ACADEMY FOR THE STUDY OF THE PSYCHOANALYTIC ARTS:

ACADEMY FOR THE STUDY OF THE PSYCHOANALYTIC ARTS:

  A RESPONSE TO THE NARROWING SCOPE OF PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY

      Patrick B. Kavanaugh, Ph.D. 

Premised in a paradigm of biology, medicine and the natural sciences, psychology and psychoanalysis have developed in the United States as empirically based health care professions concerned with repairing and normalizing pathological structures, states of mind, behaviors, and ways of thinking.  Infused with a medical ideology, psychoanalytic psychology has become a medical psychology.  And the scope of psychoanalysis increasingly narrows as the analytic practitioner and educator are subsumed by the ever-changing and restrictive rules and regulations of the healthcare professions.  Some years ago, a group of practitioners and educators formed the Academy for the Study of the Psychoanalytic Arts, organized around the scholarly objectives of participating in the project of rethinking psychoanalytic epistemology, theory, practice, education, and ethics situated in philosophy, the humanities and the arts. And, actively advancing this rethinking in the marketplace of ideas.

Since its beginnings in the early '80s, the Michigan Society for Psychoanalytic Psychology (MSPP) has provided a philosophical and professional home for those in Michigan interested in psychoanalytic psychology. In the mid '90s, the MSPP provided the space to develop a different conceptual and philosophical home for psychoanalysis and psychoanalytic psychotherapy through the formation of a new section, the Academy for the Study of the Psychoanalytic Arts.

By act of Congress in ’89, the ‘90’s had been declared to be “The Decade of the Brain” and, literally, billions of dollars were channeled into research and development focusing on the bio-medical basis of human behaviors, and emphasizing the neurosciences and bio-chemistry. The Academy’s formation was prompted by the ensuing institutional discourses -cultural, political, legal, social, and economic- that were coming together during the mid-‘90’s to transform the healthcare sector into an increasingly centralized system having the authority and decision-making powers to implement and require adherence to a uniformity of healthcare policies and procedures, thereby impacting and redefining our educational philosophies and programs, therapeutic philosophies and settings, and healthcare objectives and delivery systems.

While the conceptual understandings of human behavior were being reductively and scientifically redefined, our graduate school programs in psychology were being revised and reshaped in accordance with this bio-medical scientific vision by accrediting institutions. Future generations of practitioners were to learn the new core bodies of knowledge(s) and practice from within the managed care model" of service delivery. A bio-chemical imbalance model was favored and advanced by the major pharmaceuticals, medical insurance programs, and various governmental entities in the newly designed healthcare delivery systems: The bio-chemical model was more time- and cost-effective. The ‘90’s witnessed the medical-scientific narrative  gaining dominance in healthcare.

The industrialization of the healthcare professions, including the mental health professions, came to define for the educator and practitioner how to conceptualize and practice within the emerging healthcare matrix. And an emphasis on outcome-based education led to an emphasis on outcome-based therapy The "appropriate" and "necessary" types of treatment for individuals were prescribed through the establishment of treatment guidelines for specific diagnostic conditions; the empirically established “best practices” were encoded in manuals prescribing the appropriate treatment. And conformity and compliance with the approved “best practices” was advanced as the standard of excellence in the learning and practice communities.

And, the Decade of the Brain witnessed the beginnings of the various re-definitions of the mental healthcare professional’s ‘professional standards:’ ethical standards and principles, standards of education and training, standards of practice, and standards of care. The duties, functions, and responsibilities of the mental health professional as educator and practitioner continue to be re-defined and revised by various governmental entities, institutional entities, and accrediting bodies. 

Formation of the Academy

Responding to the emerging trends of the healthcare reformation, a small group of concerned educators and practitioners met in ‘95 to form a new section within the MSPP, the Academy for the Study of the Psychoanalytic Arts. The formation of the Academy was based on the growing concern that these powerful cultural discourses were restrictively defining psychoanalysis and psychoanalytic psychotherapy as exclusively a function or specialty of the healthcare professions, and as being "appropriate" for only certain diagnostic conditions or for.

