Psychoanalysis and Medical Ethics

by Rachel C. Conrad

On the first day of both my undergraduate (premed) and med school courses on medical ethics, I present a case without a clear answer: “We have one liver and two dying patients. How do we decide who should get the liver?”

I want them to linger with a common dilemma in medical practice—one that doesn’t have a simple answer. I want to open up space for them to acknowledge, both to themselves and to one another, that they can’t always know the “right” answer—that they have to accept ambiguity and allow themselves to feel the irreconcilable tensions that, unfortunately, their education as doctors doesn’t ordinarily acknowledge.

From the first day of college through advanced subspecialty training, the U.S. medical education system frequently instills in future doctors the notion that every question has a “right” answer. The requirements for premed undergraduates who are applying to med school include a six-hour multiple-choice test, fifteen science courses…and one humanities course. Most of the exams they take reinforce the only-one-correct-answer mentality. Physicians mock “Dr. Google,” yet much of our medical curriculum is based on the memorization and regurgitation of factual information. This sort of pedagogy encourages dissociation from irreconcilable dilemmas and uncomfortable feelings; disconnection from the more complex causes of our patients’ suffering; and the abandonment of intellectual humility.

Ethics training among premeds and med students alike seeks to challenge this mindset, and to explore questions that have no single “correct” answer—questions like, which of these two transplant candidates should be given a chance to live? In my own experience, psychoanalysis can be an invaluable asset to such ethical training. For example, it can help us better to understand the enormous complexity of both conscious and unconscious motivations.

Indeed, both the study of ethics and the experience of psychoanalysis help develop practices of reflection and a greater tolerance for uncertainty. Neither offer the sorts of definitive answers routinely sought in contemporary medical education. During my own medical ethics fellowship, we got into the habit of responding a bit sarcastically to every question with: “It depends.” And, indeed, “it” usually does depend upon a variety of complex, intersecting personal and social factors.

Premed and med school students must quickly grow accustomed to an endless parade of traumatic events. We proceed from crisis to crisis, day after day, night after night: A high school student hit by a car while biking to school. Hysterical parents being asked whether they will donate their dying child’s organs. These are not multiple-choice scenarios.

But hospitals have little time and few resources for helping our students to process such encounters with individuals and families who are enduring the worst moments of their lives. Everyone is busy and tired and trying not to become overwhelmed, themselves, by their own feelings—not to mention sheer fatigue and the toll it takes on psychological well-being. There are always more patients waiting.

During my medical school training, students were administered a “professionalism” self-assessment in which we were asked either to confirm or deny the statement: “I can control my feelings.” The correct response, obviously, was “true.” Such remnants of an antiquated culture of (largely masculine) stoicism tend to pathologize emotionality, to blame doctors for their personal and ethical struggles, and to ignore the often debilitating pressures of our healthcare-delivery systems.

Four days a week, I travel from the hospital, where I am both a doctor and teacher, to the couch, where I am a patient myself. Just as I encourage my students to get used to sitting with their discomfort, so too must I sit with mine. The thoughts and feelings we are taught to suppress during hospital hours are, of course, welcomed and encouraged, without judgment, in the psychoanalytic session.

And like the psychoanalytic consulting room, the medical ethics classroom is a space designed for feelings that the rest of our education tells us either to suppress or to “deal with” on our own. In my own undergraduate medical ethics course, my classmates and I joked that it wasn’t really medical ethics until someone cried. Some might say the same sort of thing about psychoanalysis. Both ask us to face honestly and openly whatever causes us distress. Medical training and practice certainly give us plenty to cry about—but no space or permission to do so. No allowance is made for the fact that physicians’ pain and conflicting feelings are both inevitable and meaningful and that it takes time and help from others to manage that pain and to make wise use of those feelings.

I began psychoanalysis at a point when I was particularly distressed about the cruel inequities of our healthcare system. Much of my medical training was spent in large public hospitals, treating patients who often lived in precarious and unbearable situations. These are patients for whom our medical interventions are often undermined and even rendered useless by their socioeconomic circumstances—like the 60-year-old patient who waits years for a liver transplant but misses several appointments because he’s lost his home. Without more comprehensive care and assistance, how is a 60-year-old unhoused person going to be capable of managing the demanding treatment that is needed after a liver transplant?

When such patients come to our hospitals, they might undergo extremely expensive procedures only to return to living situations that are inherently incompatible with good health: situations of domestic abuse, poverty, isolation, undiagnosed mental illness, substance abuse, and homelessness. Higher-resolution MRIs, genetic sequencing, and the latest antiviral treatments can’t adequately address—much less hope to resolve—the suffering of such patients.

With every passing year, I develop a deeper awareness of the many problems with the way we currently teach and practice medicine in this country. The multiple-choice mindset undermines patient care and stifles our own empathy and humility. Our diagnostic protocols refuse to acknowledge that diagnoses are never definitive or comprehensive, which means that misdiagnoses and errors of judgment are all too common—for example, in the case of a 20-year-old who comes to the ER with liver failure and evidence of alcohol abuse, but who also presents with a genetic disease that might or might not be recognized as the true cause of his failing liver.

