Sunday, March 20, 2016

Politics and Religion: Psychotherapy's Third Rail




I cannot advise my colleagues too urgently to model themselves during psycho-analytic treatment on the surgeon, who puts aside all his feeling, even his human sympathy, and concentrates his mental forces on the single aim of performing the operation as skillfully as possible.  Sigmund Freud

Silence is collusion.  Sheila Kitzinger

A person requires a community in order for it to be possible for him to engage in human behavior at all.
A community is characterized by a common world, a language, a structure of social practices, statuses, way of living, choice principles, and individual members.  Peter Ossorio

Amazing Grace, how sweet the sound,
That saved a wretch like me.
I once was lost but now am found,
Was blind, but now I see.  John Newton


My clinical psychology trainees rarely have trouble asking their clients to explore something problematic. The point, explicitly stated or not, is to increase understanding and free up consideration of whether something might be done differently. Such inquiry is not always welcome. Questioning implies a judgment that something is questionable.  We all know this. This is why when therapy touches politics or religion, trainees are awkward and uncertain about what they should appropriately ask.  I suspect this holds true for most of my colleagues.

Politics and religion are the “third rails” of psychotherapy, off limits and taboo, especially as practiced in the United States. Political correctness as respect for difference suggests caution. This is good policy. But when does it become unserviceable inhibition? In our cosmopolitan multi-culture, where politics and religion provide conflicted guides to behavior, this is a thorny issue. 

For good reason, we've learned to avoid these topics on Thanksgiving. 

It's no surprise the current state of American political turmoil enters the consulting room. Here’s a composite cobbled from case presentations from recent weeks:  A young junior college student, “Bob”, white, lower-middle class, complains of bouts of depression and anxiety. What brought him to treatment was the consequence of a drunken brawl that resulted in his arrest and mandated counseling. In reconstructing the day of the fight, Bob mentioned feeling “pissed” when he observed an attractive classmate dropped off on campus by a man driving a BMW. Angry, Bob described her as the sort he’d like to date but wouldn’t ask, “a stick in the ass type” who wouldn’t give him the time of day. His therapist, we’ll call him Dr. James, heard Bob mutter “sand nigger” referring to the driver. Not knowing what to do, Dr. James let the comment pass. Near the end of this first hour when asked about family, Bob said his father had a history of bar fights and usually ended up worse for wear. This was not spoken with pride. 

In the early weeks of treatment, Bob cancelled an appointment to attend a Trump rally. In the session that followed he described elation during Trump’s speech, saying he felt “solid, strong” yelling support in the packed arena. Dr. James wondered if he was being baited when Bob used “libtards” and “Gimmedat Party” in describing disdain for the “typical Boston” supporter of “Obummer”.  Dr. James recognized he needed to sort out his own judgmental stance and not react to these remarks. Too early inquiry into Bob’s words, he feared, might undermine further treatment. I agreed. 

Dr. James wondered if Bob’s ardent support for Trump wasn’t compensatory for resentful feelings of sexual, social, and economic inadequacy. James saw Trump as an authoritarian populist, a demagogue neo-Fascist, who manipulates his crowd into celebrating racism, hyper-masculinity, us against them nationalism, might makes right, and cathartic violence. We shared this political appraisal. 

We asked ourselves, is this young man’s support of Trump essentially a grievance compensation for impotence, inadequacy, and envy? Are his politics essentially vicarious identification, an unconscious wish to merge with a strong-man leader? When my supervisee asked Bob why he canceled his previous appointment, he responded that he’s been hurt by affirmative action, how Obamacare will make it impossible for him to get a decent job, and that Trump calls it like it is about Muslims.  Still, regardless of his compensations, identity politics, or wishes to merge, we need to ask, is Bob’s conscious justification unreasonable for someone in his situation? Doesn't a person's politics often address grievance? 

And what can Dr. James do, while maintaining the integrity of his own values, professional and personal, to help Bob?  (Values that James and I share in our supervisory community of two.) When is inquiry into the roots and significance of Bob’s politics appropriate and to what end? And when is the absence of inquiry collusion? Darkly, Dr. James and I worried how silence is assent to an aggrieved and violent movement, a step toward the consolidation of a dangerous political community whose specter will haunt America regardless of the election's outcome.  

I asked my friends in the Descriptive Psychology community for help. Here’s Anthony Putman’s response.  First, a bit of background to frame his comments starting with Descriptive Psychology’s understanding of psychopathology: 

A) A person is an individual whose history is, paradigmatically, a history of Deliberate Action in a dramaturgical pattern.
B) When a person is in a pathological state there is a significant restriction on his ability (1) to engage in Deliberate Action and, equivalently, (2) to participate in the social practices of the community (Peter Ossorio, The Behavior of Persons, 2006/2013).

