Some Consequences for Youth Violence of Society's Abrogation of Confidentiality and Proliferation of "Duties to Report"

by Etta Gluckstein Saxe, Ph.D.

 As someone who has worked with very troubled children and teenagers for 40 years I would like to call people's attention to issues left unmentioned in my readings about the recent Colorado horror. 

Recently we learned from the NEW ENGLAND JOURNAL OF MEDICINE that physicians without knowing it (i.e. based on their unconscious beliefs) give different care to people of different races and genders who have very similar symptoms.  Programs within medical schools are then suggested, which would encourage better acquaintance with ideas outside of consciousness.  The goal is that of increasing self-control through self knowledge, so physicians can better keep themselves from harming those who are in their care and the social contract can better be fulfilled.  I would strongly suggest that the same principle for prevention of hurting /killing other people and/or self, be applied to all people including or perhaps especially children who communicate their distress through extreme, shocking and/or rule violating behavior.

 Much is written about missed cues in discussions of these horrors, but the cues are not what is missed.  These boys were in a PROGRAM in which they met the measurable criteria for completion.  One of the boys was seeing a psychiatrist who gave him medication as his treatment.  A boy who produced an earlier horror was the day before put out of school and spoken TO about bringing a gun to school.  He was sent home without anyone speaking WITH him about the terrors motivating his perceived need to carry the gun.  He subsequently killed his parents and returned to school to continue his rampage.  His attempts to get some help in controlling himself by screaming "I have a gun" fell on ears deafened by a lack of belief that children want to control themselves at the same time that they want to make themselves less terrified inside.  As we simplify the mind to observables and deny the conflicts and controversies within all minds, so as to lessen encountering our own, we do not speak with children to ascertain the terrors and anguish that make murder a viable possibility.  We act as if we believe that such speaking is contrary to or instead of other acts done to forestall violent actions.  We also find it very difficult to allow such speaking to occur in a confidential setting for the purpose of understanding rather than with the purpose of directing positive moral behavior and with a person other than the persons, such as police and courts, whose efforts are directed to behavior and its consequences.

From my point of view we do not miss the cues.  Rather it is how we think about the cues and how we then approach these child-people where we most often fail.  We put them in categories and offer treatments based on the categories, and as often as not, the treatment is medication . We rely on so called measurable criteria which to be measurable must be behavioral, including speaking/reporting certain measurable words and NOT speaking other words.  In other words we treat them (and most so called mental health patients especially under managed care) as a type, not an individual with a mind - - a person with the possibility and responsibility of self control.  Worse than that we by so classifying them undermine their self control further by telling them they are sick and not capable of being responsible for themselves and clearly communicate that we not they, are experts on what and how they think and what right thinking is.  We thus fail to help them with either self control or mastery of their minds - - two important pathways through which experiences of self as worthwhile, valuable and human are generated. 

We do not provide (and at times we make it illegal for professionals to provide) opportunity for these troubled and often anguished people to look into themselves and find ways to reorganize themselves, in a manner which that can then allow them to act to their own advantage, as participants in the social order.  As such reorganization requires the freedom to explore all the ideas/thoughts of each person's mind in safety, including the safety of a completely confidential relationship, mounting rules stand in the way of opportunity for these very troubled people and greater safety for ourselves.  We seem to perceive this important confidentiality as a threat to those other interventions including some form of restricted participation in the social world , which might be deemed necessary for the safety of all.

I would like to elaborate some of the ideas dominant in our society which I think contribute to our predicament.  We have placed all psychologists and other professionals, as society's monitors by increasing duties to report which breach confidentiality.  We sanction them if they do not report even within closed and semi-closed multiply staffed programs where there are plenty of other professionals to be monitors.  As a result people keep matters to themselves which may then fuel some of the repetitious horrors with which we live.

Recently I heard on NPR that a teenager in a group discussion of a counseling and information gathering kind spoke freely of her recognition within herself, of possible circumstances where she would be tempted to violence.  Letting herself empathize in this way led her to the principal's office and eventually to exclusion from school, as reports of her words, seen by others as cues, led parents who heard reports of them to panic.  Since part of the purpose of these sessions was to get information from the teenagers to make life safer for all, the lack of confidentiality and the actions generated by speaking freely, as requested, can clearly be seen as a silencing of the potentials of such a process.

