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12 AND ISRAELI : IS IT TIME TO TAKE A STAND?

2. Berman E. From war to war: Cumulative trauma. Sihot Through pediatrics to psycho-analysis. New York: Ba- 1987;2:37–40. sic Books, 1975: pp. 145–156. 3. Berman E. Impossible training: A relational view of 5. Phillips A. Winnicott. London: Fontana, 1988. psychoanalytic education. Hillsdale, NJ: Analytic, 6. Renik O. The ideal of the anonymous analyst and the 2004. problem of self-disclosure. Psychoanalytic Quarterly 4. Winnicott DW. Primitive emotional development. In 1995;64:466–495.

Commentary: Political Activism: Should Psychologists and Psychiatrists Try to Make a Difference?

Rael Strous, MD

Beer Yaakov Center, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.

The fields of and psychiatry are charac- Wielding our professional skills we must resist any terizedbythestudyofhumanbehaviorandmental temptation to employ our training in areas where we processes. Their mandated “social contract” with the do not belong. Mental health clinicians have no more community is to describe, understand, predict, and authoritythanotherstocommandthecommunity’s modify behavior, particularly in cases of mental ill- attention with regard to wider issues of politics. If ness. Above all, practitioners are committed to help- psychologists and psychiatrists have the intention to ing the individual and alleviating emotional pain. engage in political activism, they should do this as Research psychologists and psychiatrists investigate “concerned citizens” and not as professionals (1). the physical, cognitive, emotional, and social aspects Too often, it is unfairly expected from members of human behavior. The field is an academic disci- of the field to solve problems of society. Psycholo- pline, a profession and a science. Mental health prac- gists and psychiatrists are particularly vulnerable titioners have privileged access to the human since they are part of what Robert Jay Lifton terms andbehavior.Thisprivilegeisvestedwithresponsi- the “shamanistic legacy”; the implication being that bilities and the primary duty to care for the mental we have some magical influence over life and death health of their patients. This is the bedrock of the that is tempting for various political interest groups profession. To act otherwise would constitute abdi- or despotic regimes to embrace and exploit in order cation of professional responsibility. to carry out their aims and to “control reality.” This Does this mean that those in the field of mental activity may range from hard-core involvement in health care have the right or possibly even the re- torture to the more subtle involvement in political sponsibility to influence political reality? How does discourse and activism (2, 3). In this manner, psy- their responsibility differ from a surgeon, electrician, chologists and psychiatrists face challenges to their or bus driver? I would argue that the involvement of professionalism and autonomy and subsequently to psychology and psychiatry professionals in political their ethical standards of conduct. These standards activity could be considered a gross boundary viola- serve as a directive for mental health care providers tion. The responsibility of psychology and psychia- in their professional and scientific activities and try to society should encompass a respect for those allow them to function at the highest ideals of the arenas of life that supersede medical practice. profession. Entering into political activity and dis-

