(Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Dr. Alan Karbelnig writes this regular column to provoke thoughtful reaction from his SGVPA colleagues. He has been a member of SGVPA since 1988, and served as its president in the early 1990s; he has chaired the SGVPA Ethics Committee for 14 years. Alan is a Training and Supervising psychoanalyst at the New Center for Psychoanalysis and the Newport Psychoanalytic Institute. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

As if finding true individuality weren’t difficult enough, Derrida, Foucault, and other post-modernists make discovery of the “real you” near-impossible. They suggest that individuality cannot exist free from the influence of the “other.” The search for individuality, however intense, requires an equally passionate understanding of what French psychoanalyst Jacques Lacan terms the “Big Other” – a subtle set of rules, encoded in language, encoded in the culture, that influences how we view self and other. The Big Other manifests like an over-riding internal object, similar to the Freudian superego, but bigger, more diffuse, more subtle, and more a function of culture.

In the world of object relations, the concept of a “dynamic structure” speaks to the same phenomenon, but on a smaller scale. W.R.D. Fairbairn, the Scottish psychoanalyst who proposed this unique idea, believed that representations of self are always linked with representations of other. If we feel proud of our work after a particular psychotherapy session, “internal objects” applaud while parts of our “egos” or selves experience a feeling of success. The concept of the dynamic structure was a key development in the history of psychoanalysis, but does not go far enough because it ignores culture.

The Big Other incorporates culture, or even God, and affects us in any number of positive or negative ways. For example, the Big Other beckons unknowingly when someone reaches out to shake our hand, and we reach out ours in return. The Big Other lies behind any number of ethical behaviors, from making coffee for our suitemates to calling them when patients appear in the waiting room at the wrong time. Derrida considers God to be the “transcendent signifier” or the ultimate “Big Other.” If we resist our impulse to murder our suitemate, we are likely responding to an injunction, as Derrida would say, from the Big Other.

Now the Big Other also influences behavior in less positive ways. It motivates us to purchase unneeded items because of a shared cultural belief that we’ll feel more fulfilled after doing so. It may cause us to feel irresistibly drawn to eat at a new restaurant, or see a particular movie, just because we’ve heard “critics” or friends rave about them. (Critics themselves, who are nothing more than other individuals, serve a powerful if absurd Big Other function).

But the presence of the Big Other may be way more subtle and unpredictable. At a recent holiday open-house, a colleague whom I’ll call Jonah found himself talking to a female of easy wit and sparkle. Despite his staunch commitment to marital rectitude – he is, as some would say, very married – he was irresistibly, passionately, dangerously drawn to this enchanting woman who was not his wife. But suddenly Jonah crashed to earth. Not because he recovered his sense of propriety or moral equilibrium. No. The encounter terminated when the future love of the rest of his life announced that she was building a second home in Boston – a city Jonah despises with mythic, pathological loathing. He clings to this deranged repugnance for a city that’s no more or less hateful than any other city or town. Here the Big Other manifests as Boston, and in an immense way. Reeling with alienation, Jonah abandoned his ex-future-wife and headed for the wine table (which promised yet another Big Other experience).

The Big Other will always exist, in one form or another, and will always play a major role in our behavior. Individuality can only be found nested within it. But interior “Bostons” can also be stifling (even though, ironically, Jonah’s Boston may have saved his marriage!). Such versions of Big Others inhibit us, create anxiety, confusion, ambivalence. They block the path towards authenticity; they prevent us from heeding the Greek poet Pindar’s injunction to “be who we are.” We must keep searching for individuality anyway. After all, no one from the ancient Greeks to those French postmodern guys ever said this crazy search for self was for the faint of heart.

(Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Dr. Alan Karbelnig writes this regular column to provoke thoughtful reaction from his SGVPA colleagues. He has been a member of SGVPA since 1988, and served as its president in the early 1990s; he has chaired the SGVPA Ethics Committee for 14 years. Alan is a Training and Supervising psychoanalyst at the New Center for Psychoanalysis and the Newport Psychoanalytic Institute. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

Simply put, psychoanalytic psychotherapists enter into intimate but bounded relationships with the persons consulting them, become embroiled in their internal dramas, and then interpret rather than enact them. Ideally, the process unfolds with both emotion and containment, facilitating a helpful shift in personality. But this requires tremendous self-discipline. Much of the training, personal psychotherapy and continuing education of psychodynamic psychotherapists serves to help them manage these highly intense encounters.

Last Spring, I provided a brief course of psychotherapy during which this dramatic re-enactment process unhappily derailed. I offer this brief and fictionalized recounting in the hope that you can avoid a similar fate. At that time, a gay attorney named Joey consulted me weekly for help breaking a pattern of aborted intimate relationships. He was in his young 40s, and had been in three significant romantic relationships, each lasting more than five years, and each ending in the same way. He would begin the relationship highly idealizing his partners– usually for their occupational achievement as doctor, lawyer, or celebrity actor – and then end with a gradual devaluation of them leading to his termination of the relationship.

By the end of the first session, I was already wondering how and when this pattern would repeat itself in the transference relationship. I actually interpreted this early on. Joey initially rejected the possibility that this idealization-devaluation cycle could be repeated in our work, citing the “outward signs” of my occupational success.

