Patrick B. Kavanaugh - 2001 Annual Letter to the Membership
2001 Annual Letter to the Membership
On behalf of the Academy's Board of directors, it is my privilege to once again wish you a very happy, healthy, and fulfilling new year. These have been very exciting years for the Academy. Individually and collectively, members continue to contribute in a variety of ways to a critical discourse on psychoanalytic theory, practice, ethics, and education. In so doing, we have encouraged and fostered a much needed conversation in the analytic community, a conversation that radically extends psychoanalytic thinking beyond the traditional bio-medical ways of thinking. And this conversation becomes more significant as the implementation of another series of changes is anticipated in the healthcare revolution.
Revolution(s) in Healthcare
In The Next Wave of Change for Psychology and Mental Health Services in the Health Care Revolution (American Psychologist, May 2000, 481-487), Charles Kiesler notes that we are currently in the third revolution in American health care since World War II. The first revolution, the era of expansion, took place between the late 1940's and the mid 1960's. During this era, the helping professions such as psychology, psychiatry, and social work entered the political- economic arena, eventually emerging as full-fledged members in the family of the healthcare professions. Individual practitioners took on the Identity of mental health professionals, received a government-issued license to practice, became eligible to receive medical insurance reimbursements for mental health services, and enjoyed the status of paying malpractice insurance premiums (?).
Identity as a healthcare professional, however, carried implications that went far beyond developing licensing laws, parity in the scope of practice, or a legislative presence. As a health care profession, the conceptual foundations of the discipline were organized around certain beliefs, values, attitudes, traditions, and ways of thinking that formed the underlying assumptions of knowledge production (a positivist science) and the ideological context (medicine) and formulations (symptomatology-etiology-pathology) in which people were understood. For the mental health professions, these conceptual foundations were firmly rooted in the biological sciences, their concepts developed in the framework of medicine, and their validation derived from the methods and assumptions of the natural sciences. These underpinnings grounded the political and ideological hierarchies of power and knowledge in the analytic culture. The second revolution referenced by Kiesler, the era of cost containment, began in the mid 1960's and was characterized by the institutionalization of health care and accreditation standards in mental health services; national licensing exams (education), utilization reviews (practice), and adherence to certain theories of moral obligation (ethics) were introduced to justify medical necessity and the appropriateness of services (quality assurance). And contain costs. Our professional standards developed in the context of such positivist notions of science, knowledge, and pathology. The era of cost containment blends with the third revolution in healthcare, our current era of assessment and accountability. In this current era, the health care system design and the individual's access to care in that system are ultimately determined by evidence-based strategies linking outcome and cost-effective research.
And what is the next wave of changes in this era of assessment and accountability? ... As noted by Kiesler, the mental health care of 88% of the managed care population has not yet been integrated with health care. As a specialty-care behavioral health plan, mental health is a carve-out, a separately capitated and separately costed category for mental health and substance abuse services. Kiesler argues quite persuasively that system integration of mental health services, i.e., carve-ins, will begin soon and will occur very rapidly. Further, not only will mental health services take place in the larger health care delivery system, the point of entry for such services will be at the level of the general practitioner. The reasoning is quite pragmatic and cost-effective: a carve-out such as mental health services is typically more expensive but only occasionally more effective as a form of specialty than is a carve-in. Put another way, mental health specialty-care such as psychotherapy costs more than treatment for the same mental disorders by general practitioners: "The recent research ... on the outcomes of separate treatment of physical and mental disorders…clearly suggests a push for carve-ins." (Kiesler, p. 483) (italics added).
This push for carve-ins has systemic consequences in the areas of education and training, delivery of services, and future research. The changing needs of the marketplace require that integral aspects of graduate education undergo major revisions. Kiesler further notes that health care providers, psychoanalytic or otherwise, must be prepared to offer their treatment at the general practitioner level, develop more appropriate review mechanisms for utilization of medical services, deal with the concept of the real costs of failed treatments, must come to accept the concept of good enough treatment in their practice, and must recognize that concepts like "medical necessity," "ethics," and "standards of treatment" are rapidly evolving in the context of physical health care. Carve-ins are expected to also produce pressures to accelerate research on measures of an individual's mental health status, factors effecting drug compliance, and to establish an empirical database justifying the effectiveness of short-term and non-traditional therapies. The continuous "quality improvement of treatment" is to be accomplished and defined through documented, observable, empirically established databases so that significant outcome-based research can take place; outcome based therapies, intervention strategies, and education are becoming the wave of the present and presage far reaching changes in our professional standards in education and training; treatment and care; and, ethics and quality. These changes in professional standards affect everyone in the practice and learning communities.