Address for Correspondence: Rael D. Strous, MD, Beer Yaakov Mental Health Center, POB 1, Beer Yaakov 70350, Israel. E-mail: [email protected] RAEL STROUS 13 course would constitute a violation of these stan- However, political activism by the profession would dards. be too divisive and destructive. Moreover, political Moreover,anadditionalconcernariseswithre- activity would diminish the mental health profes- spect to the fear that psychological technique can be sion’sstandingandrespectintheeyesofthecommu- used in excess and abused, resulting in wrongful use nity. Psychology and psychiatry’s dedication to of behavior modification in inappropriate contexts. , ethics, and integrity both as a profession and An extreme example of this would be torture. Simi- academic discipline would be sorely compromised larly, it would be considered unethical for a psychia- and diluted to the extent of placing the future of the trist to use his or her professional training and skills field’s legitimacy in jeopardy. To engage in political within the context of a governmental sponsored in- debate would be ineffectual and a reckless use of psy- terrogation or evaluation if some element of coer- chology or psychiatry where it does not belong, re- cion or abuse is engaged. This would be true even in sulting in misapplication of psychological language the interest of national security (4). A further in- and practice. has demonstrated that political stance would be involvement of physicians in execu- agendas can and do serve as a rationale to distort the tions, considered now by several international truth and engage in unethical behavior. For example, medical associations to be unethical conduct. psychiatrists in the former Soviet Union dismissed The public in this case has granted physicians ex- political dissidents with a diagnosis of “sluggish traordinary and exclusive dispensation to administer schizophrenia” (6). It becomes much easier to diag- medications. This includes to the point of uncon- nose, thereby invalidating the opposition, than to ra- sciousness as well as the insertion of tubes and nee- tionally present one’s case in a professional and dles, otherwise considered as assault. This privilege academic fashion (1). Similar intervention by mem- is carried out in order to save lives and provide com- bers of the psychology and psychiatry profession oc- fort. To make use of a physician’s skills to do other- curred in Argentina in the years prior to 1976. wise such as punishment, even in the name of the Psychoanalysts in Argentina aligned themselves and state, is a dangerous perversion (5). Society has en- exhibited overt sympathy for socialism in general trusted mental health practitioners with powerful and for communist regimes. This backfired with the abilities; the more we involve ourselves in other military takeover of 1976 when psychoanalysis was areas, the more we risk that trust. This approach ech- banished since it was seen as being incompatible oes the legal concept of “ doc- with “national values” and warranted the initiation trine,” a constitutional principle of the U.S.A., under of a “cultural” war. It is believed that many members which the legislative, and judicial branches of the profession were themselves involved in state of are kept distinct in order to prevent terror both as victims and perpetrators during this abuse of power. Dangers exist both ways. Psychology dark period in the history of the country (7). may be abused in the service of state sponsored Having said this, is however atrocities, just as it may be used inappropriately pro- a very legitimate and respectable sub-affiliate of the testing practices of the state. The practice of the pro- discipline. Political psychology represents all fields fession comprises clear and well-defined of scholarly inquiry concerned with exploring the re- expectations and responsibilities. In return for its lationships between political and psychological pro- dedication to the values to which it subscribes, soci- cesses. It is an interdisciplinary academic field ety grants to the profession certain essential and de- dedicated to the study of the interface between psy- fining rights and privileges. Political activism and chology and political behavior by voters, lawmakers, intervention is not one of these time-honored re- local and national and administra- sponsibilities. tions, international organizations, political parties Mental health care professionals may approach and associations. The field draws on several diverse mental illness and care with a great deal of devotion disciplines including social , cognitive andsensitivitybutatthesametimemayholddear psychology, psychology of personality, social psy- very different fundamental political beliefs. This di- chology, , , history, international versity does not impinge on their professionalism. relations, , and political 14 POLITICS AND ISRAELI PSYCHOLOGISTS: IS IT TIME TO TAKE A STAND? theory. The influence of psychological processes on These comparisons not only become burdened with political behavior and the effect of the political sys- political overtones, but most importantly they may tem on the thought, feelings, and motives of individ- come to alienate a significant sector of the country’s uals are explored. Thus, political psychology is population, a sector of individuals who are no less defined essentially by its preoccupation with the role deserving of mental health care than others, and who of human thought, , and behavior in politics would come to decry and despise the psychological and the links between them. The field is vast and fo- community and its “professional clinical interven- cuses on a broad range of issues affecting how ordi- tion” if the organization or a significant number of its nary citizens make sense of their political members were to take a stand with respect to politi- surroundings and how their of politics is cal orientation. linked to their beliefs and behaviors. A related area of Although the individual’s response to any outrage study is that of “” which explores the should not be discouraged (on the contrary they science of historical . In contrast to his- should be encouraged since it is this which makes us tory, it remains “problem-centered” rather than “pe- human and it is this which lies at the heart of demo- riod-centered” (8). Psychology and psychiatry cratic process), these opinions should not be hi- therefore have much to contribute to the analysis jacked as any “flag to be waved” by any mental health and study of political and historical processes within care profession branch. That Avissar claims that the the context of rigorous academic investigation. This whole country has entered a state of “moral drift and is, however, very different from political involve- declineinnationalstamina”isonceagainatbestun- ment or activism which may directly influence polit- scientific and subjective and at worst irresponsible. ical and government activity or and which is Avissar’s admirable approach to injustice, no doubt proposed by Avissar. held dear on an individual level by many other mem- Several