Approximately three months later, and just as I was beginning to experience the excruciating back pain that ultimately led to my diagnosis of endocarditis, Joey left me an angry message immediately after a session. He felt criticized at my having mentioned that he appeared sad. He was furious that I’d made him so aware of his appearance. I had no hint of his having reacted this way during the session. My recollection was that I had offered the observation with great empathy and sensitivity.

Perhaps because of my own vulnerability, I reacted strongly, and with intense concern. I immediately called him, acknowledged that I’d received the message, and invited him to come in before his usual weekly appointment to discuss what had occurred. Over the next few days, as we exchanged messages looking for a suitable extra session time, I felt increasingly anxious myself. Could I have been too aggressive in the way I pointed out the sad facial expression? Could I have been more critical than I remembered? I felt increasingly vulnerable and inadequate myself.

With each message that I left offering alternative meeting times, Joey’s negative responses escalated. This set of interchanges culminated in his ending the brief course of treatment by voicemail message. I left a final message offering a termination session to at least review what had occurred. I never heard back from him.

Now having the benefit of more than six months of retrospection, I view the experience as a painful but enlightening example of transference-countertransference run amok. If I had it to do over again, I would have simply left one message of acknowledgment with an invitation to come in sooner to discuss what occurred. I believed instead – real or imagined – that Joey needed the contact, that he needed a more overt invitation from me. In doing so I may well have initiated the same cycle that had led to his seeking help in the first place. The more vulnerable I became, the more he devalued me, finally leading him to terminate the treatment in much the same way that he’d ended many romantic relationships in the past.

So what lessons can be taken from this sad tale? Never forget the power of the drama of the person consulting you or of your own personal vulnerability to become negatively embroiled in it. Perhaps most significantly, remember the crucial importance – more than maintaining an observing ego, more than carefully managing boundaries, more than remaining emotionally attuned – of this commonsensical trait: Patience.

Obsessive Ruminations #4

(Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Dr. Alan Karbelnig writes this regular column to provoke thoughtful reaction from his SGVPA colleagues. He has been a member of SGVPA since 1988, and served as its president in the early 1990s; he has chaired the SGVPA Ethics Committee for 14 years. Alan is a Training and Supervising psychoanalyst at the New Center for Psychoanalysis and the Newport Psychoanalytic Institute. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

As they enter the consulting room for their first meeting with a person, psychotherapists should feel terrified. They enter the room with, well, nothing. They carry no technical devices. Unlike physicians, who have any number of tools from blood pressure cuffs to electrocardiographic machines, psychotherapists have only themselves. Unlike attorneys, who take notes, refer to legal authorities, and compose official documents, psychotherapists offer only ideas and emotional responses. They present in an exposed state; they carry only their inherited or learned psycho-biology and their knowledge of whomever of the various theorists they have found the most influential.

This nakedness notwithstanding, persons seeking the services of psychotherapists arrive with expectations, even demands. They complain of stale marriages, paralyzed employment situations, or painful emotional states. They request solutions and relief. They insist their psychotherapists take action. This combination of demand, on the one hand, and lack of technology, on the other, creates unease if not abject anxiety in psychotherapists – particularly in the early stages of their work.

How do they then cope with such vulnerability? Some psychotherapists take refuge in dogmatic theoretical approaches. For example, if they have the conviction that all psychopathology results from pent-up aggression and envy, they will view problems exclusively through this lens. If they believe that failures of empathy are the cornerstones of psychological difficulties, they will conclude that emotional troubles result solely from interpersonal deprivation. And so on.

At the other end of a continuum, some psychotherapists eschew theory, and practice some variety of “rent-a-friend.” As one colleague put it, somewhat crassly, psychotherapy is “a love affair without the affair.” Perhaps these psychotherapists are helpful, but they run serious risk of violating the patient, crossing boundaries, or otherwise failing to adhere to the fiduciary aspect of the psychotherapeutic contract. “Patients” are paying a fee for a service, and if only love and friendship are provided, their “sessions” smack of a variant of prostitution.

Striving to find the “middle zone” between these two extremes, psychotherapists face incredible complexity and uncertainty. Even within the confines of the psychoanalytic model, for example, wide variance in theory exists. Different theorists hold that psychopathology results from deficits in maternal care, from intra-psychic conflicts, from unresolved Oedipal complexes, from pent-up aggression and envy, from repressed sexual urges, from existential concerns like fear of death, or from primitive mental states characterized by excessive splitting and projective identification.

Ideally, all these variants should not be causes of anxiety but embraced as part of the beauty and fullness of human experience that psychotherapy uniquely mediate. Psychotherapists do face incredible ambiguity. They should feel awed and humble. They err if they are too rigid in theory; they err if they are too loose. They must struggle to find their way between these two extremes – all the while keeping an open a mind.

But keeping an open mind is anything but easy, particularly when feeling uncomfortable. G. K. Chesterson once wrote that “an open mind is like an open mouth, it looks for something hard to bite into.” Psychotherapists must avoid biting into anything hard. In his recent book called The Black Swan, Nassim Taleb describes theory as “like medicine (or government): often useless, sometimes necessary, always self-serving, and on occasion lethal.” He suggested that theory “be used with care, moderation, and close adult supervision.”