We seem to confuse getting to know someone's most intimate and scary thoughts in a confidential/professional context with making excuses for evil behavior, absolving people of personal responsibility and encouraging action.  We act on this confusion, while increasing it, by allowing elements of recent and past personal history as excuse in our courts.  As the proliferation of experts in who is to blame (TV, parents, gun manufactures) clearly indicates, we are unable to give up a mind state of "blaming" and of perpetrator and victim with which our willingness to participate in an escalating litigious society burdens us.  We often can not look beyond these mind states as maintaining them reassures us that we are in no way also, in our common humanity, the bearer of potential evil.  It is "someone else" who is the bearer of evil and ways/cues of controlling that someone are sought.  The professional who is willing to look inside his/herself as part of professional effort in providing the freedom of thought which the opportunity for reorganization makes necessary, thus becomes another bearer of potential evil who we try to control with proliferating obligation/duty to breach confidentiality, as did the honest student/teenager in the NPR report.

(Etta Gluckstein Saxe, Ph.D. is a psychoanalytic thinker and practitioner who has devoted the majority of her professional time for almost 40 years working with very troubled children and adolescents, many of whom were violent, explosive, terrified and terrorized.  She counts among her mentors and mentors of the programs at the agency at which she worked, Fritz Redl, Ph.D. of Vienna, the author of "Children Who Hate" (1951) and "The Aggressive Child" (1957).  The first of these books grew out of and reported on what was learned from children who hate through a psychoanalytic program called Pioneer House in Detroit Michigan.  Dr. Saxe has taken upon herself a retirement project of bringing psychoanalytic thinking to the attention of the public, through letters to newspapers and op-ed contributions, around "social policy" and professional issues, where she considers this perspective an important and ignored one.  This article was originally such an attempted contribution to her local newspaper.  Dr. Saxe practices in Royal Oak and Ann Arbor Michigan.

This Letter to the Editor was previously published by the Psychologist-Psychoanalyst (Vol. XX #1), a publication of Division 39 of the American Psychological Association, and in the Michigan Psychologist, a newsletter of the Michigan Psychological Association.)

Etta Gluckstein Saxe, Ph.D. is a psychoanalytic thinker, practitioner and educator whose participation in psychoanalysis as discipline, practice and scholarship spans almost 40 years. Her ongoing and continuing education is a self-directed one. She counts among her many mentors Richard Sterba M.D., Editha Sterba Ph.D. and Fritz Redl, Ph.D. of Vienna and Detroit and other members of Michigan Association for Psychoanalysis (MAPS), Marvin Hyman Ph.D. of Detroit, and Ann Arbor and Detroit based graduates of the Hampstead Clinic (now the Anna Freud Centre). She has taught and done supervisory consultation in the Departments of Psychology of the University of Michigan and the University of Detroit Mercy and in the Department of Psychiatry and Behavioral Neuroscience (previously Department of Psychiatry) of the School of Medicine of Wayne State University, Detroit, Michigan., with a specialty in work with children and adolescents. Dr. Saxe served as the vice-president and program chair of the Michigan Society for Psychoanalytic Psychology 1989-1991 and as its president from 1991-1995. Her membership in this society extends from 1980 to the present and she has served on the Board in various capacities over these years. Dr. Saxe is a long time member of the Division of Psychoanalysis (39) of the American Psychological Association and the year 2000 president and year 2001 past-president of Section IV (Local Chapters) of Division 39. She is a member of the International Federation For Psychoanalytic Education and is completing a second term as a member-at-large, with her area of responsibility the development of a Mentorship Program. She has participated in the last few years in the Children and Youth Committee of the Michigan Psychological Association in which she maintains her membership. She is an active member of The Academy For The Study Of The Psychoanalytic Arts and one of the "founding members" of this group. She has taken upon herself a "retirement project" of bringing psychoanalytic thinking to the attention of the public, through letters to newspapers and op-ed contributions around "social policy " and professional issues, where she considers this perspective an important and ignored one. Dr. Saxe practices in Ann Arbor and Royal Oak, Michigan, offering personal and educational consultation, seminars and study groups.