In ’27, Freud made the observation that "Psychoanalysis falls under the head of psychology; not of medical psychology in the old sense, nor of psychology of morbid processes, but simply of psychology." And yet, medicine appropriated psychology –and psychoanalysis- in this country. Or, perhaps more accurately, psychology and psychoanalysis fought to be appropriated. Either way, psychology and psychoanalysis have become  institutionalized and deeply entrenched as a medical profession and practice. Specifically, understandings of the human condition and mental phenomena traditionally have been conceptualized and taught from within the contextual metaphor of mental health and illness, diagnosis and treatment, and various theories of cure and curative factors. And, understandings of people and their ways of being are understood and interpreted within medicine’s organizing conceptual framework of symptomatology, etiology and psychopathology. And the beat goes on…  With congressional passage of such healthcare legislation as HIPPA (1996) and, more recently, the Affordable Healthcare Act (2009), it becomes increasingly difficult for psychoanalytic practitioners to conceptualize and practice outside of the healthcare matrix and its evolving standards of practice. And given the advent of electronic medical records and “the need to know” by so many institutional and governmental entities, confidentiality becomes more and more difficult to maintain in a therapeutic discourse.

The Academy’s project centers on the rethinking of the psychology of psychoanalysis as fundamentally other than a medical psychology, and the practice of psychoanalysis and psychoanalytic psychotherapy as being fundamentally other than a specialty of the mental healthcare professions. The project involves rethinking psychoanalysis and psychoanalytic psychotherapy from within a psychological –as opposed to a medical-scientific- framework and to articulate a humanistic way of understanding and working with people, the understandings of which are premised in philosophy, the humanities, and the arts: for example, the philosophy of language, semiotics, linguistics, narrative story, and the performance arts.  

The Academy's project includes the presentation of an ongoing series of forums and symposia, and a cyber presence, to which those from other disciplines such as philosophy, the theatre, and the anthropic sciences, for example, are most welcome to come and participate in the ongoing debate, deliberation and discourse (www.academyanalyticarts.org/).

The Academy’s project also includes presenting through its website to the community-at-large that there is a confidential psychoanalytic discourse and space available in the community that does not require that the participants make quasi-public declarations of sickness, illness, disease, disorder, or disturbance in order to participate in its discourse of self-discovery and self-determination and, in so doing, addressing one's quality of life, and in which discourse the length, duration, and objectives of the endeavor are based upon mutual agreement between the participants.

Lastly, the Academy’s project includes the opportunity for interested individuals to participate in student-centered programs of study that are self-designed and self-implemented –as opposed to the more traditional Institute-centered programs in the medical–scientific tradition- for the practice of psychoanalysis and psychoanalytic psychotherapy.  

An earlier version of this article was originally published in the February 1995 newsletter of the Michigan Society for Psychoanalytic Psychology (MSPP). 

A New HIPAA-cratic Oath for Healthcare Professionals:

                           A New HIPAA-cratic Oath for Healthcare Professionals:

                               On the Questions of Privacy and Confidentiality

                                                           

                                                                        by

                                                    Patrick B. Kavanaugh, Ph.D.

Born on the Greek island of Kos in the early 5^thcentury BC, Hippocrates is widely considered to be the Father of Medicine in the westernized cultures. Acknowledged as the first physician to separate the discipline of medicine from religion, he believed that diseases were caused by environmental factors, diet and living habits, not a punishment inflicted by the gods. His therapeutic approach was based on the healing power of nature in which, he believed, the body contains within itself the power to rebalance and heal itself. His therapy focused on simply easing this natural process.

   Hippocrates taught and practiced a humble, passive and respectful form of medicine. His Hippocratic Oath, a seminal document on the ethics of medical practice, serves as a foundation for other similar oaths and laws that define good medical practice and ethics, the cardinal principle of which is,

                                                Primum non nocerum.

                                                   (First do no harm)

   The Hippocratic Oath is taken by physicians, physicians assistants, and other healthcare professionals upon entering their respective professions. It is one of the oldest binding documents in history. Written in antiquity, its principles are held sacred by doctors to this day: treat the sick to the best of one's ability, preserve patient privacy, teach the secrets of medicine to the next generation, and so on. "The Oath of Hippocrates," holds the American Medical Association's Code of Medical Ethics (1996 edition), "has remained in Western civilization as an expression of ideal conduct for the physician." In taking the Oath, each healthcare professional pledges to practice medicine ethically and to the best of his or her ability and judgment.