The remarks that follow rest on the way Descriptive Psychologists use the concepts of satisfaction, ultimate satisfaction, community and world.  I’ve written that a person feels satisfied when they have competently engaged in behavior that reflects their intrinsic hedonic, prudential, aesthetic, or moral/ethical values. Putman adds that “satisfaction is participation” and this clarifies his very interesting thought that ultimate satisfaction is the immediate experience of participation that establishes or shows how a person's world comes together and make sense. Naturally, this includes one's place in that world. Tony introduced this concept in describing his experience as a young mathematician solving a proof and suddenly feeling "how it all comes together into a single irrefutable whole".  At that moment he was participating in the great chain of mathematicians, a young man competently expressing an aesthetic value intrinsic to the world of mathematics. At these moments a person feels cohesive, authentic, sound, and belonging.  Understandably, the corresponding elation, bliss, and vitality, once felt becomes desire.  Or, if appraised pejoratively, addiction. Once found, the taste is hard to relinquish.

Ultimate satisfaction requires a community that facilitates the expression of a person's intrinsic values. Religions and political movements provide this space. 

Tony’s comments:

“Bob's a good example of how pathology is understood through the lens of status and world. In lieu of a carefully reasoned analysis, some points:

Bob seems to be suffering from status degradation, in his own mind and, he believes, in others. He wants to be eligible with the attractive classmate but knows he is not; he doesn't have the resources and opportunities others do; he can either see that as his own failure (depressing), or see it as an unfair provocation (anger). Anger does not limit behavior potential like depression; he chooses more behavior potential over less having learned this from his Dad.

Bob clearly does not experience ultimate satisfaction in his world; his place does not fit him. Then he goes to the Trump rally and find a community whose world makes sense to him; he participates in it and experiences "elation" -- a very good way of identifying ultimate satisfaction. Finally, I can be me and say what I think, and it fits here! Good luck prying Bob away from his new world. 

Dr. James has to chose between being a therapist for Bob as he is or sticking to his own political/religious guns. I suggest that the latter is unprofessional and unethical. Dr. James has no play here unless he genuinely gets Bob's world and recognizes the core therapeutic issue: Bob lives in a world with no authentic place for him. He needs a world that does -- and that's the core issue of his therapy.

Dr. James has a core dilemma: In doing therapy with Bob: What am I doing by doing that? The canonical answer is: helping my client live an authentic, satisfying life. But of course he may also say: Helping a budding fascist realize his full potential. Therapeutic ethics say the first trumps (I know...) everything else -- but therapists are people, living their own lives and what is right for James may appropriately override what's right for Dr. James. Hard choice, made as all choices in the light of incomplete information -- but that's life as an adult.” 


I think Tony captured the central dilemmas. Let's work with:

"Dr. James has no play here unless he genuinely gets Bob's world and recognizes the core therapeutic issue: Bob lives in a world with no authentic place for him. He needs a world that does -- and that's the core issue of his therapy."

Can therapy can provide a space where participation is authentically satisfying?  For this to happen, it requires establishing a significantly valued relationship.  And this has to happen first before a person's politics or religious practices can be questioned. 

How can therapy accomplish this? When I posed this question to Saturday's study group, Bryan Harnsberger spoke of maintaining empathy and Al Ossorio suggested carefully noting the problematic themes with a question along the lines of, "how do you imagine I'm feeling about what you are saying?" To be fair, I thought, asking this might require the therapist to show his hand. (And, if it seemed inappropriate to ask the client about the therapist's feeling, a safer route might involve asking Bob how other significant figures in his life might feel.)

Therapy, I believe, requires patient and uncertain negotiation, with the therapist empathically attending to the unfolding improvisation that one way or another will demonstrate professional and personal values.  This happens silently or out loud. Therapists with their careful attention, kindness, and appreciation of their client's struggle show and model their deeply held values. But something also needs to change in a manner that helps the client along. That is why the client is there. The client needs acceptance but something about them, something they are doing needs to be addressed. This requires a new perspective and perhaps new skills.  Re-description, interpretation, and tactful confrontation serves this end. This is also where "how do you imagine I'm feeling..." might come to play. Appropriate functioning requires understanding that everyone stands at the center of their world.  For all sorts of reasons, people forget this or don't adequately keep it in mind. 

