By Alan Karbelnig, Ph.D.

(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 practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

By devoting this issue of Analyze This to politics, the editors advocate passionate action over quiet passivity. To become involved in an organization, to take a stand, to write or to speak out – these all constitute outward activity of some sort.  In contrast, professional psychology tends to be an unusually passive vocation, rendering its practitioners’ participation in political activities unusual or even rare, and for several distinct reasons.

Regardless of whether practicing psychological assessment, psychotherapy, or some other professional activity, we psychologists tend to work in isolation. We may practice in a suite of colleagues, but our days are passed working individually with our patients. Unlike our medical colleagues, we have few routine consultations with our peers. By virtue of the extreme sensitivity of our work, we share little if anything of the details of what we do with our family and friends. In essence, we work alone.  And as our colleague Rico Gnaulati pointed out, our work requires extreme concentration and focus. Arguably unlike any other professional, even surgeons or anesthesiologists, we cannot leave the room during a session, even to make a telephone call or use the rest room.

Also, since we are working towards helping others in virtually any aspect of our work, we can rightfully feel that we are contributing to society in some fashion. While legitimate on one level, this is a rationalization on another.  We may rely on this form of giving to avoid other forms of philanthropy. Why serve humanity in a broader sense when each and every day involves care for others?

Finally, the work is tiring. Except perhaps for those psychologists who solely perform assessments, psychotherapy is extremely intimate, satisfying some needs and exhausting others.  Some of us err (somewhat cheaply) by obtaining our needs for closeness through our work; this allows us to remain in an invulnerable position while enjoying high levels of interpersonal intimacy.  Ironically, the very personal nature of the work is likely the most exhausting element of it.  We often feel intensely fatigued by the end of the day or the end of the week.  Who can blame us for eschewing political action and instead taking refuge in hiking, theater, reading or other non-political pursuits during our precious free time?

Despite these basic truths of the isolated, helpful, and intimate nature of our work, we psychologists are nested in an unavoidable, larger social context.  Starting from within the field itself, we are under attack by insurance companies who would like to reduce or eliminate reimbursements for our services; we are surrounded by a mass media that typically misunderstands what we do; we struggle with a portion of medicine and of course the massive pharmaceutical industry which derogate our work and push “medicines” for help with any kind of mental pain.

If the circle opens even just a bit wider, well, then we face real horror: Haiti, the Middle East, Somalia, global economic recession, hunger within our own borders, and oh so much more. (A recent Gallup survey revealed that one in four Americans has trouble providing food for themselves and their families).

In the final analysis, then, and despite our good works, we should really escape from our offices and do something more for the society and the planet. Our Ethics Code suggests it, but even more powerful universal ethical principles demand it. We are blessed with involvement in a wonderful profession: How many offer an ability to help others in such an intimate way?  But the limited populations we serve just don’t make enough of a difference; we have skills that could have much broader impact, and for that the world awaits. So, whatever means works for you – volunteering, leading, writing, or shouting, please make sure that – in consonance with the theme of this issue –you venture away from your offices and share your talents with the wider world.

The End

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Confusions of Freedom

April 20, 2009

(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.)

Although it may sound idealistic or even grandiose, the heart of our work as psychotherapists lies in enhancing freedom. More specifically, it lies in expanding freedom of choice. We help liberate persons from self-deception, from tyrannical internal dramas, or even from painful academic, occupational, or interpersonal situations.

The unfortunate name for our endeavor, “psycho-therapy,” implies a discrete entity, the “psyche,” for which a specific intervention, the “therapy,” is provided. This grossly distorts the truth of the matter. The psyche, unlike any other entity to which “treatment” is applied, arises only partially from the biological substrate; it also emerges from such non-material factors as early social relations, culture, language, and socio-economic status. Therefore, ethics and politics, and therefore ideas like freedom, lie at the core of the psyche. Comparing “therapy” for the psyche to “therapy” for muscle pain is patently absurd. The variables affecting the psyche approach the infinite; biological systems clearly predominate in the case of a strained muscle.

Whether patients are highly regressed or extremely mature, we psychologists strive to increase their autonomy. In cases of acutely distressed psychotic persons, for example, we tend to be more active, focusing on reducing distress and improving coping capacity. We might even work on basic activities of living and medication compliance. But we are still striving to increase their autonomy. With highly functional persons, the “problems” for which they seek assistance, whether depression, anxiety, substance abuse, or whatever, also cause restrictions in freedom. While we are of course working to reduce their pain, we are also helping them to freely be themselves, to get out of their own way, and to take actions like improving friendships, obtaining exercise, seeking spiritual solace – all intended to improve the quality and meaning of their lives. We build autonomy and thus greater freedom of choice.

This focus on freedom creates paradoxical problems for psychotherapists as licensed professionals. Due to the laws governing the practice of psychology, and to our society’s litigation-proneness, excessive responsibility falls on psychologists. For example, in accordance with the Tarasoff precedent, we psychologists must protect potential victims of violence. Since the Goldstein v. Ewing case, we must also now consider not only information from patients, but what we learn from patients’ friends or families. We risk being sued or imprisoned if we fail to do so. We have become agents of the state.

Or consider, more benignly, psychologists whose outgoing voice mail messages instruct callers to phone 911 in case of medical emergency. These messages insult the callers, and treat them as if they have no autonomy. They incessantly remind them of what an average two-year old knows: Call 911 or go to an emergency room if you are acutely ill!

These conflicts between the autonomy-enhancing role of psychologists, and the protection of society as a whole, require ongoing and serious consideration. Psychologists have been mandated reporters of child abuse since the 1970’s – another way they serve as agents of the state. But this is not without other societal consequences. Many child abusers, pedophiles, and others who prey on vulnerable children now avoid seeking help from psychotherapists. They view us, correctly, as informants. State legislators now contemplate making domestic violence a mandated reportable event. Where will it stop? Will we be required to summon the police the next time adolescents advise us they are smoking Marijuana?

This dilemma was brilliantly addressed centuries ago by the motto of the French revolution: Liberty, Equality, and Fraternity. Be all that you can be (liberty), be considerate of others as you do so (equality), and remember that we are all in this together (fraternity). In applying our method of enhancing personal freedom, we psychotherapists will always be emphasizing liberty for individuals, within their particular social context. Certainly we do our work in a broader societal context but, in the final analysis, our loyalty lies to the agency of the person, not of the state.