Hopefully, psychotherapists cherish the mystery of the persons who sit before them. Hopefully, they strive to understand what they speak, feel, or display, and then respond in a unique fashion. And as they navigate through the clouds on their lonely journey towards helping others, they can ultimately rely only on this: Their own sense of integrity.

Obsessive Ruminations #3

(Dr. Alan Karbelnig, who somehow slipped into his 50s and lost much decorum in the process, writes this regular column to provoke reaction from his SGVPA colleagues. Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Alan strives to offer ideas to stimulate thought. Having been a member of SGVPA since 1988, Alan served as president in the early 1990s; he has chaired the SGVPA Ethics Committee for the last 14 years. He is a Training and Supervising psychoanalyst at the New Center for Psychoanalysis and the Newport Psychoanalytic Institute. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

Having visited hell early this summer, I return to terra firma with many tales to tell. I could write of the incredible devotion and bravery of my wife and two daughters, of the blessings and curses of our health care system, of the real experience of post-traumatic stress disorder, or even of the incredible meals that we’ve been served here at my home thanks to the generosity of all of you SGVPA members. But I choose to fill this first Obsessive Rumination since my illness with a brief description of what occurred, and then a review of the clinical and ethical errors[1] I made when I was suddenly hospitalized.

Before reading further, please imagine this scenario: You abruptly have about five pain-and-terror-filled minutes to close up your practice for six weeks or more. What would you do? Who would you call for help? How would you achieve this while maintaining patient confidentiality, preserving your therapeutic relationships, and attending to your own urgent needs? And more importantly, how could you avoid this problem in the first place?

Avoiding Denial and Disavowal
In retrospect, I believe I was ill as early as late April 2008, but was denying the intensity of my discomfort. I believe that I showed signs of endocarditis that early. Endocarditis is an inflammation of the heart resulting from a bacterial infection of the blood – in my case bacteria of oral origin, from flossing, or from biting my lip, or some such. I usually don’t see a physician until I’m really symptomatic (a form of avoidance and disavowal from which I’ve now completely recovered). I delayed consulting my internist, Claire Tilem, MD, until 10 days into severely painful GI symptoms I had after attending a wedding in Jamaica. I assumed I had the “touristas.” Dr. Tilem gently admonished me for waiting so long, and prescribed an antibiotic. I failed to tell her then that I was also having night sweats, and was generally not feeling quite right. Towards the end of May, I began experiencing excruciating back pain. I assumed I’d pulled a muscle during my usual weekend gardening. Muscle relaxants and physical therapy did not help, and my sense of feeling generally tired and worn-out gradually increased in intensity.

On Tuesday, June 10, 2008, I went for a spinal x-ray series and immediately afterwards, without an appointment, consulted Dr. Tilem again. This time I shared more of the symptoms with her. She ordered more extensive blood tests. Within 24 hours, I received a rather frantic call from her indicating that my hemoglobin (red blood cell) count was dropping. That meant that I was likely bleeding internally, or worse. I first began to feel frightened then. Dr. Tilem called her friend, an infectious disease specialist, Kim Shriner, MD, and together they put together that the symptom-complex could indicate endocarditis. I first met with Dr. Shriner on Friday, June 13 when she ordered a blood culture test and an echo-cardiogram. I had my second appointment with Dr. Shriner on Tuesday, June 17, 2008, at 1pm.

Now we meet denial, disavowal, and even rationalization because I was convinced by the time I saw her that second time that she’d tell me I was fine. I had decided that the blood loss was likely from the two weeks of GI symptoms. I anticipated that Dr. Shriner would tell me I needed an intramuscular injection from an orthopedist to alleviate my back pain. I was so confident, in fact, that I had a whole afternoon scheduled in my own office starting at 1:45pm that same day. As soon as I sat down in her office, she said straight out that I had to cancel the imminent family trip that I’d planned for a year, that I needed to go into Huntington Hospital immediately, and that I could be helped but I was really sick with endocarditis. I’d never really had any serious illness, and have not been in the hospital since I was age 12 and had an appendectomy. I just couldn’t believe it.

While I will not run to doctors with every little sniffle, I sure as hell will go running whenever I have anything more significant. I am still left wondering if I could have avoided open heart surgery had I sought more intensive medical evaluation in late April. Here’s a quick version of the rest of the story: 20 hellish days in HMH, daily immersion in IV antibiotics, more than a week of heavy narcotics to reduce the unbelievable pain in the back (that was actually caused by a bacterial infection in two inter-vertebral discs), and then the real slammer: Open heart surgery to repair a small cardiac aneurism and to replace my aortic cardiac valve – both problems caused by the bacterial infection. By the time I was discharged I weighed 134 lbs, about what I did in middle school.

