APsaA members are concerned with the social issues that confront our society. A psychoanalytic perspective, employing core psychoanalytic concepts such as the unconscious, transference, conflict, and development, adds nuance and depth to the understanding the complexities of these issues.
Some of the issues the American Psychoanalytic Association has addressed recently are:
Medical privacy has been protected worldwide for centuries by canons of medical ethics, and in the United States, by the Constitution and the Bill of Rights (the first ten amendments to the Constitution). The Fifth Amendment provides for a right to liberty with respect to the Federal government, and the Fourteenth Amendment protects that right with respect to the States. Privacy advocates contend that if citizens have no right to privacy, they consequently lose their right to liberty, so the right to privacy is a component of the right to liberty. The First Amendment is often cited as protecting the right to free public speech, but the courts have also interpreted it as protecting the right to private speech. The American Psychoanalytic Association’s Principals and Standards of Ethics for Psychoanalysts state that confidentiality of the patient’s communications “is a basic patient’s right and an essential condition for effective psychoanalytic treatment and research.” Accordingly, APsaA has consistently taken the position that an individual’s private conversation with his or her doctor, particularly in psychoanalysis, is protected by the First, Fifth and Fourteenth Amendments to the Constitution and APsaA’s standards of ethics and should not be disclosed without the patient’s consent.
The Right to Privacy Under HIPAA
The debate over medical privacy and the public disclosure of medical records began during the Clinton Administration’s health reform effort. After the health reform effort failed, Congress subsequently enacted the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with the goals of: (a) enhancing the rights of consumers with respect to their health information, improving the quality of health care in the U.S., and (b) improving the efficiency and effectiveness of health care delivery by building a national framework for health privacy protections that builds on efforts by states, health systems, individual organizations and individuals. 65 Fed. Reg. 82,463 (2000). The Original HIPAA Privacy Rule (the administrative implementation of the law) issued by the Clinton Administration recognized and preserved the patient’s right of consent for routine uses and disclosures of their health information. APsaA worked with the Clinton Administration to help formulate those provisions and goals.
The Bush Administration saw the priorities of HIPAA differently and sought to block implementation of the Original HIPAA Privacy Rule when it took office in January of 2001. The Original HIPAA Privacy Rule was made effective April 14, 2001, after APsaA, working with consumer organizations, threatened to sue to compel implementation. While the Bush Administration recognized Congressional intent to protect the privacy of health information in the evolution of electronic information systems, it gave greater emphasis to Congressional intent to improve the efficiency and effectiveness of the health care system by facilitating the electronic exchange of health information with respect to certain financial and administrative transactions. 67 Fed. Reg. 53,182 (2002). In August of 2002, the Bush Administration issued a Revised HIPAA Privacy Rule that reversed the Original HIPAA Privacy Rule and granted federal “regulatory permission” for the use and disclosure of patient health information in routine situations without patient consent and even over the patient’s objection. While the Original HIPAA Privacy Rule was viewed as a medical privacy law, the Revised HIPAA Privacy Rule came to be regarded by many as a medical disclosure law.
APsaA has consistently taken the position that the need for efficiency and effectiveness in the health care delivery system should not override the privacy rights of patients as recognized under Federal and State constitutional law, Federal and State statutory and common law and standards for the ethical practice of medicine, psychoanalysis and psychotherapy. The reason is that protection of the patient’s right to privacy is essential to both quality health care and public acceptance of electronic health information systems. APsaA developed a set of “Privacy Principles” based on these legal and ethical standards as a model for legislation to strengthen the HIPAA Privacy Rule.
Since January 2005, there have been reported breaches of more than 50 million electronic health records. It has been estimated that this is less than half of the actual number of electronic health record breaches since neither the HIPAA Privacy Rule nor state laws required reporting of privacy breaches, until recently. Since 2005, 44 states have enacted data breach notification laws in response to public concern over the privacy breaches of electronic health information systems.