Articles such as Kiesler's are written as if organized psychology and psychoanalysis are passive and helpless victims of powerful social, economic, and political forces. And further, that the task that lies before mental health professionals is to overcome their resistances and unquestioningly adapt to the systemic changes outlined in the service of implementing the industrializing vision of the institutional discourse. Another perspective, however, might consider that organized psychology and psychoanalysis have a vested interest in perpetuating a science and pathology driven model of mental health services and actively participate in the re-shaping of professional standards in the learning and practice communities. In the past several years we have seen organized psychology and psychoanalysis advance national standards for psychoanalytic education (Division 39- Consortium), empirically validated treatments (APA-Division 12), mandatory continuing education (APA-MPA), and proposed changes in our medical code of ethics (APA task force) and licensing laws (PEW Health Professions Commission task force). And in so doing, bringing the standards of education, treatment, and ethics more in line with the medical model and the managed care marketplace.
Conceptual Revolution(s) Outside of Healthcare
For many, the mythology of psychoanalytic psychology as a positivist-medical science has been unraveling for quite some time as the conceptual foundations of its ethics, education, and theories have been questioned, challenged, and rethought. As noted by Carlo Strenger (1998), the past twenty five years have heard a chorus of voices questioning the assumptions underlying the positivist's notions of history, truth and psychology (Schafer, 1983; Arlow, 1985); renouncing the tendency of psychoanalytic theory to order the human universe in a developmental hierarchy (Mitchell, 1993; Stolorow et. al, 1994; Aron, 1996); dismantling such dichotomies as normal- heterosexual and pathological-homosexual, the discontent with these meaning-making categories centering on questions of gender and sexuality (Chodorow, 1994; Benjamin, 1995); and, challenging seemingly self-evident propositions in which nature prescribes the proper developmental track, the morality for leading the right way of life, and how things ought to be in one's thinking and behavior. The Academy has vigorously joined in this discourse.
The project of the Academy is a statement of fundamental disagreement with the traditional science and pathology driven model, its healthcare and accreditation standards, and the professional standards that derive therefrom. The academy's project, however, is much more than simply a "statement of disagreement" with the medical model, industrializing trends and professional standards. Our mission statement succinctly states our project in the affirmative:
To advance the study of psychoanalytic epistemology, theory, and practice, ethics, and education within a psychological framework consisting of philosophy, the arts, and the anthropic sciences as opposed to biology, medicine and the natural sciences through:
1) the re-thinking of psychoanalysis as a creative intellectual discipline dedicated to the understanding of the psyche;
2) the re-thinking of psychoanalytic practice as consisting of a collaborative inquiry to further self-understanding rather than the "treatment" of disease, disorder, or deficiency;
3) the development of educational programs for the study of the many modern and postmodern versions and visions of psychoanalysis that proceed from contextual metaphors such as narrative story, semiotics, amsufism, and psychic theatre;
4) the articulation and advancement of an ethic and principles consistent with this psychological framework; and
5) the presentation of these ideas to the academic, professional, and lay communities.
The academy joins with a growing number of educators and practitioners in rethinking and rewriting a radically different text for the understandings of people and life. And for the analytic discourse and its ethic. Such rethinking has led to a variety of theoretical and methodological positions that derive from the orientations of existential-humanistic, hermeneutical, narrative, semiotic, cultural, relational, transpersonal and integrationist psychologies. These more contemporary psychologies of psychoanalysis have differing conceptions of the world, people, and life as well as different understandings of the concepts and meanings of Identity, the Subject, Causality, and Truth. These psychologies premise different understandings as to the basic nature of people, posit different methods of knowing about people, and assume different purposes for the analytic discourse. The pluralism of contemporary psychoanalysis contrasts boldly and sharply with the uniformity of the logical positivism of yester-year in which the humanistic discipline of psychoanalysis was represented as a natural science, grounded in a medical ideology, and guided by a compassionate code of ethics. The days of a monolithic psychoanalysis are far behind us.