Patient Calls in Altered States
As professional psychologists, we have a responsibility to the persons who consult us. But we must always be balancing that with care for ourselves. I lost that balance, at least for the first few days. I was literally in tears from fear and back pain as I drove the two small blocks to Huntington from the MD’s office. Nonetheless, I began speed dialing the numbers of the patients I had scheduled for that day. I don’t remember some of these phone calls, likely due to the intense pain, which is worrisome. I learned later that I failed to complete a call with one woman who was to meet with me later that afternoon. I cut her off quickly because my wife was calling me, and I never returned her call. It wasn’t until a week later that she learned more reassuring details of my condition. Luckily, my wife Amy had met me at the hospital’s admitting department. By then, the pain was simply too great for me to function. I gave her some patient phone numbers, and also gave some to my psychological assistant, Matthew Cantrell, MA.

I was started on Morphine within minutes of my admission, and that became another problem. Once the pain receded, I insisted on making as many patient calls, personally, as I could. The difficulties here should be obvious, but I want to add one point emphasized by Amy: You do not always feel mentally altered even though you are. I thought I was lucid a few days later when I was literally hallucinating. Somehow, over the course of the first few days of my hospitalization, all of my patients were advised of my condition and its positive prognosis. But, in retrospect, this process was haphazard. I should have had a much better plan.

In Praise of Dr. Linda Bortell
Part of any plan is having someone close to you – a fellow professional – in whom you deeply trust. I knew Linda’s professional accomplishments well – CPA Board Member, LACPA president, SGVPA president, etc, but did not personally experience the incredible extent and depth of Linda’s competence until she was abruptly thrust into this helping role. I cannot possibly put words to my appreciation for Linda’s efforts. Sometime early that first afternoon – maybe while I was still driving – I called her and advised her of the situation. She responded immediately, and amazingly. My only complaint: She did get somewhat nasty with me at times, but only when I really deserved it, like, for example, when I wanted to keep calling and rescheduling my patients even while on Morphine, Methodone, Dilaudid, and more. She’d get that demanding tone of voice, and then talk to my wife, and I’d be rendered powerless. A few days into the hospitalization, Amy actually wrenched my cell phone from me as I tried to send a text message to a patient, fomenting one of the only violent episodes of my life. I threw a water pitcher at her. How 21st century, huh?

Again, in the middle of Linda’s own busy day, she started pursuing all the proper issues, in the correct order, and so much more. I never gave her my voice mail code, but she was, of course, completely on track nonetheless. She began covering for me; several fairly needy patients began consulting her. She pinch-hit for some supervision of psychological assistants. She cooked me several amazing meals and was one of the SGVPA members responsible for spoiling me with so much food. She visited me many times. She took daily notes of her interventions regarding my practice, and gave them to me to review later, when I could think. Linda Bortell is one amazing human being and professional psychologist.

The Limits of Panicky Voice Mail Greetings
At some point – I no longer remember when – I recorded an outgoing voice mail message saying something like: “This is Dr. K, I’ll be away due to a medical emergency causing me to be absent from my office the rest of July. I will not be returning messages. If this is urgent, please call Dr. B, etc.” Within 24 hours, Linda called me on my cell and told me, in my doped-up state, that my message was “scaring the shit out of your patients.” That’s an exact quote. I listened to it and found that it scared me to listen to that message! I wrote out a script and had my youngest daughter Natalie help me to record it. She was cracking up because I couldn’t follow the script. I kept improvising sections, part out of creativity (I think) and part out of intoxication from the pain medications. If this ever happens to you, please let a colleague or even a family member or friend record your message. Let them script it as well, particularly if you are really ill, on major narcotics, or any other such nasty combination.

Make Sure to have a Clear Record of Your Patients and How to Reach Them
It was actually only a few days ago that Amy recounted Linda, Matt and her efforts to figure out my schedule so they could call people and cancel upcoming appointments. I use “Therapist Helper” software, and all of this information is recorded there, but I have no way to access that when away from my office. I keep my schedule on my cell phone, but all patient names are unidentifiable, i.e. Jill E on Fridays at 2pm – nicely HIPAA-esq. I also still use a Daytimer to track appointments, particularly because there are always changes of some form every week. Amy tried to read these entries, but could hardly make out any names. I vaguely remember listing out the appointments in the ensuing week or two. Linda put a note in the waiting room advising the persons there that I was on medical leave through July. Luckily, only three or four people showed up during the entire time so the various means of contacting them worked fairly well. Matt, Amy, and Linda were eventually able to contact all of my active patients by telephone, but even this took several days, and again was somewhat sloppy in form.

The Risks of Written Communication
Sometime by the end of the first week, I wrote a letter advising all of those in my practice of my medical leave. I put much thought into it – or so I believed – and mostly wanted to get as much information onto one page as I could. I included the names of the two primary MDs taking care of me, the main conditions, and the fact that the prognosis was so positive. Being a psychoanalyst, I am well aware of the controversy surrounding such a degree of self-disclosure. More conservative therapists might have just indicated that they were away due to a family emergency. That is not my style. But as Linda and several others pointed out to me, I was also really not in good enough shape to write that letter. It contained more information (like the names of the doctors) and too many details of the three illnesses that I had (endocarditis, diskitis, and cardiac damage requiring surgical repair). You, like me, like offering help: That’s what we’ve molded our careers around. Sometimes you have to know when you need it yourself, and how to surrender yourself to it.