The Right to Privacy Under the HITECH Act
In February of 2009, Congress passed the “Health Information Technology for Economic and Clinical Health Act (HITECH)” as part of the American Recovery and Reinvestment Act, also known as the “stimulus” bill. The HITECH Act contained numerous provisions strengthening the privacy protections in HIPAA and incorporated many of APsaA’s Privacy Principles. The HITECH law requires notification of individuals if the privacy of their health information is breached, provides for the segregation of highly sensitive health information (such as the HIPAA Privacy Rule did for “psychotherapy notes”), allows individuals to prevent the disclosure of their health information to insurance plans by paying out of pocket, and preserves, by statute, the common law psychotherapist-patient privilege recognized by the Supreme Court in Jaffee v. Redmond. APsaA worked closely with Congressional Committee staffs and with Congressman Ed Markey (D-MA) and Senator Olympia Snow (R-ME), among others, to secure these additional privacy protections in the HITECH Act.
Find out more about APsaA's advocacy efforts on Medical Privacy
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Mental Health Issues for Soldiers and Veterans and their families
In its 2008 report, "The Invisible Wounds of War," the Rand Corporation studied the mental health problems of returning veterans of the Afghanistan and Iraq Wars. Its authors concluded that 18.5% of returning veterans struggle with PTSD or major depression, while another 19.5% suffer from traumatic brain injuries.
Veterans, even those without a diagnosed mental illness, often find great difficulty in transcending the gap between what they have experienced and the world that they find on their return, in which even loved ones do not have a clear idea of how they may have changed given their traumatic war experiences. They may find it difficult to re-connect to communities that admire but that do not understand their combat experience, and may miss the intimacy of their combat units. This may give rise to situational difficulties even in returning soldiers who were not initially depressed or struggling with PTSD.
Because of the stigma against mental health difficulties within the military and because of limitations in access of veterans to confidential mental health care, many veterans' difficulties are going untreated. Of the half of those with significant symptoms who do seek treatment, a half in turn were being offered only minimal care (Tanelian & Jaycox, 2008). In a related finding, the suicide rate among veterans and active –duty military personnel has been rising as well, with preliminary reports within the Department of Veterans Affairs suggesting that a thousand veterans within V. A. care were committing suicide on a monthly basis (Finnegan, 2008). During the summer and fall of 2010, a rash of suicides among the active military provoked grave concern and heightened efforts within the Defense Department to address military mental health. APsaA has worked to find a consulting role, emphasizing that military personnel who are concerned about privacy will not seek care, and also offering suggestions to deepen the Army’s resilience program using ideas familiar to psychoanalysts.
Families of deployed and returning soldiers have difficulties as well. A recent study by Christopher Warner MD, MAJ, MC, U.S. Army and others from Winn Army Community Hospital in Georgia found that spouses of deployed soldiers experienced high stress levels and that 43% of those spouses who responded to their questionnaire were significantly depressed. Warner’s group found that 90% of parents left behind struggled with fears for their spouse’s safety and with loneliness. It is a sad fact that, in the face of such stress and parental depression, it is often a struggle for the remaining parent to respond to her children’s needs. There is a higher level of child abuse or neglect in families left at home during a parent’s deployment, with 42% more reported cases than average. And for families trying to re-incorporate the returning parent, there are strains as well, as family members need to again recognize and reconnect with each other.
In 2008 APsaA instituted its Service Members and Veterans Initiative (SVI). The SVI chose two foci—adovcating for the availability of long term treatment when necessary, and understanding and dealing with the effects of war on children and families, including transgenerationally. The web pages of the SVI include readings and a filmography containing psychoanalytic perspectives on war, information on volunteer opportunities for psychoanalysts, and numerous other resources. APsaA has issued several position statements on soldiers and veterans issues, including the first position statement issued by a mental health professional organization urging repeal of “Don’t Ask Don’t Tell”.
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Gay Lesbian Bisexual and Transgender Issues
The American Psychoanalytic Association opposes and deplores public or private discrimination against gays, lesbian, bisexual, and transgender individuals.
The Association’s component training institutes select candidates for training on the basis of their interest in psychoanalysis, talent, proper educational background, psychological integrity, analyzability and educability, not on the basis of sexual orientation.
Same-gender sexual orientation cannot be assumed to represent a deficit in personality development or the expression of psychopathology.