other problems exist with respect to bers of his profession, should be laudable and en- Avissar’s proposition. First, while it is true that politi- couraged, however maintained at a personal level. cal events are part of modern life and awareness of Anything more would be seen as divisive and politi- political factors is high throughout the population, cal manipulation. His approach thus becomes an- this does not mean that professional boundaries other one of the numerous political (and not need necessarily to be violated with members of the professional) agendas held by various political inter- mental health care field entering the foray of political est groups nationally and around the world. It there- activity. It is precisely mental health care providers fore must be respected but cannot be judged who should be acutely sensitive to conditions of limit seriously. The silence of the psychological commu- setting. While issues may confront the individual’s nity today as opposed to in the past may be ac- conscience from both sides of the political spectrum, counted for by any number of reasons. These may this should not be acted out upon individually include professional maturation since the first inti- within the context of the clinical care setting and fada following which the follies of political involve- communally as an organizational response. In con- ment were subsequently realized. It may also arise trast to what Avissar argues, the ethical and profes- from the shock felt, even by elements of the politi- sional responsibility “not to be involved” — should cally “left” establishment, at the brutality of suicide become as strong a sentiment as to become involved. bombings during the second intifada. It is precisely Moralistic aphorisms do not accomplish anything. the confrontation between “leftist” and rightist” ele- The inherent becomes obvious ments within the profession that is inappropriate, whenAvissar’scomparesasequals“stonesthrownat servingnohealthypurpose.Statementssuchasde- soldiers to suicide bombers,” “soldiers hitting Pales- fining “Imut” members as protesting tinian civilians to bombs launched at crowded areas for the moral cleanness of society would be seen by in Palestinian cities” and “suicide bombings to mili- any objective party other than themselves as conde- tary actions in civil population centers.” This is un- scending and demeaning. This unfair attitude will deniable proof of how political dispositions may lead only lead to the demise of the profession in Israel in to distortion and even “blind” orientation to reality. cases of such involvement becoming vocal and sus- RAEL STROUS 15 tained. One would hope though that psychologists the psychology and psychiatry profession as an orga- would not be paradigms of “passivity” as Avissar de- nization. This approach echoes insensitivity and scribes them, but rather active empathic mental alienation, precisely the factors that would serve to health care providers doing all they can to assist pa- blunt professionalism and interfere with clinical tients in their quest for growth and treatment of any boundaries in a one on one relationship with a pa- mental health issues. Moreover, involvement in poli- tient. Avissar’s suggestion that a psychologist’s “gen- tics as an organization will divert or sap much of the eral tendency… to avoid personal involvement… profession’s intellectual capital; patient care inevita- reflects a need for security, control and power… bly will be compromised. Academic commentary [and] this passive, neutral and noncommittal may have its place in analysis; however, political ac- stance… allows for the status-quo to exist” is simply tivism is dangerous and unprofessional — accompa- incorrect. In fact it would be somewhat grandiose of nied by unavoidable boundary violations. The non- the profession to suggest that all politics would de- politically active mental health care provider does pend on activism of psychologists. A psychologist not lose out by “accepting the existing or repressing shouldremainjudgemental;itisthiswhichmain- theoutrageous.”Tothecontrary,heorshegainsso tains our perspective, awareness and humanity, but much in respect of professional neutrality and judge- no less important we should always remain non-con- ment. Imagine the scene of a politically active psy- demning. These concepts are not mutually exclusive. chologist meeting with a patient of obvious opposite Political activism by mental health clinicians would political beliefs, the proverbial “elephant in the be divisive, damaging and unethical; community ac- room” will inevitably interfere with the psycho- tivism in the context of voluntary contributions to therapeutic process by defining the interaction. society, however, would be desirable and honorable. Avissar’s reference to psychologists offering their Refraining from political involvement does not per- “professional skills” as activists in states of conflict petuate the status quo, rather our role, mirroring the echoes a dangerous and unethical precedent by clinical therapeutic process, is to facilitate change the “Goldwater Affair.” In 1964 during the Barry and not “make better.” This is best accomplished in a Goldwater and Lyndon Johnson presidential elec- manner other that that of political activism. Psycho- tion campaign, 1,189 American psychiatrists re- therapy is not about bringing about political sponded to an inquiry by a now defunct magazine change… as mentioned this would be a glaring for their opinions of the candidates. Most of the boundary violation of our social contract with soci- “professional skilled” responses, couched in psychi- ety and our professional mandate to treat. We can atric terminology, were so unfair and so outrageous become involved, though, as individuals or as an or- to Goldwater that he sued and obtained a substantial ganization at an academic level in research and anal- settlement. It was suggested that this survey of psy- ysis. Thus when Avissar refers to “psychologists chiatrists contributed to Goldwater’s loss. struggling for values even if those are unpopular,” it The American Psychiatric Association issued a clear is this which makes us human. But it is this that statement decrying such analyses and in 1973 refer- shouldbedoneasindividualsandmembersofsoci- ence to this unethical practice was included in the ety, and not as professionals. This is especially so “Principles of Medical Ethics With Annotations Es- since there may be other members of the profession pecially Applicable to Psychiatry.” Thus, even in- who perceive political reality in a different light. volvement at this politically modest level was Avissar is correct that as mental health professionals considered unethical. we need to “enhance our own awareness… [of] the Avissar further suggests that political action social and political.” But once this awareness is en- should be possible whenever personal safety is not hanced, the information should be used to boost our being severely threatened. This obviously depends understanding of where our patients “are at” and where the individual is living. Not