Enough for Now
Writing this has served many purposes: Sharing my experience, seeking to be helpful, and perhaps venting some of my considerable residual anxiety, hopefully without projecting excessive fear into you! I hate to end on such a cliché note, but only the usual aphorisms come to mind: This is a precious life so make sure your work is only part of it; since our work involves such an immense degree of responsibility, please make preparations for what you should of course hope will never happen to you. That includes not only plans, but a close connection with someone who can step in and help, quickly and professionally. And finally, remember that I felt, like you almost certainly feel, that “this will never happen to me.” I am looking forward to the return of that shield of denial, but can assure you that I will have a new plan in place when it does.

NOTE:
1. Since this article is certain to be presented to me by opposing counsel next time I’m involved in a forensic case, let me note from the onset that none of these errors would rise to the level of an extreme departure from the standard of care nor would they even remotely form the basis for a malpractice lawsuit. I do not believe I was ever truly negligent nor do I have any indication that those that consult me were actually harmed by these “errors.”

Obsessive Ruminations #2

(Dr. Alan Karbelnig, who lost much decorum in the process of slipping into his 50s, writes this regular column to provoke reaction from his SGVPA colleagues. Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Alan strives to avoid the pablum that characterizes most professional newsletters. He instead offers ideas he hopes will stimulate thought. Having been a member of SGVPA since 1988, Alan served as president in the early 1990s; he has chaired the SGVPA Ethics Committee for the last 15 years. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

Writing this article nearly pulled my brain inside out. I wanted to make a strong statement about the negative effect of strong beliefs — particularly fundamentalist ones — held by depth psychotherapists; I then got all tied in knots over the fact that, in doing so, I was expressing a strong belief. The article became recursive, like an infinitely repeating loop.

I have long had concerns that certain training programs, the Fuller Theological Graduate School of Psychology, for example, or even the Psychoanalytic Center of California, espouse specific belief systems that could be antithetical to the provision of depth psychotherapy. The former espouses evangelical Christianity and the latter specific Kleinian psychoanalysis. Professors at Fuller must literally take a statement of Christian faith. My concerns extend beyond religious or ideological faith to encompass any fervently-held belief system. I have the same unease about scientism that categorically disavows the spiritual. Even atheism, if too-ardently espoused by depth psychotherapists, could equally damage psychotherapy, as could any all-encompassing or global value system.

Immanuel Ghent, one of the key figures in the relational school, noted that depth psychotherapists’ theories themselves are belief systems. Theories make a difference in how psychotherapists hear, on what they hear, on how they assemble what they’ve heard, and on how they conduct themselves in the psychoanalytic setting. In The Black Swan, his recent book on the impact of highly improbable events, Nassim Taleb preaches that “a theory is like medicine (or government):often useless, sometimes necessary, always self-serving, and on occasion lethal. “He suggested that theory “be used with care, moderation, and close adult supervision. ”

In most depth psychotherapeutic models, the personalities of psychotherapists are central to their work; and of course belief systems are foundational components of personalities. Psychoanalyst Lewis Arons considered the psychoanalytic relationship a mutual but asymmetrical one, highlighting the intimate nature of the therapeutic relationship, even if it focuses mostly on the subjectivity of only one of the parties. Thomas Szasz thought depth psychotherapists offered only three things — their personalities, their rhetorical influence, and their observations of interpersonal rules or contracts. The centrality of the personality in these models creates a fundamental tension:Psychotherapists influence those who consult them — they cannot help it — but they must facilitate the discovery of their patients’ own systems of belief.

So while we might be highly trained in a few languages of psychoanalysis such as object relations theory or inter-subjectivity, in the consulting room we will hopefully remain as open as possible to any number of complex, interwoven explanations of the phenomena revealed in and by the patient. Then and only then will we apply our theory, or any other theory. . . or perhaps no theory at all. Such openness is an awesome task, one obviously never achieved to the ideal.

The issue can perhaps be framed by analogy to our preferences in art. Let’s say impressionism is the style someone considers the best, even though it’s impossible to objectively determine whether impressionism is better than cubism or expressionism, just as we can’t determine that Freudian psychoanalysis is better than Object Relations or Inter-Subjectivity. The problem arises if I decide that such determinations can be made and assert my own artistic preference with militant zeal. I may consider Picasso the best, but I’ve obviously gone fanatic if I think that Picasso is the only true artist and all art museums should feature Picasso’s and Picasso’s only. Likewise with my belief-system. Ideologies exist on a continuum of fervor, with extreme fundamentalist convictions on one end and pluralistic, fluid convictions on the other. The danger to the psychotherapeutic process likely lurks at both extremes: at one end extreme certitude in which my way is the only way for everyone, and at the other end such extreme ambiguity that you are free to do whatever you wish, even if it’s abusing children.

But what indeed if an actively child-abusing patient were to consult you? Here’s an instance where openness and flexibility fail to offer a foolproof solution to the problem of the impact of psychotherapists’ beliefs. How could child-abuse not fly in the face of your belief system and render it highly difficult to remain affectively neutral?Or what about suicidal persons, ones involved in elaborate self-mutilating behaviors, or psychopaths?These types of human experiences run counter to universal ethical themes, and challenge the receptivity of all of us — regardless of how elastic our belief systems. We are trained to keep our value systems out of the room, as much as possible, but in these areas the true violence presented to us makes that nearly impossible. Such is the way with many things in our profession, beset with complexity and paradox. At the same time this should make us aware, even more keenly, of the need for constant mindfulness.