There is a growing base of support among other like-minded individuals and groups in the analytic and psychological communities interested in thinking, conceptualizing, educating, and practicing in an ethical system outside of a health-care matrix. The humanistic psychologists of the APA (Division, 32), for example, have taken strong positions opposing the medical system as the right place for people to address questions of meaning, ethics, values, self-development, and improvement. Maureen O'Hara, Ph.D., president of the Saybrook Graduate School in San Francisco, states in the APA's Monitor (March 2000) that humanistic psychologists are beginning to align themselves with several emerging professions outside of the medical model of care that aren't reimbursed through insurance. These professions are rooted in the study of all aspects of human experience, including those explored by philosophy, the humanities, and the arts. The focus of their understanding is human experience as it is lived by the subject living it. Thus, objectivist science is not the primary method of knowing; narrative, qualitative, and historical methods of research are used in the search for understanding people. The humanists are currently in the process of revamping their image outside of a healthcare matrix (Monitor, March 2000); developing practice guidelines of humanistic psychosocial services outside of the medical language and system (Humanistic Psychologist, vol. 24, Spring 1997, pp. 64-107) and presenting their views on empirically violated treatments (Psychotherapy Research, 8(2) 141-157, 1998) in which, it is argued, empirically validated treatments are restrictive and scientifically unjustified. The Academy is quite like-minded with such a humanistic philosophy, agenda, and objectives. Visit the Links Section of our website and acquaint yourself with the thinking and activities of other such groups; for example, the Independent Practitioners Network (http://ipnosis.postle.net) a group formed in the United Kingdom to support members of the professions practicing independently and outside of the regulation and control of accreditation standards.
Programs and Presentations in The Marketplace of Ideas
Membership Through Involvement continues to define the academy as an active relevant, and radical group of psychoanalytic thinkers. And doers. Amazingly, over two thirds of our membership is quite actively involved in the academy's committees, organizational life in other societies and groups, or through the presentation of their thinking in local, national, and international forums during the past several years. In this way, the principles, values, and beliefs contained in our mission statement are actively advanced in the market place of ideas.
At a local forum… Many presentations have been made at the MSPP's monthly meetings at the Fisher auditorium at Providence Hospital (Southfield, MI) during the past two years. Marvin Hyman, Ph.D. presented his paper, The Joy of Analyzing (December '98); Patrick B. Kavanaugh, Ph.D. presented his paper, An Ethic of Free Association: Questioning a Uniform and Coercive Code of Ethics (January '99); in a joint meeting of the Academy and the MSPP, Bette Glickfield, Ph.D. presented case material discussed by Linda J. Young, Ph.D. at The WHY Behind the HOW in Working with Kids: Philosophy, Ethics, and Technique (February '99); Gloria E. Cruice, Ph.D. presented her paper, ?Question-ing Bodies of Knowledges and Mark-ing Psychoanalysis as Uncertainty? (April '99); Patrick B. Kavanaugh, Ph.D. presented his paper, How Will Bodies of Knowledges Speak the Psychoanalyst in the 21st Century? Some Thoughts on the Art(s) of Psychoanalytic Education (September '99), and Leaving the Garden of Eden.. The Codes of the Culture, The Codes of Perversion, and Psychoanalysis (December '99).
During this past year, Marvin Hyman, Ph.D. presented his paper, Failure in Psychoanalytic Therapy: An Oxymoron (January '00) and participated in the MSPP's Spring Conference What Does Psychoanalysis Have to Offer, If Not A "'Cure?" The Articulation of Experience??? (March '00); Gloria E. Cruice, Ph.D. participated in a round table discussion on The Futures of Psychoanalysis: How Might They Unfold? with Roxanna Transit, Ph.D. serving as facilitator of the discussion (April '00); Lisa A. Kelly, Ph.D. participated in a panel presentation on Echoes of Time -- Aging in the New Millenium (May '00); Karen Colby Weiner, Ph.D. participated in a panel presentation entitled Psychoanalytic Psychology and the Regulation of Psychology in Michigan (September '00); Gloria E. Cruice, Ph.D. presented her paper, Changing Concepts of Presence, Meaning and Responsibility in Psychoanalytic Thinking and Patrick B. Kavanaugh, Ph.D. presented his paper, The Decline of History as Reminiscence, Knowledge, and Tradition: Reclaiming an Historical Sense in Psychoanalytic Thinking as part of the conference Courage to Change, commemorating MSPP's 20th anniversary (October '00).
