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.