Returning now to the matter of teaching institutions that are extensively immersed in any one system of belief. Institutions teaching depth psychotherapy should offer as many diverse viewpoints as possible, particularly in view of the incredible complexity that determines mental status. Any special emphasis on a particular belief system — whether political, ideological, religious, economic or academic — is clearly problematic. Biological, social, cultural, historical, interpersonal, spiritual, and many other causative categories continue to vie for privileged status as the cause of “mental disorder. ” None has yet been empirically proven. If anything, mental disorder results from a highly dynamic and interactive process of all these factors and more.

So I’ll move towards the end now by sharing the words of a friend who wrote: “Shalom is based not on everyone thinking the same way and so achieving peace. It is based on the wonder and mystery of everyone thinking totally differently and still achieving peace, the lion lying down with the lamb.”

I so agree. Differences of belief must and should thrive. What I’m highlighting here is how profoundly belief systems can affect the therapeutic process. We are best served by maintaining an attitude of self-evaluation or, even better, self-doubt. Bear in mind what Jacques Lacan defined as the hallmark of psychosis: a dogmatic certitude about the world’s reality. As depth psychotherapists, attached in varying degrees to the reality of this or that self-evident truth, we should allow ourselves to see Lacan’s words in the broader context of our profession, always confronting certitude — our own and others’ — with radical suspicion.

Obsessive Ruminations #1

(Dr. Alan Karbelnig, who quietly slipped into his 50s last year and lost all decorum in the process, writes this regular column to provoke reaction from his SGVPA colleagues. Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Alan strives to avoid the pablum that characterizes most professional newsletters, and instead strives to serve up more zesty reading. Regarding his professional career, Alan is a long time member of the SGVPA, having served as president in the early 1990s; he has chaired the SGVPA Ethics Committee for the last decade. He practices clinical psychology, psychoanalysis, and forensic psychology in South Pasadena.)

I recently had lunch with two of my illustrious SGVPA colleagues who, in the course of discussing their clinical work, used words such as “attachment,” “affective attunement,” “activation,” and “dysregulation” repeatedly. I understood what they meant. They were describing the phenomena of being close to other persons, of resonating with them, of becoming excited, and of feeling overwhelmed. After lunch I returned to the office perturbed. My fellow practitioners know these words trouble me. Maybe they use them with more vigor when I’m around to demonstrate their attachment or attunement to me. Maybe they want to get me activated. But this time I just felt like shouting. I offer this rant for the SGVPA newsletter instead.

In the middle part of the last century, the psychoanalytic lexicon was rife with earlier versions of these words. Had you dined with psychoanalysts in, say, 1955, you would have heard about patients’ cathexis to their analysts, or about their ego weaknesses, or about the corruption of their superegos. If the patients were particularly emotional, perhaps you would have heard them described as overwhelmed by Id impulses that had perforated their repression barriers, over-riding proper ego functioning.

I suppose such language may suffice for communication between professionals, and therefore I should not be so dysregulated by it. But as Thomas Szasz used to say, we psychotherapists need to be careful not to literalize our metaphors. These interesting words – then and now – are chock-full of mechanistic, post-Enlightenment ideology. Used without caution – and this is the danger Szasz alludes to—these terms can violate sanctity of the human subjects who engage us in our consulting rooms. No disrespect to the Age of Reason, but our patients are not motorized contrivances we can deconstruct with a Newtonian calculus. They exist as real, fleshy, sentient human beings experiencing a near-infinite range of sensations, thoughts, feelings, and images, all of which swirl around in inter-relationship with one another, never to be reduced to finite categories. These persons demand to be received in all of their complexity and fullness

Attachment, a horrible word, sounds like a button, or a snap, or a piece of Velcro. What if, instead of affective attunement, we think about being present, as completely as possible, to the being of the person meeting with us? Attunement sounds like a melody produced by a mouth harp, or an mp3 file. Perhaps we could just strive to “be” ourselves instead of being attuned. Perhaps we could flow with others’ words, thoughts, fantasies, images, and feelings. The same holds true for “activation” or “dysregulation,” terms suggesting that a hose attached to your cooling system has come loose. These “technical” phrases are too constrictive as well as too robotic to describe the complexities of the human experience

Samuel Johnson once said that all professions are conspiracies against the public, and I suppose these automaton-like words represent part of the conspiracy of professional psychology. We take the intense richness of human experience and reduce it to a few scientific-sounding categories. That way we can design studies, pretending that we work in a branch of the natural sciences. We can imagine a human person reduced to a set of internal regulatory mechanisms that we can then “treat” according to certain algorithms that emerge from our studies. We can simply ignore the impossible richness of the living subject who will forever lie beyond our categories.