Humanistic study—such as the study of psychoanalysis, or literature, or philosophy, or anthropology—would help students learn to probe the varied and complex questions about human experience that are rarely prioritized in the education of doctors. While a liberal arts major nicely complemented premed requirements during my own undergraduate years, I found that, as my medical school training proceeded, I was made to feel that reading novels, for example, was self-indulgent and should be relegated to occasional vacations.

During my first year of medical school, a friend happened to make a reference to Shakespeare, which was met with blank looks as something both unfamiliar and presumably irrelevant. Yet the works of such authors immerse us in the vast range of human experience and the complex ethical questions we all face—including pressing questions of medical ethics. If I ask my students how they feel about those who risk death through self-destructive behavior, what resources can they draw on to formulate compassionate and insightful answers? Humanistic study, including the study of psychoanalysis—now almost never taught at the undergraduate level, and increasingly rarely even in psychiatry departments—could better equip future doctors to address, with both enhanced empathy and fuller understanding, such life-or-death questions.

Announcement: APsaA Conference Externship Program

Calling all undergraduate juniors and seniors and graduate students…in all disciplines!

Applications are now being accepted for an expenses-paid externship to the next Annual Meeting of the American Psychoanalytic Association (APsaA): January 31 – February 5, 2023
Hilton Midtown Hotel, New York City

Professors: Let your students know about this fantastic opportunity!

Application deadline: November 10, 2022.

Please open this pdf document for further details and application instructions:
APsaA 2023 Externship

Teaching 𝑎𝑏𝑜𝑢𝑡 Psychoanalysis and Teaching 𝑤𝑖𝑡ℎ Psychoanalysis; or, Contemporary Undergraduate Psychoanalytic Education and the Future of Transferential Pedagogy

by Max Cavitch

Launched three years ago, the “Psyche on Campus” blog has continued to be extremely fortunate in its contributors—including academics, clinicians, and students from many colleges and universities in the U.S. and the U.K.—and extremely fortunate in its readers. In fact, the blog now has well over 10,000 readers in dozens of different countries. And in 2022, for the second year in a row, “Psyche on Campus” has been selected by FeedSpot as one of the “15 Best Psychoanalysis Blogs and Websites.” Posts continue to be published every 6-10 weeks, and readers can anticipate forthcoming posts by Jane Abrams, Gila Ashtor, Rachel Conrad, Brian Connolly, Marcia Dobson, and Nicholas Ray, among others. (If you have an idea for a post of your own, please let me know!) And our “Syllabus Archive” continues to grow. (Again, relevant syllabi from your own courses are very welcome!)

Continue reading “Teaching 𝑎𝑏𝑜𝑢𝑡 Psychoanalysis and Teaching 𝑤𝑖𝑡ℎ Psychoanalysis; or, Contemporary Undergraduate Psychoanalytic Education and the Future of Transferential Pedagogy”

Psychoanalysis through a Psychosocial Lens

by Stephen Frosh

Forty years ago, I wrote and published a short paper—one of my very first—in the Bulletin of the British Psychological Society (now known as The Psychologist). It was called “Teaching Freud to Psychology Students” and was all of two pages long. I don’t remember fully what it said (I’m not even sure if I still have a copy), but I do recall that some of my academic colleagues were irritated by what they took to be my complaint that there was insufficient attention paid to psychoanalysis in the psychology curriculum.

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“Grief Garden”: Rites of Private and Public Mourning

by David L. Eng

March 16, 2022 marked the one-year anniversary of the Atlanta Spa Shootings. Six of the eight victims were Asian American women. That same week, in my course, “Introduction to Asian American Literature and Culture,” I asked my students if they could name even one Atlanta victim. They could not. Nor, for that matter, could I. So we did our research, and I will name them here:

The victims at Young’s Asian Massage were:
Daoyou Feng, age 44
Paul Andre Michels, age 54
Xiaojie Tan, age 49
Delaina Ashley Yaun, age 33

The victims at the Gold Spa were:
Hyun Jung Grant, age 51
Suncha Kim, age 69
Soon Chung Park, age 74

The victim at Aromatherapy Spa was:
Yong Ae Yue, age 63

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Psychoanalytic Psychology and the Academy: Identifying and Addressing the Growing Crisis

by David Ramirez

Among those contemporary college students who seek counseling—and despite their heterogeneity along lines of class, culture, race, gender identity, and sexual orientation—most share similar experiences of discomfort, distress, and a desire for relief. Something’s not right in their life, and it’s taking a toll: interfering with simple pleasures; undermining productivity; compromising functioning; obstructing relationships; causing, in some cases, thoughts of suicide and/or self-destructive behaviors like heavy alcohol- or drug-use and cutting. Moreover, many of them tend to perseverate on certain existential questions: What am I doing? Why am I here? Whose life am I leading? How do I know what I really want?