all would agree what not to let influence our clinical relationship that an individual living today in Israel remains un- with them from a countertransferential perspective. threatened by terrorism. It is precisely this closed ap- It must be noted that in the not too distant past, proach that would lead to dangers of involvement by an illustration exists demonstrating the perils of 16 POLITICS AND ISRAELI PSYCHOLOGISTS: IS IT TIME TO TAKE A STAND? mental health involvement in politics. A mere 60–70 ber of the profession to further his or her own politi- years ago members of the psychology and psychiatry cal goals. profession allowed the political mood to influence The role of psychology and psychiatry in the un- their professional practice. The results were devas- derstanding of political behavior is clear. We are re- tating.DuringtheperiodoftheNaziregimeinthe quired to assist in the answering of several critical years 1933–1945, psychiatry supported compulsory questions required for civilized political process to sterilization and euthanasia of the mentally ill and continue. Questions for which our skills are required subsequently the killing of “inferior” races. They did include how do people develop their political atti- this by applying scientifically invalid conclusions tudes and how may we test them? What are the ambi- from evolutionary biology, yet considered valid due tions and motives of political leaders, and where do to prevailing political (9). Many psychia- they come from? What makes a political leader char- trists at the time maintained that they had an inher- ismatic? What determines success as a leader? How ent responsibility more than other medical can one explain behavior and party prefer- professions to be involved in community and politi- ence? How may one understand political cynicism, cal affairs. This belief arose since psychiatry by na- patriotism and ? What are the origins of ture inculcates a holistic approach to the patient political violence and terrorism? Entry into the pro- often including societal factors and contemporary fession of psychology and psychiatry is accompanied ideology. While the unique role of psychiatry in the by certain well-defined expectations and responsi- genocide during these years was not exclusive since bilities demanded for professional life and are em- other areas of medicine were also involved, psychia- bodied in the professional Ethics Code. Standing up trists fitted in particularly well and arguably were the fortherightsofpatientsisincludedwithinthisru- most prominent. Therefore the dangers inherent in bric of moral instincts, particularly when these rights such political involvement using the Nazi experience are encroached upon due to political process such as as an extreme example of such perversion do be- budget and service cuts or when human rights viola- come obvious when important boundaries become tions directly affect patient care. This approach in- blurred. Clinical practice and political machinations corporatesthedutytoencouragethegrowthof need to be maintained separate. A more recent, how- community projects and to find appropriate social ever less ominous example, of this interference may application of psychology and relevant psychological be noted in the advice of a prominent psychiatrist in skills (11). Similarly, as mental health practitioners the U.S.A., Paul McHugh. Using psychiatric con- we have a legitimate medical concern about how the cepts, terminology and treatment practice in trying law affects the mentally disordered as a class. When to make sense of the 9/11 terror attacks on U.S. soil, the mentally disordered are not treated justly and ap- he advocated brute force as a response by the U.S. propriately by the legal system the law should be military. This he based on the understanding of challenged by members of the profession at an orga- “overvalued ideas in anorexics and alcoholics” who nizational level (12). However taking an active are treated by psychiatrists by means of “interrupting stance in areas of politics that do not directly affect their behavior.” Psychiatrists, he maintains, do not clinical management, such as government policy re- listen to explanations or of these pa- garding territory or terror management, would be tients, similarly he states we should not listen to problematic and thus not recommended. The cor- grievances expressed by terrorists, rather they rect approach includes for each mental health pro- should be devastatingly bombed as well as the coun- fessional the expectation and obligation to uphold tries from where they originate. As such, McHugh professional standards of conduct rather than permit abandons science and logic in order to apply his the political abuse of health care and its practitioners ideas in a political sense, supporting and encourag- (13). Nothing less than the legitimacy of the profes- ing actions of the government (10). In so doing, he sion is at stake. Ideological bias must never be per- exploits his psychiatry in the political arena. Not mitted to interfere with the overriding goals of the only is the result bad science, this approach is mis- mental health care professions. Entering into the guided and has no place being used by a senior mem- broader political foray as a professional body is reck- NISSIM AVISSAR 17 less and would violate the code. Such activity would 6. Reich W. Psychiatric diagnosis as an ethical problem. not serve the best interests of our vital, engaged pro- In: Bloch S, Chodoff P, editors. Psychiatric ethics. fession or of our patients. We can never abandon our Oxford; New York: Oxford University, 1991: pp. 101– 135. core principles in light of any political activism; any- 7. Hollander NC. Psychoanalysis and state terror in one doing so needs to be called to account. Argentina. Am J Psychoanal 1992;52:273–289. 8. deMause L. Foundations of psychohistory. New York: References Creative Roots, 1982. 9. Strous RD. Hitler’s psychiatrists: Healers and research- 1. Scheurich N. Commentary: Psychiatry and values: ers turned executioners and its relevance today. Harv Mental health as Trojan horse. Psychiatric Times 2000; Rev Psychiatry 2006;14:30–37. 17:6. 10. Marshall J. Reading Paul McHugh: Politics, psychiatry 2. Gluzman SF. Abuse of psychiatry: Analysis of the guilt and the response to terror. Perspectives on evil and hu- of medical personnel. J Med Ethics 1991;17:19–20. man wickedness 2003;1:92–98. 3. Summers C. Militarism, human welfare, and the APA ethical principles of psychologists. Ethics Behav 1992; 11. Vogelman L. Psychology, mental health care and the 2:287–310. future: Is appropriate transformation in post-apartheid 4. Wilks M. A stain on medical ethics. Lancet 2005;366: South Africa possible? Soc Sci Med 1990;31:501–505. 429–431. 12. Grounds A. Forensic psychiatry and political contro- 5. Gawande A. When law and ethics collide: Why physi- versy. J Am Acad Psychiatry Law 2004;32:192–196. cians participate in executions. N Engl J Med 2006;354: 13. Zwi AB. The political abuse of medicine and the chal- 1221–1229. lenge of opposing it. Soc Sci Med 1987;25:649–657.