Earlier this month, the new year began with Lisa A. Kelly, Ph.D. presenting her paper, Atypical Residents in an Atypical Place Working in an Atypical Treatment: Sharing the Journey of Finding Truth and Freedom in the Heartbreak Hotel (January '01); next month Patrick B. Kavanaugh, Ph.D. will be presenting his paper, Thinking About Psychoanalytic Thinking: A Question(ing) of Identity, Purpose, and Ethics (February '01); and on February 25th, Barry Dauphin, Ph.D. will be presenting his paper, PSYCHOANALYSIS: Science? Humanity? Do We Want a Place or a Palace?.
At national forums… Etta Gluckstein Saxe, Ph.D. organized and chaired a panel presentation at the Division 39 Spring Meetings in San Francisco (April '00) entitled Analyzing in a White Coat, a False Self for Psychoanalysis. In this presentation, the panelists articulated their thinking about the psychoanalytic situation and demonstrated with process examples psychoanalysis as other than healthcare. Four members of the academy participated and presented their thinking: Etta Gluckstein Saxe, Ph.D. presented her paper Expanding Hyman's 'Why Psychoanalysis Is Not a Healthcare Profession to Practice'; Susan D. Gendein-Marshall, Ph.D. presented her paper Two Consecutive Associative Hours- Process in Process- For Discussion; Johanna Krout Tabin, Ph.D.-ABPP presented her paper Psychoanalytic Process and Freedom; and Marvin Hyman, Ph.D. and Susan D. Gendein-Marshall, Ph.D. presented their paper No White Coat: Bearing the Uncertain Truth of Psychoanalysis. At the Division 39 meetings in Washington, Etta Gluckstein Saxe, Ph.D. organized and chaired another panel, Psychoanalysis, Philosophy and Science: Inquiry Enriching Knowing for Theory and Practice, where she presented her paper entitled Contexts, Processes and Ethics of Inquiry - Discovering and Creating Knowing and Barry Dauphin, Ph.D. presented PSYCHOANALYSIS: Science? Humanity? Do We Want a Place or a Palace? (August '00).
At international forums… Marvin Hyman, Ph.D., Etta Gluckstein Saxe Ph.D., and Patrick B. Kavanaugh, Ph.D. were members of the conference faculty at the International Federation for Psychoanalytic Education's tenth annual interdisciplinary congress in San Francisco (1999). Marvin Hyman, Ph.D. presented his paper, Standing Firmly on All Sides of the Issues and Patrick B. Kavanaugh, Ph.D. presented the president's address, Thinking About Psychoanalytic Thinking: A Question(ing) of Identity, Purpose, and Ethics. At the Federation's eleventh annual disciplinary congress in Chicago (2000), four academy members were part of the conference faculty: Gloria E. Cruice, Ph.D., Marvin Hyman, Ph.D., Patrick B. Kavanaugh, Ph.D., and Johanna K. Tabin, Ph.D.-ABPP. Gloria E. Cruice, Ph.D. presented her paper, The Politics of Subjectivity and Semiotics: Broadening the Concept of Psychosis; Patrick B. Kavanaugh, Ph.D. presented his paper, Madness in Psycho(analy)sis: The Ear-rationality of Treating Illusion as Reality; and Johanna K. Tabin, Ph.D.-ABPP presented her paper, Grandiosity: Sometimes a Defense Against Grandeur. The Federation's 12th annual interdisciplinary congress will be held in Florida in early November this year. The theme of this year's congress will be Culture and Psychoanalysis; the Call for Participation will be sent out in the near future.
And in the cosmic forum of cyberspace.… At the time of my last letter in January of 1999, the academy's website had been on line for less than two months. At that time, there was a sense of cautious optimism and excitement about the possibilities that the website offered in carrying out the intellectual and political aspects of the academy's project. More specifically, the board had hoped that the website might enable the Academy to develop a scholarly body of knowledge centering on the questioning and rethinking of psychoanalysis outside of healthcare. And enable the development of the political aspect of our project: to actively advance this knowledge in the marketplace of ideas. We also hoped that the website would provide us with the opportunity to establish contact with individuals and organizations pursuing similar agendas. Our cyberspace forum has exceeded our most optimistic expectations.
Shortly after going online, the Academy's board assumed the responsibilities of overseeing the development, the policies, and the procedures of the website. In November '98, we went on-line with 18 papers published, representing the work of 7 different authors. In December '00, we have published, or are in the process of publishing, a combined 49 papers and 4 letters, representing the work of 23 different authors. A minimalist philosophy underlies the criteria for the publication of articles and papers on the website. More specifically, the material published must be related in some way to advancing the mission of the academy and, in the interests of absolute confidentiality, material from the analytic discourse is not referenced. Upon receiving articles for publication, they are reviewed by two independent readers to determine if they meet these basic criteria. Please consider submitting a paper or article for publication on the website. ....In the meantime, we believe that the scholarly aspect of our project is being realized.