The oath speaks to a series of professional ethical and moral standards of practice, not the least of which pertains to the significance of privacy and confidentiality in the practice of healthcare:

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

—Translation from the Greek by Ludwig Edelstein.

From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

Since ancient times, the foundational significance and necessity of privacy and confidentiality in the physician-patient relationship has been recognized, appreciated and respected in the healthcare professions and by society. With government and health-care organizations demanding patient information as never before, however, how can a physician, psychologist, or psychoanalyst maintain a patient's privacy? How can he or she maintain a patient’s confidentiality in our highly technocratic -and ruthlessly efficient- IT systems? Does the cardinal principle, “Do no harm,” still apply to the healthcare practitioner and setting in terms of the ethics of privacy and confidentiality? Has the Hippocratic Oath transformed from an invaluable moral guide to a meaningless relic, a pro forma ritual?

Unfortunately, the Hippocratic Oath is being replaced by a more progressive and contemporary version: the HIPPA-cratic Oath. While they might sound the same, there are profound and far-reaching differences between the two.

The New HIPPA-cratic Oath

Passed in Congress with broad bipartisan support, the privacy rules of the Health Insurance Portabiltity and Accountability Act of 1996 (HIPAA) went into effect for most covered entities some years ago. And the American Association of Physicians and Surgeons (AAPS), among other groups, went to court to protest HIPAA and the privacy provisions developed by the Department of Health and Human Services (HHS). Based on their analysis of HIPPA and its privacy provisions, AAPS wrote to the HHS secretary,

                        In a nutshell, we object to the way the rule gives greater rights of

                        access to the government than to the patient himself ... There is no

                        justification for permitting public health surveillance and dissemination

                        of personal medical records.

                                                The American Association of Physician and Surgeons

And further, the AAPS warned the HHS secretary in a separate letter that the regulations,

                        ...would have unintended consequences: the worst would be to enable

                        if not guarantee wholesale invasions of privacy. We fully support the

                        effort in Congress to repeal this work of the previous administration.”

                                                The American Association of Physician and Surgeons

Do the HIPAA privacy provisions from HHS not protect patient privacy? In practice, the permitted uses and disclosures of patient information under HIPAA are anything the government authorizes - without patient authorization. And, the Institute for Health Freedom, a nonpartisan think tank in Washington D.C. that analyzes healthcare issues, made known its grave concerns about the HIPAA privacy provisions. After studying the 1,200-page regulation, president Sue Blevins said,

                         The rule does not provide true medical privacy. Rather it actually

                        weakens individuals’ ability to restrict access to their medical records.

                                                                                    defendyourprivacy.com:FAQ

   With the HIPAA requirements, it appears that the privacy and confidentiality of medical information is not solidly protected. The HIPAA-cratic oath requires the entry of personal and private information into a nationwide computer data-base from which it can be accessed by dozens of governmental entities and agencies, thousands of bureaucrats, pharmaceutical corporations, private insurance companies, police agencies, foreign government officials, and others - without the person’s consent. According to the AAPS’s analysis of HIPAA, this is what happens to information in the HIPAA IT systems. Furthermore, the sharing of records and information can take place for purposes that include: reporting physical, sexual, and emotional abuse, health oversight activities, law enforcement, judicial and administrative proceedings, organ procurement, military and intelligence functions, workers compensation, healthcare research projects, marketing health-related products and services, and providing the data-base for health-related fund raising projects.

   In many respects, the HIPPA-cratic Oath of contemporary times has replaced the Hippocratic Oath of ancient times. And the impersonal rules and regulations of the new HIPPA-cratic Oath provide for the technocratic rationality that governs the use and dispersal of private, personal, and confidential information. The industrialization and de-professionalization of the healthcare professions continues unabated as the healthcare reformation redefines the professional standards of the healthcare professional according to its wisdoms, rationality, and values.

The New HIPAA-cratic Oath: Organized Psychology and Psychoanalysis

With the enactment of HIPAA, there has been a radical, dramatic, and disturbing shift in the nature of the relationship between the government, various professional associations, and the citizenry. Recent years have witnessed a ruptured break from the traditional commitment of society to the individual and a corresponding shift to the commitment to “the best interests of” the collective. Coupled with the more recent passage of the Affordable Health Care Act of 2009 and its privacy provisions, and the implementation of electronic medical records by various hospitals and clinics, steps are taken towards the increased centralization of authority and decision making power in various governmental entities regarding issues of privacy and confidentiality, particularly as it pertains to physical healthcare information gathered in the consulting room. 

