The American Psychoanalytic Association and Torture--no Moral Ambiguity

For those of us in the mental health field, one of the more shocking aspects of the Department of Justice memos regarding “enhanced interrogation” released by the Obama Administration last weekend was the description of the central role of a psychologist (or psychologists)  in justifying the techniques used—waterboarding, isolation, humiliation, etc.  It appears that the psychologist's “expert opinion” was used to maintain the position that no prolonged mental harm was caused by these techniques, and therefore, by the then current (reinvented) definition of torture, they could not, (again, by definition) constitute torture.

 

The DOJ memos reveal that a psychologist was present when an al Queda subject was interrogated.

 

Then follows a morally astounding section of the memos that argues that though waterboarding clearly constitutes a threat of imminent death, as long as the technique is not intended to cause prolonged mental harm, it is not torture because of the alleged intention of the interrogators.

 

So the psychologist involved comes in handy in two ways.  He or she states that based on his or her expert opinion, waterboarding does not cause prolonged mental harm.  A story on National Public Radio yesterday (April 21) added the background that the basis for this claim came from a study of volunteers in the American military undergoing the same procedures for training purposes (the SERE experience) which showed that these soldier/volunteers suffered no long term mental harm.  But you don’t have to be a psychoanalyst to figure out that being a volunteer undergoing certain awful experiences administered by your colleagues is a really different experience from being an “enemy combatant”, helpless and confined and completely unable to control your present or your future.  Also you don’t have to be a psychoanalyst to know that it takes a long time to evaluate the presence of long term effects.  Duh.

 

The other role for the psychologist  in the interrogations was to play some role in the peculiar and disturbing dance around the issue of “intent to torture”.  This too boggles the mind.  What was their intent then?  Why does the intent of the interrogator change the assessment of the effect of the technique on  the person questioned.  If I run you over and kill you you’re just as dead if it were an accident or intentional.  Perhaps my punishment would differ, based on my intent, but the ill effect you suffered would be the same.

 

All the major mental health organizations now have statements opposing torture.  The American Psychoanalytic Association unambiguously and unambivalently opposes torture in all its forms.  I hope that no mental health colleague will ever again engage in the moral shell game these memos reveal.

In 2008, the American Psychoanalytic Association approved this position statement on torture:

POSITION STATEMENT

The American Psychoanalytic Association joins with other mental health and medical professional organizations in strongly condemning the use of torture. As an organization of psychoanalysts who have devoted their lives to helping people undo the effects of trauma in their lives, APsaA strongly protests all torture, including any governmentally administered and governmentally approved torture of people who are detained. Torture degrades those tortured and those torturing. The effects of that physical and moral degradation, we know, are transmitted to the families and offspring of both victims and perpetrators. APsaA also strongly condemns the participation or oversight by any mental health or medical personnel in any and all aspects of torture. Such actions are contrary to the basic ethical principles fundamental to the helping professions.

 

 

 

 

 

 

Psychoanalysis and gay rights--40 years of change

Reflecting on the 40th Anniversary of the Stonewall rebellion, the New York Times published a most peculiar piece on Sunday April 12. Titled “Word for Word: Deviates and Inverts” the anonymous "Week in Review" piece seemed to be a kind of apology for the language and attitude the Times presented as “news” about homosexuality in 1963.

In their broadly quoted “news” story of the early 1960’s, the Times relied upon the expert opinion of a psychoanalyst. The April 12 2009 piece also relied heavily on quotes from this psychoanalyst, who argued, among other long since abandoned ideas, that viewing homosexuality as an illness can be very helpful (now we know that view causes great pain, and even the loss of life especially in vulnerable young people), that homosexuals are inherently emotionally unstable (huh), that homosexual relationships suffer more from jealousy and personality clashes than  heterosexual relationship  (really??).

The Times notes that “the article’s language, from sources and reporter alike, is outdated at best, derogatory at worst, and many of its assumptions and assertions are long discredited” I'll say. 