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Child’s Play at APsaA: Discovering Psychoanalytic Play Therapy

by Esha Bhandari

Starting college, I thought I had everything figured out. I was going to study the social sciences, enlist myself as a research assistant in a few of my university’s psychology research labs, and then eventually I’d get my Ph.D. and begin my life as a clinical psychologist. By my junior year, I had taken nearly every psychology course that was offered at my university—courses that spanned what I thought was every field in the discipline, including social psychology, clinical psychology, cognitive psychology, developmental psychology, cultural psychology, educational psychology, psychology and the law, and community psychology.

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Making “Black Psychoanalysts Speak”

by Basia Winograd

[Note: Director Basia Winograd’s 2014 documentary, Black Psychoanalysts Speak (which can be screened via YouTube, here), is required viewing in many of the undergraduate courses that I and my colleagues teach in the Psychoanalytic Studies program here at the University of Pennsylvania and in many such courses at other colleges and universities throughout the U.S., Canada, and the U.K. Whether our students are interested in psychoanalytic theory or in the history of psychoanalytic practice, they find that this splendid film answers many of their questions about the changing face of the profession and the changing terms of clinical and metapsychological discourse. What is the place of race in analytic thought and practice? Why are there still so few African American psychoanalysts? And what do they have to say about their own professional formation and about the extent to which discussions of race and related sociopolitical, cultural, and intergenerational experiences have been, until recently, virtually excluded from the analytic consulting room? My own students continue to be both dismayed and encouraged by the stories they hear from the analysts Winograd interviews in the film—stories of institutional and personal racism, stories of patients whose experiences as African Americans are routinely ignored or dismissed, and stories of gradual but meaningful change. Because Black Psychoanalysts Speak features in so many contemporary undergraduate courses on psychoanalysis, I’ve asked Basia Winograd to tell the readers of Psyche on Campus a bit about the making of the film and about the relation between cinema and psychoanalysis from the filmmaker’s perspective. Happily, she’s agreed!  —Max Cavitch, editor]

As a documentarian, I’m often approached by someone convinced they know what my next film needs to be. Almost invariably, the project they have in mind is the moving portrait of an organization grappling with one of our civilization’s most pressing problems: climate change, poverty, gender inequality, racism, etc. I hate to sound cynical, but I’ve learned over time that such “films” rarely turn out to be more than vanity projects: fundraising videos disguised as art. I understand the need for fundraising, and I’m as terrified as anyone about all the world’s current and impending cataclysms. But let’s keep our categories clear. I went to film school. I know what a film is.

Thus, when I was approached in 2013 by a group of Black psychoanalysts searching for a filmmaker, I had my doubts about getting involved. At the time, I had only the vaguest notion of what a psychoanalyst was. Kind of like a psychologist, I thought, but maybe more eccentric? Maybe even a little perverse? I have plenty of admiration for mental health practitioners, but also a strong suspicion of anything that smacks of eurocentrism…like a universal theory of human behavior developed by a cigar-smoking middle-class doctor in turn-of-the-century Vienna.

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Loving Yourself Workshop: A Poem

by Susan M. Schultz

According to a JED Foundation Survey published October 22, 2020, eighty-two percent of college students deal with anxiety, sixty-eight percent with depression, and one in five (nineteen percent) of students have had suicidal thoughts in the past month. In bold print, the report asserts, “Mental health should be a top priority for schools.” I have spent the past seven years advocating at the University of Hawai`i-Mānoa for better campus mental-health services. If you read recent press releases from UHM, you would think these services had improved dramatically. But if you pay closer attention, you will hear the hollowness of the language of care. In fact, even as the rhetoric improves, the level of care diminishes.

Thus begins my essay, “The Language of Care in (My) Neo-liberal University,” which is based on a talk I gave at the recent Webinar Colloquium, “Poetics and the University in Crisis” (March 3-5, 2021). My argument—based on many years of activism at the University of Hawai`i-Mānoa (UHM)—was that the university, in its response to demands for better mental health care, gave only the semblance of actually caring. Communicating a public message of ‘care’ fulfills the university’s public relations priorities while downplaying its unwillingness to spend the money that would be needed to strengthen the Counseling and Student Development Center. It was one more sign, sad to say, of the university’s overall unwillingness to revive the notion of the university as a community of care.

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Discovering Psychoanalysis as a Business School Student

by Ryan Collins

My exploration of psychoanalysis began with philosophy. Like many people my age, I was seeking answers to certain existential questions: “Who or what governs our behaviors, and are they rational?” Philosophers—from Plato, Aristotle, and Marcus Aurelius to Descartes, Hume, Kant, and beyond—have been asking similar questions for millennia. Although he was not a philosopher, Freud’s founding of psychoanalysis tackled such questions as well. While many of his theories have been challenged and revised, his discovery that our behaviors are often governed by unconscious conflicts between our desires and internalized societal demands remains relevant today. Although Freud continues to be a controversial figure, he critically challenged our belief in human rationality by demonstrating the unconscious and “irrational” nature of most of our behavioral tendencies.

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