I am of course just as guilty as many of my colleagues. Since I also do some psychological assessment, perhaps I don’t notice my own use of terms such as “behavioral control,” “affect modulation,” or one of my favorites from the Rorschach, “a tendency to abuse fantasy.” I obviously like the phrase “obsessive ruminations,” which of course is also the title of this column, but maybe “ranting” would be more precise, especially if followed by an exclamation point!

So we should persist in our conspiracy, as we must, but since the real human experience is the focus of our profession, I think it would behoove all of us to remember that metaphor is metaphor, and that people live in a real experiential world of language and imagery and feeling. I enjoyed lunch with my distinguished SGVPA peers. I certainly came away feeling peeved, but neither activated nor dysregulated.

Assaults on Privacy:

February 27, 2008

Reflections on The Erosion of Confidentiality in Psychotherapy

Until the mid-1950’s psychologists and their patients enjoyed a highly private, confidential relationship. No reporting requirements existed. The Evidence Code was rarely utilized to intrude upon psychotherapist-patient privacy. Their relationship was about as private as that between priest and penitent, or journalist and source. Individual privacy rights reigned supreme.

In contrast, psychologists practicing today must contend with societal controls unknown and perhaps unthinkable a generation ago. Now the rights of society have been elevated. The contemporary psychologist practicing psychotherapy must contend with at least 15 distinct potential incursions into the privacy of their consulting room. These include, but are not limited to, reporting on child abuse, elder abuse, threats of violence to others or to themselves (that most recent exception being related to the Menendez brothers’ trial), access by insurance companies, managed care companies, other providers with releases of information or family and friends of the patient with signed releases of information, various permitted disclosures allowed by the Evidence Code (section 1024), requirements of whatever agency or institution the psychologist may be employed by and the whole range of legal incursions related to subpoenas or court orders be they concerning civil, criminal. administrative, workers’ compensation, internal revenue service, EEOC or other matters. The sad fact is that the psychologists’ consulting room has become a rather crowded place, replete with a number of welcome and many unwelcome intruders. The rights of society to have access to information it deems important, even in that private space. now reign supreme (Alderman & Kennedy, 1995).

In the ensuing paragraphs, the identities of these intruders will be briefly delineated with some commentary made upon the appropriateness of their presence. The unwanted intruders are particularly problematic in that they interfere with clinical processes, especially the process of free association and the analysis of projective identification; the very foundations of most psychoanalytic approaches.

Beginning with the welcome and even necessary intruders, these consulting room guests have been present ever since psychotherapy started more than a hundred years ago. They consist of three sets of people. First, patients are accompanied by the ghosts of their past, be they parents, siblings or other influential figures during their developmental years. As practicing psychotherapists know, these ghosts constitute an integral part of the psychotherapy process. By understanding them, how they are projected into various interpersonal relationships and how they affect self-concept, psychotherapy unfolds. The unconscious family of the psychotherapist comprises the second group of hidden intruders. The concept of counter-transference rests on how these ghosts of the psychotherapist either interfere with or facilitate the process of growth in the patient. The third set of intruders consist of the theorists who guide the psychotherapist’s work.

Perhaps the most benign intruders who were introduced more artificially than these first three, consist of the authors of the ethical principles of psychologists established by the American Psychological Association (APA). Section five of the Ethics Code devotes itself entirely to issues of privacy and confidentiality. Section 5.01, for example, requires psychologists to discuss the limitations of confidentiality at the onset of the psychotherapeutic relationship. Section 5.02 requires that psychologists familiarize themselves with the state and federal laws and institutional rules governing privacy. This section establishes that maintaining confidentiality is a primary professional obligation. Section 5.03 requires that psychologists minimize intrusions into that privacy. Section 5.09, which concerns itself with preserving records and data, mandates that psychologists maintain their records in a fashion that maximizes patient confidentiality. The most recent version of the Ethics Code also requires that psychologists make plans for the disposition of their records in the event of their death or disability.

When legal mandates, such as subpoenas, call for violation of confidentiality in a manner that conflicts with the above-noted ethical requirement, the ethics code requires that psychologist adhere to their ethical principles. General standards section 1.02 requires that psychologists follow the ethics code even when it conflicts with the law. In such instances, they make known their commitment to the ethics code and try to resolve the conflict in as efficacious a fashion as possible, always working toward the maintenance of the privacy of the psychotherapy patient.

As if this group of extra-therapeutic observers were not enough, psychotherapists, whether aware of it or not, have assembly people and senators from the California State Legislature and justices of the California Appeals Court, the California Supreme Court and the United States Supreme Court in the room with them as well. Section 1024 of the evidence code, which was the creation primarily of legislators who in turn were repeatedly influenced by court precedent, allows for a number of incursions into psychotherapeutic privacy. Delineation of all of these potential incursions lies beyond the scope of this paper but include that psychologists may violate the confidentiality of their patient if the patient tenders their mental status as an issue in a legal proceeding, the patient uses the psychotherapeutic relationship to plan the commission of a crime, or if the patient threatens a reasonably identifiable individual.