As to the political aspect of advancing this knowledge in the marketplace of ideas….. Working closely with the board, Roxanna Transit, Ph.D., chair of the Community Information Committee (CIC), has worked to develop and implement the policies and procedures of publishing and growing the website. From November 1st, 1998 until December 15th, 2000, a period of nearly 25 months, we have received a phenomenal number of visits to the website, with traffic concentrated on the papers and articles published. In the past year, the number of people visiting the website has more than doubled and the number of links placed in other sites connecting to the Academy's website has quadrupled; traffic to the website continues to grow by leaps and bounds. This past November, for example, our website received a new average high of close to five hundred visits per day with most of those hits to the papers of the website. Whereas most of the traffic to our website is from the United States, we receive significant numbers of visits from Canada, the United Kingdom, and Australia. And the website, itself, continues to grow.... In the past year, we have added a Links Section, currently offering 29 links to other websites and organizations who represent some of the expanded definitions of a philosophical-psychical way of working with and understanding people. Additionally, we have added a page to the website on Important Practice Issues and a page Of Topical Interest. The Lexicon Project, chaired by Marvin Hyman, Ph.D., is being developed as an interactive section encouraging people to discuss the development of a lexicon in psychoanalysis outside of a medicalized context. And a proposed Legal, Ethical, and Professional Issues Section, chaired by Cynthia McLoughlin, Ph.D., brings a new dimension of commentary and critique on the legal and ethical context in which we practice. Also, considerations are underway for beginning a discussion list where interested people can subscribe and participate in e-mail discussions on the different versions and visions of psychoanalysis. The past two years have been quite extraordinary in developing and advancing the project of the Academy through these local, national, international, and cyberspace forums.
We had developed the website with the above scholarly and political objectives in mind. And with the hope of establishing contact with like-minded others. We were quite surprised and honored to learn this past summer that the academy's website and several of the individual papers published on the website were highly ranked by an organization in France on a website entitled "150 Best Websites in Psychoanalysis." And we were equally surprised and delighted when the board was notified this past May by the Academic Resources Channel that the Academy's website had been reviewed and selected for inclusion in the Online Subject Catalog of Academic Resources (O.S.C.A.R.)... The Academic Resources Channel is a systematic directory of manually edited index entries covering a select number of the most representative resources for academia. Congratulations to each member on receiving an OSCAR!!!!
Last September, Bethann Kalt, Ph.D., chair of the Members Liaison Committee, mailed a survey to members of the Academy. The results of the survey indicated interest in having some future programs sponsored by the Academy. On Friday evening, March 30th at 8:00 pm, Fred Peters, Ph.D. will be presenting his paper entitled Playing Devil's Advocate: Nietzche's Attack on Women and Jews, Scientists and Democratic Man, and Other Enemies of Intelligence, Creativity, and Civilization at the North Campus Commons in Ann Arbor. Implications of Nietzche's ideas and their disturbing relevance to a medically based mental health system will be considered. If there are any questions, please contact Linda Young, Ph.D., chair of the programs committee.
Since its inception, the academy has been interested in carve-outs as in "carving out a space" where one can think, conceptualize, practice, educate, and develop a system of ethics outside of a healthcare matrix. As mental health carve-outs are integrated (carved-in) in an overall health care system, there might be more interest and incentive for like-minded others to join with us in carving out a space for education and practice outside of the growing constraints of the health care matrix. Tell a friend about carve-outs and carve-ins. And that you are part of a very active and dedicated, local group making noteworthy contributions to the rethinking of theory and ethics in psychoanalytic practice. Invite your friend to one of the programs coming up in the next several months (February 11th at the MSPP; March 30th at the North Campus Commons in Ann Arbor).,
The driving force of the Academy continues to be the dedicated, committed, and involved members who have joined together in the creative implementation of the Academy's project. As we begin our seventh year, we hope that you continue to be in agreement with the project, the directions, and the collective efforts of the members of the Academy in representing your individual interests during this healthcare revolution. If you are interested in membership information, please contact Raymond Vasser, Ph.D., chair of the membership committee at 999 Haynes, Suite 250, Birmingham, MI 48009, or email at RJVasser@AcademyAnalyticArts.org.
Carpe Diem (CD),
Patrick B. Kavanaugh, Ph.D., President