Legal, Ethical, and Professional Issues in Psychoanalysis and Psychotherapy
Psychology: A Profession and Practice At Risk
A Position Paper Adopted by the
Michigan Psychological Association (MPA), July 1994
The Decade of the 90's has witnessed the emergence and rapid development of three identifiable and disconcerting trends which quite directly impinge upon the practice and profession of psychology: the "industrialization of the health care professions", the prominence of a bio-reductionistic way of conceptualizing human behavior in the formulation of health care policy and in the design of health care delivery systems at the national level, and the adoption of the "managed Care Model" for the delivery of such health care services. Considered in combination, these trends have had a profound and, all too often, under recognized impact on the professional status of health care providers. Psychologists currently face unprecedented challenges to their professionalism and professional autonomy, regardless of one's specific function and area of specialization, e.g. diagnostic assessment, psychotherapy, neuropsychology, behavioral medicine, or the setting within which one practices, e.g. hospital (private or public sector), Community Mental Health, Day Treatment Programs, outpatient clinics, or private practice. One of the most far reaching of the challenges posed to the psychologist's professional status and autonomy by these trends is the functional redefinition of the profession of psychology as a craft in which therapists become interchangeable and diagnosis determines the prescribed treatment plan. Irrespective of one’s area of clinical specialization, theoretical orientation, or the setting within which one practices, such policy formulations constitute a threat to professional integrity.
A profession, as distinguished from a craft, is a vocation in which some body of valid and reliable scientific knowledge is developed and utilized in the service of discharging the functions of the profession. Further, every profession is characterized by certain aspirational goals and ethical standards of conduct which are intended to serve as guides for each of its members in their professional and scientific activities and to serve as the highest ideals of the profession for each member.
Historically, there has been a social contract entered into between members of a profession on the one hand and members of society on the other. Entry into a profession brings with it clear and well-defined expectations and responsibilities such as dedication to truth, ethics, integrity, and other such values, all of which take precedence over monetary ones. In sum, the profession holds itself accountable to the highest of ethical and professional standards. In return for its devotion to the values to which it subscribes, society grants to the profession certain essential and defining rights and privileges including the right of self regulation, autonomy of function in pursuit of professional objectives, the right of discretionary judgement in the performance of professional activities, and the right of privacy in the best interests of those whom the profession serves.
Entry into the profession of psychology brings with it certain well-defined expectations and responsibilities attendant to professional life as are embodied in the APA Ethics Code. These include for each psychologist the expectations and obligations: to uphold professional standards of conduct; to serve the best interests of those with whom there is a professional relationship; to be concerned with the ethical compliance of colleagues in their scientific and professional conduct; to be respectful of the fundamental rights, dignity, and worth of all people which would include the rights of individuals to privacy, confidentiality, self determination, and autonomy; to contribute to the development of a valid and reliable body of scientific knowledge; to improve the conditions of both the individual and of society; to weigh the welfare and the rights of those served; to meet certain professional and scientific responsibilities to the community and society in which they work and live; and to contribute a portion of their professional time "for the good" of the individual and/or the community through either teaching, training, practice or some other professional contribution. Clearly, the ethical obligations and responsibilities associated with being a psychologist extend to those issues surrounding the delivery of psychological services. For example, the psychologist is continuously forming clinical impressions, reassessing and revising treatment interventions, as well as the overall treatment plan, based upon dynamic information as evaluated in the context of clinical experience and judgement. Fees are negotiated when possible and when realistically indicated, taking into account the recipient's resources and the services indicated, providing only those services considered to be "appropriate and necessary". Psychologists are also involved in a continuing process of education, consultation when indicated, and in the development and refinement of clinical skills.
