Two years ago I wrote a post on Responsibility. In part it was a bit of an explanation of why I Blog and what I Blog about:
Looking back on what I have been writing about on this blog, I think there is an underlying theme that animates my thinking. The Psychoanalyst interprets defenses (essentially to help people stop fooling themselves about their own mental processes) in order to bring into consciousness those motivating ideas and feelings that the person has been incapable of facing directly. As I have pointed out to patients on many occasions: When you do not know why you behave the way you do, or feel the way you feel, you can not change anything. It is only once you understand why you are feeling the way you feel and why you do the things you do, that you have the choice of changing the behavior that causes you, and others, grief. In brief, the goal of psychoanalysis is to enlarge the area of mental life, feelings and behavior, that a person can take conscious responsibility for.
It seems to me that many of the most contentious areas of disagreement in our culture lie between those who attribute the appropriate locus of responsibility to different agencies. In the broadest terms, between those who see the primary locus of responsibility lying within the individual and those who would place the locus of responsibility in a place external to the individual.
[Please note, this is not an absolute. Many people accept responsibility for themselves yet do not expect the same level of accountability from others. Other people accept some responsibilities while vigorously trying to avoid other responsibilities. I am purposely distilling the issues, perhaps unfairly, but I take full responsibility for the decision.]
We see this argument at the base of disagreements ranging from the immigration debate (should we expect immigrants to take responsibility for having transgressed our laws or should we grant them some form of relief from responsibility for their actions?) We see the struggle playing out in Congress in terms of the War in Iraq and the greater war on Islamic fascism, where the Democrats and some Republicans attempt to position themselves in such a way as to claim responsibility for ending the war but eschew responsibility if the war and/or post-war goes badly. The MSM are an immeasurable help in this venture, but do their best to avoid acknowledging their responsibility for shaping the debate.
Attempting to avoid responsibility is one of the charms of childhood and adolescence. We correctly hold children and adolescents to significantly lesser standards of responsibility than adults, yet in many ways parents hold their children to a much higher standards than themselves, a function we refer to as hypocrisy.
The divergent discourse on responsibility starts at the most fundamental levels. Last week I wrote about the question of Universal Health Care. In response R2, a Medical Doctor who specializes in in-patient care (a Hospitalist) sent me a note. He explained that much of the crisis in health care stems from the use of ER's as primary care by the uninsured, especially Illegal Immigrants and a second, even larger group:
Second, older adults not yet on Medicare, who are suffering the ravages of substance abuse. The clinical sequelae of tobacco and excessive alcohol use are well known to our profession. Patients enter the hospital with seizures, GI bleeding, vascular catastrophes, respiratory failure, lung cancer, liver failure, strokes, heart attacks, car wrecks and so on. These folks often are unable to hold jobs and usually do not have insurance. They also, as demonstrated by their lifestyle choices, have no interest in being financially responsible for their self-caused illness. I submit that it is actually possible to make them ante up. By doing so, the cost of medical care for the rest of the population will radically decline. The answer lies in taxing the hell out of the offending substances, using these funds to pay for health care for everybody who suffers health problems from these 2 agents, and prohibiting insurance companies, Medicare, or anybody else from paying for the care related to the illnesses caused by tobacco and alcohol. My estimate is that another large fraction (perhaps as high as 1/2) of indigent care goes to these folks.
I think R2 oversimplifies a bit but the sense of people not being treated as if they had any responsibility for their problems runs deep in our culture. Smokers and drinkers are addicted, ie they are unable to control their substance abuse. Obese people have metabolic problems or a food addiction. A serial adulterer may have a sex addiction. In our society, the original meaning of the work "addiction" has become so adulterated as to lose all meaning beyond its status as a pseudo-technical term used to eschew personal responsibility.
Last week, The Anchoress posted The Bootstrap Nation; Bill Clinton’s Best Legacy? - UPDATED, where she made the eminently sensible observation that when Clinton signed the Welfare Reform Bill it had far reaching consequences:
The world did not end. What ended was the seeming-entrenchment of whole groups of people, of all ethnic backgrounds, into a hopeless dependence upon the government which led nowhere, gave no promise, encouraged no future, thwarted dreams and individual potential, and perpetuated the whole idea of helplessness, of inability, of needing a caretaker.
Why did welfare reform work? Perhaps when people were liberated from the shackles of socially-engineered government dependence, when they were freed from the quicksand and muck of “Free Government Cheese” and able to move to the higher ground of “Unleashed Potential,” they grew in self-respect, self-confidence and - most importantly - in hope. The message “you can, if you try” was a louder, clearer and more spiritually sustaining message than “you can’t, so just give up”
I split my time between my private practice, where I see relatively successful individuals of means, and a Community Mental Health clinic where the patient population tends to be poor. There are many differences between the populations but a great deal of overlap as well. However, in every patient I see, I address the same issue, upon which depends my treatment recommendations and the patient's long term prognosis: My primary concern during the evaluation, beyond the presence or absence of various symptoms, character structure, development, intellectual level, family structure, and myriad other aspects of the person is an assessment of their capacity to tolerate and eventually, accept responsibility for their present circumstances. Those patients for whom there is even the tiniest inkling of awareness of their own role in their current straits are the people most likely to be able to make use of Insight Oriented Psychotherapy. Where the person insists (both consciously and in their less overt manifestations) that they have no responsibility for their circumstances, that their spouse, or their mother, or an abusive father, or the system have kept them in their unhappy place, Psychotherapy can never do much more than make them feel a little better as they continue in their miserable place without any real hope of change.
Since my profession of Psychoanalysis has to bear some responsibility for the current sad state of affairs we have reached, in which so many are held to be victims rather than active agents, it might be useful to suggest how Psychoanalysis and Marxism (which allied itself with some of the worst notions to arise out of Psychoanalysis and misunderstood Psychoanalysis) came to be devoted to the cult of the victim rather than the elevation of the individual.
As such, I plan to describe two very similar patients I have seen who illustrate the differing course depending on where the locus of responsibility is placed.
Tomorrow: A Victim of Circumstances Beyond Her Control.
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