Anti-homosexual bias negatively affects mental health, contributing to an enduring sense of stigma and pervasive self-criticism in people of same-gender sexual orientation through the internalization of such prejudice.
As in all psychoanalytic treatments, the goal of analysis with homosexual patients is understanding. Psychoanalytic technique does not encompass purposeful efforts to "convert" or "repair" an individual's sexual orientation. Such directed efforts are against fundamental principles of psychoanalytic treatment and often result in substantial psychological pain by reinforcing damaging internalized homophobic attitudes.
Gay and Lesbian Parenting
The American Psychoanalytic Association supports the position that the salient consideration in decisions about parenting, including conception, child rearing, adoption, visitation and custody is the best interest of the child.
Accumulated evidence suggests the best interest of the child requires attachment to committed, nurturing and competent parents. Evaluation of an individual or couple for these parental qualities should be determined without prejudice regarding sexual orientation. Gay and lesbian individuals and couples are capable of meeting the best interest of the child and should be afforded the same rights and should accept the same responsibilities as heterosexual parents.
Gays, Lesbians, and Bisexuals in the Military
The American Psychoanalytic Association (APsaA) opposes the military policy mandated by Title 10 of the United States Code (Section 654) which prohibits an individual's service in the military on the basis of sexual orientation. Section 654 bans openly gay, lesbian and bisexual individuals from serving in the military. APsaA strongly advocates that the United States Government overturn the current policy.
Sexual orientation is not germane to any aspect of military effectiveness, including unit cohesion, morale, recruitment or retention. Empirical evidence, as well as comparative data from foreign militaries and domestic police and fire departments shows that when lesbians, gay men and bisexuals are allowed to serve openly there is no evidence of disruption.
Same-Sex Civil Marriage
The American Psychoanalytic Association supports the legal recognition of same-sex civil marriage with all the rights, benefits and responsibilities conferred by civil marriage, and opposes discrimination against same-sex couples, and the denial to same-sex couples these same rights, benefits and responsibilities.
Same-sex couples have the same desire and potential for sustained loving and lasting relationships and for loving and parenting children. Denial of marital rights has a significant psychological and social impact on gay and lesbian couples and their families and denies full citizenship into American society.
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Race, Ethnicity and Psychoanalysis
The American Psychoanalytic Association recognizes that race continues to be a complex and pervasive issue in American society. Cultural differences may have specific impacts on the conduct of a psychoanalysis which is a subject of study by psychoanalysts and an issue which needs attention by analyst and patient.
Psychoanalysis can help increase psychological freedom from internalized aspects of oppression.
The psychological effects of race and racism can be explored in a well-conducted analysis.
Development of trust between patient and analyst is a process. Reservations and doubts one might have about working with someone of another race can and should be addressed in the treatment. Processing these issues can be extremely productive, though it can also be uncomfortable at times.
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Trauma and Children
Natural disasters, terrorist attacks, and other life-threatening events normally will provoke a range of immediate and delayed emotional reactions in both adults and children. These may include anxiety, depression, rage, insomnia, nightmares, and irritability. In the short run, such reactions are normal. However, sometimes they persist and interfere with the age-appropriate tasks of daily life.
For those who are helping children and adults cope with potentially traumatic events, the American Psychoanalytic Association suggests tailoring your responses to the varying emotional and intellectual capabilities of those you are assisting. An 8-year-old and an 18-year-old will have very different perspectives on the same tragedy.
Limit Exposure to the Media
It's always wise to buffer children, adults and the elderly from unremitting media coverage of disasters, especially the man-made variety. Repetitive broadcasts provide a false impression about the frequency of such events. Instead, make good use of the media by looking for opportunities to assist the affected people (e.g., by volunteering your time or making donations). Like adults, children often feel better when they are able to help in some way.
Reduce Anxiety through Reassuring Discussions
Do your best to contain your anxiety and that of others; review the ways in which you can protect everyone from another tragic occurrence. Ask children to share what they have understood about the event; this will give you an opportunity to clarify any misunderstandings and to reassure them that you are doing your best to protect them from danger.