But as a psychoanalyst, and president of the American Psychoanalytic Association (APsaA), it deeply troubles me that the Times did not bother to note how profoundly psychoanalysis has changed in its attitude toward homosexuality in the decades since Stonewall. Like other mental health professionals, we know that homosexuality is NOT an illness, that gays and lesbians are NOT inherently unstable, that gay and lesbian relationships and families are no less rich and resilient and stable than heterosexual ones. (which is to say, I guess, that relationships and having strong families is hard, gay or straight, but being gay does not give you a handicap in this arena.)

My colleague Ethan Grumbach, Chair of our Committee on Lesbian, Gay, Bisexual and Transgender Issues, writing on behalf of the American Psychoanalytic Association, wrote this letter to the editor of the Times on April 13:

Deviates’ and ‘Inverts’ (Sunday, April 12) references the study of gay men by Dr. Irving Bieber, a psychoanalyst who believed that homosexuality was an illness that could be treated or prevented. Like New York City, psychoanalysts have come a long way- in their case, by the fact of having discredited Bieber's view. Today, The American Psychoanalytic Association, 3,300 members strong, ardently supports gay marriage and opposes and deplores public or private discrimination against male and female homosexually oriented individuals. Social justice is paramount to psychoanalysts in all aspects of human life- regardless of sexual orientation.

At the American Psychoanalytic Association we are particularly proud of a series of position statements we have approved over the last decade addressing issues such as gay marriage, gay adoption, and gays in the military. Please take a look.

The Ethical Centrality of Patient Consent

A few days ago, I received a call from a company describing itself as an agent of my patient's health insurer, charged with the task of determining the "medical necessity" of her treatment. (A haunted term I was pleased not to have heard in a while). I told the caller that I didn't have a consent from the patient to release the information they wanted, which included "physician's orders, treatment plan, progress notes, and lab results" and in any case I only responded to written requests. The caller became irate, and said "everybody does it [on the telephone]" and eventually hung up on me.

My patient wanted me to provide the information, since in the economic downturn he needs the money the coverage provides.

I finally got a written request from the "health management system". It contained the following extraordinary paragraph:

This review and request for medical record information is part of the utilization review process and is performed at the request of the patient, provider and/or health plan. As such, there should be no charge for the medical record. [why is this exactly?] In accordance with HIPAA regulations, the requested information will only be used for payment, treatment and health care operation purposes and does not require a release of information, consent or authorization. [what would require a consent in their view?] [As a practitioner, I thought the whole point of HIPAA regs was to provide consent, though I understood that provisions allowed companies to have patients give blanket consent] [comments in color obviously my own]

Perhaps the "health management system" meant to say that they had previously received a blanket consent from the patient that allowed them to bypass the need for specific consent this time. However, it interested me that it didn't occur to them that I might need to have consent to release the information, that went beyond their angry assurance that (1) I had to do so and (2) "everybody does it".

I know this story happens every day to psychoanalysts and other therapists, doctors, nurses and "entities" as we have all become in the healthcare-industrial-complex.

APsaA's legislative representative Jim Pyles recently wrote a somewhat heartening note, regarding APsaA's history in the fight for the patient's right for consent, and a promising new development in which it seems that at least one hospital sees a marketing and economic advantage in providing electronic medical records which remain in the patient's control.

This comment is from Jim Pyles on April 6, 2009:

An article in today’s New York Times states that one of the largest hospitals in New York is implementing an electronic personal health record controlled by the patient. Of course, the essence of the right to health information privacy and consent is the patient’s right to control the use and disclosure of the information. Some of you may recall that we fought hard in 1996 to defeat inclusion of legislation drafted by Senator Bennett (R-UT) that would have prohibited this type of control being offered to patients. He apparently understood that unless the right of control and consent were outlawed, it would become the health care standard when the first health care provider offered it because it is what most patients want.

Our success in the original HIPAA legislation, in the HIPAA Privacy Rule and in the latest health IT legislation in preserving the opportunity for patients to obtain a consent process has led to this development where health care providers are using patient control to gain a competitive advantage. It is a good thing when hospitals and health IT vendors compete to see who can best protect the patient’s right to
privacy.

Jim Pyles

New York Times: A Hospital Is Offering Digital Records By STEVE LOHR