The therapist who achieves sufficient value, trusted and fair minded, and demonstrates an accurate appreciation of the client's experience is in a position to employ re-description, interpretation, and empathic confrontation. But how to handle "sand-nigger" and the joy of participating in fascism?  This boils down to whether Bob can find an authentic place for himself in the therapeutic work as a participant in the tiny community he has with Dr. James. Here, size doesn't matter but significance does. For this to work, James must able to accredit and maintain Bob's good standing within the dyad. They both must value belonging before participating in negotiation and improvisation can allow the possibility of a new "ultimate satisfaction".  It will require moral dialog, a disclosing of actual values. This mutual self-disclosure can be uncomfortable, risky, and something therapists reluctantly practice. 

Therapeutic improvisation requires an openness and acceptance to tolerate the to and fro assimilation and accommodation that takes people somewhere new, someplace likely unanticipated.  But consider the dilemma when one party tosses something unacceptable to accommodate. Rather than throw it right back, hold it a bit longer, pause, look at it closely and somehow indicate, hmm, what do I do with this? I am reminded of the annoying but sometimes wise parental move of indicating a child's behavior is bad without attributing essential "badness" to the child. This works if a basic trust that the child is a valued member of the family is securely intact. I often remind students of the similarities of parenting and therapy. 

Dr. James is smart to recognize he needs a firm alliance with Bob before he can take issue with Bob's politics. (And this assumes Dr. James has sufficient reason to).  If the relationship is significant enough, Bob will engage Dr. James' value laden questions and disclosures and make of them as he will. And who knows the outcome? There are no mechanics of necessary change beyond what happens when a person can safely consider another's view within a relationship that provides them a reason to do so. 

But why touch the third rail in the first place?  Why not stop with "to the extent a person can effectively engage in their communities, it is not the therapist's job to judge". This, of course, is complicated by the overlap and conflict that naturally attends communities. All of us are members of multiple communities, professional, ethnic, religious, recreational, and so on.  Some get along better than others and some are in intractable conflict. 

Forgive what might appear a digression. Back in the 1950's, the psychiatric anthropologist George Devereux wondered how to identify the normal and the abnormal in cultures different from his own. He explored this question while observing the lives and practices of Mojave shamans. He pointed out that no Mojave would ordinarily choose to become a shaman since it's a nasty and liminal role. Nonetheless, shamans occupy an important place in Mojave culture.  
  
Devereux observed a pattern common in the developmental history of shamans: offering a cure by becoming a shaman. The Mojave recognized that it is unfortunate to be disturbed, but if crazy in a particular way, with proper training, some of the afflicted can enter the ranks of healer. Some forms of craziness can be shaped by ritual. Devereaux thought Mojave shamans had ways to manage their own severe but culturally common neurosis, what I suspect are versions of Borderline Personality Disorder. 

Devereux contrasted the shaman's culturally syncretic disturbance, common in Mojave culture and guided by the culture's ritual options, with idiosyncratic disturbances that rendered an individual simply pathological, without a valued place to be. 

Perhaps you see where I am going. Politics and religion may provide a way to find satisfaction even while disturbed, but only if the disturbance is sufficiently shared and valued within the community. If the crazy dance fits, the otherwise troubled can engage in some of the valued practices of the community.  

But if your problem is idiosyncratic without community to provide membership and guidance, you're out of luck. Fortunately, psychotherapists occupy this domain with our license to question. 

Let me complicate this a bit further.  Devereux also described the plight of the Tonkawa. Although the stories may be apocryphal, the Tonkawa were alleged to eat the slain bodies of the warriors they constantly fought in ongoing wars with neighboring tribes. The Tonkawa are probably extinct owing to the alliance their neighbors formed to wipe them out. Being a normal Tonkawa ended up untenable. Devereux also wondered about the normality or pathology of the German Nazi and whether from May to June of 1945 the "normal" Frankfurt Nazi managed to become, depending on which side of the Main River, a communist or a Christian democrat.  

Communities exist side by side, overlap, share, compete, and clash. Sometimes the integrity and survival of one community requires action against another. This is a matter for politics, not therapy. Free from the consulting room, will Dr. James and Bob act with indifference, forge an alliance, or go at each other's throats? 


Kindred themes are taken up in On Indoctrination and in Empathy, Inclusion, and Moral Dialog or What Gets in the Way of Negotiating Social Justice.


Thanks to C. J. Stone for the clarity he provided regarding "political correctness" and to The Boston Descriptive Psychology Study Group's openness to explore. And special thanks to my William James students who put up with my trying to figure these things out with them and on their dime.