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Mental Health Aspects of Infertility
When childbearing is complicated or impossible, individuals and couples, as well as health providers, often turn to technologically-oriented assisted reproduction. Rarely are questions concerning the emotional and mental health aspects of those procedures asked or answered. Psychoanalysis can provide a framework for approaching infertility and its treatment in a holistic manner.
- Impact of Infertility on Self-Esteem
- Technological Intervention: Individual Hopes and Fears
- Psychoanalysis Offers Strength and Resilience
Impact of Infertility on Self-Esteem
Infertility has multiple causes across the physiological – psychological spectrum and there is no simple source for reproductive difficulties. Infertility is a significant life crisis for couples who hope to conceive. Loss of a child due to miscarriage causes the dual emotions of grief and fear; fear that the couple’s chances to conceive and deliver another child are fading. Both men and women suffer a profound sense of loss, hopelessness, uncertainty and self-doubt. They may turn to technological intervention as a beacon to lift them out of their sadness.
Technological Intervention: Individual Hopes and Fears
Fertility centers do not routinely include mental health professionals as part of their staff. Instead their marketing materials boast of success rates and happy families. Consequently, the essential emotional needs of individuals and couples seeking to have children are often neglected.
The far-reaching and infinitely complex psychological ramifications of infertility are often misunderstood and minimized by friends, relatives and healthcare professionals both when fertility treatments are successful and when they fail. Couples who actively fantasize about having a child find themselves immersed in assisted reproductive therapy, with intrusive interventions that can be experienced as disembodied procreation or an adoption by technology.
Psychoanalysis Offers Opportunity for Self-Exploration
Psychoanalysis offers a unique opportunity to elaborate fully the complex realities and dilemmas faced by couples throughout the infertility experience. Analysts can help people to explore the effects of infertility and assisted reproductive therapy on their sense of self, their identity and their self-esteem. While this exploration may not lead to successful conception, psychoanalysis can help infertile couples and individuals build strength and resilience.
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Psychoanalysis and Adoption Issues
Psychoanalysts have a long history of engagement with adoption, both as clinicians working with individuals and families and as consultants working with agencies and policy-makers. While an adoption usually involves many people, the adopted child, the relinquishing parents, and the adoptive parent(s) -- the so-called adoptive triad -- always stand at the center.
- 21st Century Adoption
- Psychological Challenges for the Adoptive Triad
- Goals and Results of Psychoanalysis
21st Century Adoption
It is difficult to predict how any particular person will absorb the experience of adoption. In 21st century America, adoption often involves older children, children with various medical complications, children from distant countries and cultures and children in “open” adoption agreements. Many adoptees now have legal rights, once they become adults, to information about their birth parents.
In this context, it is worth emphasizing that the vast majority of adopted children and adoptive families do well in their development. Professionals who work with adoptees and their families repeatedly are impressed by the resilience that they encounter. However, adoption does have within it some psychological "hooks" that can entangle any member of the adoptive triad.
Psychological Challenges for the Adoptive Triad
Some adopted children get caught up in feelings of having been "given up" that color all of their experiences and relationships. Some adoptive parents find themselves blocked in their ability to love all of the many sides of their adopted children. And some parents who have relinquished children for adoption find it impossible to move on in their lives.
When difficulties like these become embedded in one's character there is no quick or easy remedy. While drugs or behavioral interventions may diminish some symptoms, one cannot escape one's character.
Goals and Results of Psychoanalysis
Psychoanalytic treatment offers a long-term, intensive relationship that is particularly well-suited to addressing internally-generated problems that have become embedded in character. Psychoanalysts have extensive experience in working with the ambivalences and conflicts that can attach themselves to any member of the adoptive triad and, like barnacles, impede their progress.
The goal of psychoanalytic treatment is not do away with life's difficulties, but to help equip one to face what life brings and to apply all of one's resources to creating a fruitful and satisfying life.
Psychoanalytic consultation can be extraordinarily helpful in making some of the "judgment" calls that pop up in the lives of adoptees and their families. While adoption agencies often have rules about the sharing of information, analytic consultation provides an opportunity to examine how such rules make sense -- or don't make sense -- in the context of a specific child and family.