   And, what about the profession and practice of psychology and psychoanalysis in this changing healthcare matrix? Specifically, what happens to confidential and private information in the “talking therapy” of psychology and psychoanalysis? By history and politics, organized psychology and psychoanalysis have allied themselves with the scientific vision of the medical community, have identified themselves as healthcare professionals, and have adopted the purpose and ethics of the physical healthcare professions. As such, psychology and psychoanalysis respectively fall under the rules and regulations of the new HIPPA-cratic Oath.

   Strict confidentiality is the cornerstone of a psychotherapeutic and psychoanalytic discourse. In The New Informants: The Betrayal of Confidentiality in Psychoanalysis and Psychotherapy, Bollas and Sundelson (1996) assert that the practice of observing therapeutic confidentiality is so riddled with exceptions that it has all but disappeared in the analytic and psychological community. Their book considers the disappearance of privacy in the therapeutic community and, further, how this loss has been destructive to the integrity of both the profession and practice psychotherapy and psychoanalysis. Consider if you will, the various duties to warn, report, and medicate. The psychological practitioner, psychoanalytic or otherwise, has the ethical duty and responsibility to protect the patient from him or herself, protect society from the patient, protect the patient from society, and protect the patient from the unscrupulous practitioner – including him or herself. In many respects, the practitioner is expected by ethics and law to function in loco parentis for those who consult with them.

   What positions have the political and educational institutions of psychology and psychoanalysis taken regarding HIPPA and other such actions taken by congress? For the most part, the focus of our professional associations has been on advancing new healthcare delivery systems, developing empirically based “best practices” for the practice community, outcome-based education for the learning community, and working towards the seamless implementation of HIPPA, the Affordable Health Care Act (2009), and electronic medical records. Apparently, it now takes a village of educrats, bureaucrats, governmental agencies, and professional associations to mandate, monitor and mediate matters of privacy and confidentiality.

    One of the observations made in the AAPS’s analysis of HIPAA is that most professional associations, consultants, seminar producers, and lawyers neglect to advise physicians – and metaphysicians- of the option of being a non-covered entity under the HIPAA Act. And unfortunately, this seems to hold true in the psychological community as well. HIPAA, for example, is talked about in terms of how to be compliant as a covered entity; the option of being a non-covered entity is rarely mentioned, much less considered.

   HIPAA-related information and questions presented to the practice community through conferences and workshops are usually organized around encouraging the practitioner’s compliance with the rules and regulations of the new HIPPA-cratic Oath: Are you aware of the requirements mental health professionals must meet to be HIPAA-compliant? Are you aware of the new liability risks posed for mental health professionals by the HIPAA privacy regulations for non-compliance? Are you aware of what the state or federal penalties might be if the proper forms are not kept, or the wrong information is released? and, Are you aware of how unforgiving the HHS might be if you are not HIPAA-compliant and violations inadvertently occur?

   It seems that considerable time, money, and effort have been spent by our professional associations and organizations on the question of becoming HIPAA-compliant rather than, as with the AAPS, protesting those privacy rules and regulations that might compromise the privacy and confidentiality of the therapeutic space. Very little resources, however, seem to have been spent on critically assessing HIPPA’s impact on the practice and profession of psychology or psychoanalysis.

   More and more our professional associations seem too willing to turn to the government to validate our standards of practice (licensing laws), our bodies of knowledge(s) and outcome based educational programs (national healthcare accreditation standards and licensing exams), and our scientific view of people and outcome based treatments (EBT’s, DSM-IV and the soon to be DSM-V). Regulations regulate; standards standardize; and, institutions institutionalize.

   The Hippocratic Oath is concerned with medical practice and ethics. Are there any plans to survey the psychological or psychoanalytical community to determine HIPPA’s impact on issues of confidentiality and privacy on the therapeutic discourse? Is there any opposition to the HIPPA or Affordable Health Care Act’s (2009) privacy rules by our national or state associations or organizations? It seems rather HIPAA-critical for our professional organizations to do otherwise as confidentiality is the cornerstone of the therapeutic endeavor.

   It might make it easier for people to consider speaking with someone in a therapeutic discourse if her or his personal and private information stays in the consulting room, unless she or he specifically authorizes its release.