As healthcare becomes more industrialized, professionals are no longer named as such, considered to be, or treated as "professionals". As part of the redefinition of the health care professions, psychologists and other professionals are thus designated as "providers" or "vendors" in the vernacular of the industry. More importantly, health care professionals are viewed as craftspersons rather than professionals. This current trend towards the "industrialization" of the profession proceeds from the largely unquestioned premise that the profession and the practice of psychology is a craft; that psychologists comprise a "cottage industry" of loosely organized and minimally regulated craftspeople; and, that the next evolutionary step for the profession is to adapt to the health care systems being devised and to practice from within these systems. Considered in combination, the current trends of industrialization, bio-reductionism, and managed care models are functionally serving to redefine the profession of psychology, at great cost to the profession and, ultimately, to the members of society it serves. More specifically, with the increased "industrialization" of the profession and of the practice of psychology, there is a corresponding intolerance within this bureaucratized milieu for the exercise of professional discretionary judgement by the psychologist. Bureaucratization in the form of regulation of professional activities, formularized treatment plans, and the implementation of the formulary becomes the institutionalized adversary of discretionary judgement. It is this discretionary judgement which is one of the central and defining characteristics of the profession of psychology and one of its greatest strengths. These trends have served to further remove the discretionary professional judgement of the psychologist from the clinical situation. With the development of health care service delivery systems based upon cost management factors and the evaluation of such systems based upon cost effectiveness factors, the increasing "industrialization" of the profession has placed the psychologist squarely within a bureaucratic maze of procedure and regulation. Professional judgement is being replaced with the rather mechanical application of prescribed treatment plans based upon diagnostic classification. Professionals thus are expected to be laborers on the factory floor of the health care industry without independent judgement, concern for recipients, or freedom to function independently and in privacy.
If these current trends continue, large numbers of psychologists and a large percentage of psychological services will be incorporated into this highly bureaucratized system of service delivery in both the public and private sector. There are certain pragmatic consequences for the practitioner and for the recipient of psychological services which derive from these current trends. Namely, limits are imposed upon the autonomy of the practitioner and of the recipient to choose not to participate in either the prevailing system of health care delivery; or in the prevalent conceptual model of symptomatology, pathology, and etiology; or in the particular treatment plan determined to be "appropriate and necessary" as prescribed by various practice and treatment guidelines. The type, frequency, duration, objectives of treatment and every other aspect of service as well as the fee arrangements for the psychological services will be prescribed and regulated for both the practitioner and the recipient. With the practitioner viewed as craftsperson, then that practitioner is considered to be interchangeable with any other craftsperson who is equally well trained and has a demonstrated competency with particular treatment applications for certain diagnostic conditions. This interchangeability of providers proceeds upon a premise that neither recognizes nor appreciates the clinical relationship as a unique ingredient in the delivery of psychological services. The uniqueness of the individual gets lost in the implementation of formularized treatment plans which seek to manage the frequency, quality, and duration of treatment. Lastly, the necessary transmission of personal and sensitive information to various individuals (e.g., gatekeepers, utilization review committees, quality assurance committees) in such a bureaucratized system erodes and compromises confidentiality. Thus, for many private practitioners the entrance of third parties serves to dilute if not distort the conditions necessary for the delivery of psychological services. For example, for many practitioners, the fee arrangements between themselves and the recipient of the services are considered to be an integral aspect of the psychological services being provided. To remove the responsibility for determining the fee arrangements from the recipient and the provider is to remove an essential and indispensable aspect of the treatment from the clinical situation.
When the current trends, in effect, mandate that the treatment formulary to be implemented derives from a bio-reductionistic way of conceptualizing and treating human behavior, then there is an essential question to be confronted by our profession: At what cost do we limit our collective response to that of adaptation to the redefinitions of our profession and practice by policymakers and legislative actions? Ultimately, it would be at a great cost to the profession, to the practice, and to the recipients of psychological services to forgo a psychological way of understanding and working with people. To limit our collective efforts to a reflexive adaptation to policy and legislative redefinitions of the profession of psychology is to participate in the gradual dilution of professional functioning and responsibility, the erosion of a psychological way of understanding and working with people, and in the eventual demise of the profession of psychology.
It is the position of the Michigan Psychological Association (MPA) that the preservation and safeguarding of the essential and defining characteristics of clinical practice is fundamental and crucial to the profession and to the public it serves. The advantages and benefits which derive from the preservation of these essential characteristics could be succinctly grouped as: (1) cost containment advantages, (2) utilization of "appropriate and necessary" services, (3) preservation of conceptual diversity, and (4) innovations in theory and advances in technique with different populations. By way of brief elaboration: When financial responsibility and accountability are removed from the clinical relationship of the practitioner and the recipient, costs have escalated exponentially. Several sources have traditionally contributed to this escalation of costs. As any psychologist intern knows, clinicians who are not directly responsible for costs tend not to concern themselves with "cost effectiveness" in the work they do together. In most health care systems, costs become inflated with each added layering of staff and personnel within the bureaucracy which generate more regulations, requirements, and reviews. Within the organizational system, there are pressures to evaluate the practitioners' competence based upon a quantification of service units provided. For practitioners, justification for their position within the organizational system rests upon this evaluation.