Because of these possible intruders, psychologists increasingly find themselves caught between the Scylla and Charybdis of the interests of the individual versus the interests of society. These legislature/court mandated possible incursions, which include child abuse and elder abuse reporting, are based, simply put, on the idea that it is in the greater interest of society to be aware of the potential threat of these individuals than it is the right of these individuals to obtain treatment in absolute privacy. There once was a time when these individuals could obtain that treatment in such a private fashion; that time, at least for now, is over. Psychologists have become, as Christopher Bollas (1995) has written, the “new informants.”

Interestingly, California law also holds psychologists responsible for maintaining confidentiality as much as possible. In the psychology licensing law, which was similarly pieced together by state legislators, psychologists are required to maintain confidentiality – and that is according to law, in addition to ethics. Section 2918 of the licensing law reads, “The confidential relations and communications between psychologists and client shall be privileged ….” In section 2960, which delineates the various reasons that can cause a psychologist to have their license suspended or revoked, reason (h) reads, “willful, unauthorized communication of information received in professional confidence.”

So we have a consulting room already crowded by the patient and their unconscious family, the psychotherapist and their unconscious family, the psychotherapist’s theorists, the authors of the Ethical Codes of the APA and various state legislatures and justices. The room will become further crowded by the lawyers and municipal or superior court judges, in the event that a psychologist’s patient becomes embroiled in any type of legal proceeding, whether criminal or civil. Indeed, the very rationale behind the Evidence Code is to allow attorneys access to certain private communication revealed in a psychotherapist’s office in order to prosecute, or defend, an individual involved in a legal proceeding. Many of the subpoenas that arouse such anxiety in practicing psychologists arc related to just these type of matters.

There are two additional sets of intruders. If the patient is using insurance to pay for all or part of the treatment. then the executives of that insurance company, whether they provide indemnity or managed care coverage, are additional and perhaps the most unwelcome intruders into the consultation room. The insurance contracts signed by psychotherapy patients may require the psychotherapist to limit the degree of treatment, to report on extremely private details of the patient’s life, or to provide copies of actual clinical notes. Failure to adhere by these regulations can cause benefits to be disallowed or, in the case of managed care contracts, for the psychotherapist to be dropped from the managed care panel or even potentially sued for breach of contract.

The last type of unwanted intruder only applies to psychologists working for an agency or institution. For those psychologists, the administrators of whatever agency or institution they work for are also present in ghost form. These psychotherapists may be required to make certain other mandated reports, such as of spousal abuse or HIV infection, if the particular institution for whom they are employed requires such disclosure.

The incursions into psychotherapeutic privacy by these overzealous intruders can be limited, or perhaps even ejected from the consulting room, by the psychology profession as a whole. Organized psychology has failed to sufficiently establish the importance of the tenet of confidentiality and privacy, is the very foundation of any psychotherapeutic approach. Perhaps by educating the public, members of our own profession and state legislators regarding how and why maintenance of privacy and confidentiality is absolutely crucial to provision of effective, competent and ethical psychotherapy will the tide be turned back toward maintaining the privacy the consumer of psychotherapeutic services deserves.

Our profession has unfortunately been emphasizing societal rather than individual needs, sacrificing some degree of privacy and confidentiality in the process. Bollas noted that, in a policy statement during 1989, the APA declared “the social policy of protecting children from child abuse outweighs the social policy supporting the protection of confidentiality in the therapy relationship.” Although psychologists were initially left out as mandated reporters of child abuse, the then president of the California Psychological Association, Lewis Carpenter, Jr, PhD, wrote a letter to State Assemblyman Lockyer, on June 3, 1977, insisting that psychologists be placed on this list of mandatory reporters of child abuse. As discussion regarding adding mandatory disclosure of spousal abuse or HIV infection grows in intensity. psychologists who practice psychotherapy must increasingly wonder when their role as patient advocate will be entirely replaced by one of patient informant.

In the meantime, individual psychologists can best serve the needs of their patients by understanding all of these potential incursions. They then need to work, in full compliance with the law and the Ethics Codes, to limit these invasions of psychotherapeutic privacy. These strategies include, but are not limited to, fully understanding the Ethical Codes, the various laws that allow for intrusions into the consulting room including reporting requirements and the Evidence Code, and familiarizing themselves with the policies of whichever institution for which they work, or of whichever insurance company is contributing to payment for the treatment process. When their patients become involved in legal situation that can allow for violation of their psychotherapeutic privacy, then treatment providers need to familiarize themselves with the nature of that specific legal situation and be willing to contact their local experts in ethics, or their own legal counsel, so as to best protect their patient’s privacy.

Through the combination of working as a community to change laws affecting legal or insurance company incursions into the psychotherapeutic process, bolstering our ethical codes in the favor of protecting patient privacy, and educating psychologists regarding these various potential incursions and how to control them, the profession as a whole will hopefully be successful in working toward protecting, if not increasing, the foundational privacy and confidentiality that lies at the heart of any successful psychotherapeutic approach.

References
Alderman, E. & Kennedy,C. (1995). The Right to Privacy. New York: Knopf.

Bollas, C. & Sundelson, D. (1995). The New Informants. Northvale, New Jersey: Aronson.

Published as:

Karbelnig, A. (1999). Assaults on privacy: Reflections on the erosion of confidentiality psycho therapy. The California Psychologist, 32(6), 34-37.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)