitude. Understanding does not mean condoning. INTEGRATION

A related topic that a course in psychoanalytic ethics addresses is our ethical stance toward our colleagues. For instance, if we observe that a colleague seems to have a problem that is interfering with his or her capacity to function as an analyst, what is our responsibility to that colleague? Further, what is our responsibility to that colleague’s analysands, and to the psychoanalytic community at large? Discussing these issues can result in a group sense among the students of compassion and concern, an awareness of the poignancy of the vulnerability of an analyst. Can that compassion and concern be extended to a colleague who has committed a sexual violation of boundaries? Is it possible to empathize with that colleague? Those questions can result in “instant recoil,” a strong sense of repugnance. Further exploration of that response can lead to a strong sense of ambivalence, a mingling of outrage with sorrow. How can an instructor help students address these ambivalent responses? Analytic empathy does involve the ability to imagine walking a mile in someone’s shoes—or perhaps just a few steps in those shoes. There are no easy answers. There are straightforward answers, though. I have not come across any students who would condone the enacted violating behaviors. Nor have I come across any analysts who would, either. Of all the situations described in The Ethics Case Book, none evinces a universal response other than sexual boundary violations. Other situations may evince an initial universal response, yet often students begin to modify their beliefs as discussion unfolds. One way of addressing the dilemma of conflicting feelings in contemplating a transgressive analyst is bringing up another ethical concern: outreach. Most psychoanalytic institutes have some sort of outreach committee for analysts in distress, a committee that a concerned colleague might refer a distressed colleague to,

216

MERLE MOLOFSKY

or might directly contact. A colleague outreach committee is not a panacea, not a solution, but it does provide a model for understanding and concern. Reporting blatant unethical behavior to a governing body is a grave matter, and thus discussing the response to an awareness of sexual boundary violation inevitably will result in a discussion of a course of action. Should it be reported? Who should report? What should be done? The discussion can open further areas of inquiry. What other ethical violations should be reported? Why? When? By whom? In these discussions, what emerges is pertinent to the basic philosophical stance I take teaching psychoanalytic ethics. I know the codes, the standards, I know the literature. But I am not the exemplar of ethics. My beliefs, my sense of what should be done, is not necessarily more refined than anyone else’s in a class. Ultimately, the practicum of discussing a broad range of ethical issues, with all their ramifications, is what helps analytic candidates build a knowledge base, and develop their inner ethicist. Perhaps the most desirable outcome is that students will internalize the importance of maintaining an ongoing concern for ethical behavior in clinical practice, a concern that will neither overwhelm their ego functions so that they lose their sense of what is truly ethical and act out, nor inhibit their creativity.

REFERENCES

Dewald, P. A., & Clark, R. W., eds. (2007). The ethics case book. New York: American Psychoanalytic Association. Dostoevsky, F. (n.d.). The brothers Karamazov (C. Garnett, trans.). New York: Modern Library. Freud, S. (1928). Dostoevsky and parricide. In J. S. Strachey, ed. and trans, The standard edition of the complete psychological works of Sigmund Freud, 24 vols. London: Hogarth Press, 1953–1974. 21:173–194. ______ (1933). New introductory lectures on psychoanalysis. Standard ed., 22:1– 182. ______ (1945). Dostoevsky and parricide [rev.]. Internat. J. Psycho-­Anal., 26(1/ 2):1–8. Gabbard, G. O., & Lester, G. P. (1995). Boundaries and boundary violations in psychoanalysis. Washington, D.C.: American Psychiatric Publishing. Maslow, A. H. (1943). A theory of human motivation. Psycholog. Rev., 50 :370– 396.

TEACHING PROFESSIONAL ETHICS217

Raubolt, R., ed. (2006). Power games. New York: Other Press. Shakespeare, W. (1936). The complete works of William Shakespeare. New York: Doubleday. Spinoza, B. (2005). Ethics (E. Curley, trans.). London: Penguin. Villela, L. (2005). The chalice of silence and the case that refuses to go away. Psychoanal. Rev., 92:807–828.

26 W. 9th St., Suite 2B New York, NY 10011 E-­mail: [email protected]

The Psychoanalytic Review Vol. 101, No. 2, April 2014