There are legitimate purposes and goals in the practice of psychological services beyond and/or in addition to the amelioration of symptoms which bear quite directly upon this question of cost containment. First amongst these goals is that of prevention. Prevention can frequently take the form of providing services for psychological difficulties that otherwise would be manifested in frequent visits to the primary physician for "physical complaints". "Problems in Living" constitute another large grouping of asymptomatic precipitants for seeking psychological consultation. These "problems in living" do not fit into diagnostic schemes. Frequently, they are the early indications of the existence of psychological processes which, if left unaddressed, might well develop into costly diagnosable conditions. The provision of psychological services to children for "school problems" or other behavioral manifestations which are not considered to be "pathological" or a diagnosable disease are none the less worthy of psychological intervention because of the significance and impact of the "school problems" in the development of the child.
As a profession, psychology has actively encouraged, fostered, and recognized the value and merit of multiple and diverse approaches to psychological health through various psychological treatment modalities which have been developed through the years. This diversity of treatment modalities, theoretical orientations, and types of therapeutic interventions is based upon differing conceptualizations and understandings of human behavior and motivational causalities. This conceptual diversity provides for a breadth of viable treatment approaches in working with a wide range of specific populations in different treatment settings, e.g. children, adolescents, adults, senior citizens, inpatient, outpatient, day treatment, and school settings. Further, this diversity in conceptualization and treatment approach provides the impetus for advancements in theory and for continuous refinements, if not revisions, in therapeutic techniques for the practice community. This conceptual diversity has led to the application of psychological principles of understanding and treatment to individuals who only a short while ago would have been considered to be "untreatable" by psychological means.
Psychological treatment has advanced to the stage where it is widely acknowledged that health care services rest upon a clinical process that has as its scientifically established base the uniqueness of the clinical relationship between the provider and the recipient of the services. Thus, each treatment plan must be maximally sensitive and responsive to this uniqueness of the clinical relationship and to the particular situation of the recipient. One of the central characteristics of each treatment plan developed must be its flexibility so as to accomodate to the particular person and circumstances of the clinical situation. From a psychological way of understanding and working with people, diagnosis is considered to be only one of a multiplicity of factors to be considered in the determination of an individualized treatment plan.
Actuarial studies have shown that the cost of changing from limited psychotherapy benefits to unlimited benefits is readily justified by the expected savings. Psychotherapy outcome research has indicated that when people have the opportunity to participate in long-term psychotherapy, the costs to society and to the individual are easily justified by the economic savings realized from reductions in the utilization of general medical services and increases in employee productivity, not to mention the frequently reported intangible benefit of an individual's increased sense of well-being and improvement in their "quality of life."
It is widely acknowledged that there is currently a continuum of effective psychotherapeutic styles, strategies, and techniques. Amongst these conceptually diverse psychotherapeutic sytems are those psychotherapies of indefinite length and which are psychodynamic in nature. As a group, these psychotherapies constitute perhaps the oldest, best studied, and most widely practiced form of psychotherapy. For many practitioners, the length of psychological treatment is an unknown variable particularly during the initial stages of meeting with an individual. For many, if not most practitioners, the length of therapy is a function of an ongoing assessment by both provider and recipient, and the decision to end psychological treatment, ideally, is arrived at through a process of mutual determination and agreement between the provider and the recipient. This form of psychological service can neither be practiced in a managed care environment nor within the constraints of a cost containment environment. Further, access to psychological services ought not to be strictly limited to those who are willing to make quasi-public declarations of having a mental illness. For some individuals, the primary impetus for seeking services is dissatisfaction with their "quality of life," rather than a desire to eliminate a discrete set of symptoms. While third party payers must have the right to restrict their payment for services to those which are generally recognized as clinically necessary, those who wish to seek services at their own expense for their own reasons must be free to do so without having to label themselves as "diseased" or "sick." An individual's decision to participate in a therapeutic process and discourse for purposes of self discovery and self determination serves as its own justification. Further, it is to be recognized that for many recipients, the preservation and protection of confidentiality is of crucial importance, and for many others, it extends even to privacy in the decision to seek psychological services.
The Michigan Psychological Association (MPA) endorses the principle that it is essential in our democratic society to preserve and to protect the right of each citizen to enter freely into private contracts for professional services independent of any organized health care system or plan. Further, any health care system devised must explicitly provide for and protect this right of the practitioner and recipient to contract independently and confidentially based upon a mutual determination as to type, frequency, duration, objectives, fee arrangements, and mutual evaluation of treatment effectiveness without regulatory restraint and/or penalty by any private entity or health care reimbursement plan.
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