Author’s Response: Who’s Afraid of Politics? Or, Psychotherapists as Political Entities

Nissim Avissar

It is a pleasure for me to take part in this fascinating tionships. According to this wider definition, a polit- debate. When I submitted the transcript for “Politics ical action may very well be an act of an individual and Israeli psychologists: Is it time to take a stand?” I and may not take place within the public sphere. Ad- did not imagine that it would ignite such a vibrant ditionally, positioning relationships of all kinds and rich discussion. To a large extent my purpose is within a broader context of time, place and society is fulfilled. Still, some clarifications are required. in fact an act of revealing of the political within the First, let us make sure that the discussion is based personal. Similarly, therapists who take into account on similar basic definitions. It seems that this is not their own (gender, national, cultural, socio-econom- the case here. The most central definition at issue is ical, etc.) background and are aware of possible that of the term “politics.” Zemishlany defines poli- power relations within the psychotherapeutic work tics as “the art or science of government”; this is the are politically aware. traditional and narrow of the term. It seems The second key definition is . It that Strous referred to the term “politics” in a similar seems that the dispute in the present discussion is fashion. However, this is not the meaning I assign to over its definition. Indeed, as Totton remarks, “once the term. Politics in its wider sense deals with the we turn to ‘psychotherapy’ itself, however, we find pushes and pulls of a person or a group over other/s. that defining the term itself is a political act, rising Hence, it has to do with relations in which power is thoroughly political questions” (1). Some relevant present, overtly or latently. Therefore, politics may fundamental questions are: What is the nature of reveal itself within very personal and intimate rela- psychotherapy? What are its goals? What are its le-