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Psychoanalysis and Marriage
Most Americans hope to marry, but many never achieve this goal, or, if they do, they fail to sustain the marriages they begin. Other marriages are long-lived but lack vitality and intimacy. Some go on the rocks because of sexual or parenting problems. Others end following midlife crises, extra marital affairs, depression or other failures of the spouses to adapt to the challenges of life and marriage. In all of these situations, psychoanalysis or psychoanalytically-informed therapy can provide help.
Prior to marriage, psychoanalysis is frequently the optimal treatment for people who have been unable to form constructive, happy relationships – those who are “afraid to commit” or those who repeatedly appear drawn to inappropriate or problematic partners. In such cases, analysis helps uncover and explore previous traumatic relationships (with childhood caretakers or former lovers) which contribute to the person’s inability to achieve intimacy. Usually inappropriate fears of relationships are based in expecting the past to repeat itself, so that people keep their distance unnecessarily, find themselves unable to commit or open themselves up, or erect other off-putting but self-protective measures to avoid a replay of the painful past. By contrast, persons choosing inappropriate partners are often attempting to restage the past in hopes of a happier ending (e.g. the child of an alcoholic parents who repetitively dates problem drinkers.) Others lack the self-esteem and social skills to love and be loved. What psychoanalysis offers uniquely beyond it’s understanding of such “depth psychology” (the hidden issues, conflicts, and motives that prove self-destructive) is the idea that change and personal growth can come from careful exploration of the patient’s relationship patterns as they manifest themselves in the relationship with their psychoanalyst. Here their maladaptive patterns of relating can be studied in a safe atmosphere and healthier patterns can be developed. These healthier patterns can then be “taken on the road” and used in new intimate relationships.
Despite limitations like those just mentioned, many people find the courage to press on and marry. When they do, the same concerns will limit their capacity to fully engage in marital intimacy. For others, marital problems will be the first sign of long-standing problems with trust, intimacy or sexuality. Others will turn out to lack the maturity required to manage the inevitable conflicts and expectable wear and tear that married life brings. Some will be excessively sensitive to criticism, and others will be insufficiently self-assertive. Sexual problems may also emerge, some having their roots in early life and others the result of current marital unhappiness. In these and other typical scenarios, psychoanalysis can bring insight, healing and a fresh start to chronic painful patterns of relating.
For most marriages, an additional task beyond attaining intimacy and managing conflict, is that of bringing up children. This challenge can also be interfered with by “ghosts from the past,” defense mechanisms and personality limitations. Parents will have greater than average difficulty parenting children around issues that are still unfinished or conflicted for themselves, or at times when the children’s ages and developmental tasks bring to mind unfinished business from the parents’ own lives. Again psychoanalytic insights and exploration can help free the parent better to face the realistic challenges of parenting.
Divorce and Bereavement
When marriages end – whether through divorce or bereavement – spouses often find themselves stuck and unable to move on. Commonly, this is due to fears that the experience of loss will be repeated. In other cases, there are unmetabolized issues of the marriage that need to be worked out. For instance, people may feel ashamed of having been rejected or abandoned by a partner; or guilty about being the one who has not done more to save the marriage. In cases of divorce, partners may find themselves continuing to fight with each other, in and out of court, in an unproductive tangle of escalating, painful interactions. While they may be divorced legally, they are still enmeshed psychologically. Again psychoanalytic treatment can be helpful in assisting people to accept the past and move forward with their lives.
Psychoanalytic Couples Therapy
In some cases of marital or relationships distress, partners will benefit from meeting conjointly with a therapist. This is commonly helpful when dealing with marital infidelity, parenting disputes, and (more generally) with repetitive interpersonal conflict. Again the issues the psychoanalytic couples therapist will attend to include personality defenses and limitations and unfinished business from the past. An additional topic of study can be the in-the-room process of the couple conversing, the pathological dance that couples become caught up in and unable to escape. Psychoanalytically-oriented couples therapists attuned to deep personality hopes, fears and survival strategies can help couples find a safe space to work through disagreements and injuries so they can move forward towards greater togetherness and intimacy.
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