Magazine article Clinical Psychiatry News

Yes, We Can (Ethically Change)

Magazine article Clinical Psychiatry News

Yes, We Can (Ethically Change)

Article excerpt

As I loosen my American flag tie, and press on to finish this column on the day of our national presidential election, it's hard not to think about change. Once the theme solely of Sen. Barack Obama's campaign ("Change We Can Believe In"), it was so appealing that Sen. John McCain also tried it out ("Change Is Coming").

One clear example of change in the campaign, compared with previous contests, is the demographics of the nominees. In Barack Obama, we had our first black person to win a major party's nomination for president. Sen. McCain would have been the oldest first-term president. And Gov. Sarah Palin was the first woman to run on the Republican ticket. These firsts represent symbolic and perhaps substantive change in some social schisms in America: racism, ageism, and sexism.

Such precedents have not been limited to national politics. In our own American Psychiatric Association's last election, for example, we elected Dr. Alan F. Schatzberg our president. Dr. Schatzberg, a renowned academic psychopharmacologist, has a background that has not been represented among our recent presidents--despite the ascendancy of medications in our specialty. It's also interesting to think about change in the context of psychiatric patient care. With that idea in mind, over the last 2 days, I have been soliciting my patients' point of view about political change. About half offered no comment on a confidential questionnaire, but the rest expressed hope for a systemic change along the lines of national health insurance. As one patient who has received treatment in the public and private sectors wrote: Insurance that is "fair and just ... is simply required."

All this talk of change in our national politics and in psychiatry prompted me to wonder what change really means. From our clinical work, we know that change is possible in terms of symptoms and personality. But it is often elusive. People can certainly change developmentally, but what enhances change over a lifetime? As I think about the question of age in the presidential campaign, I ask myself what changes I am going through as I approach my retirement years, and how these changes are affecting my work.

The Psychology of Change

As I wondered about these aspects of change, I thought of a video of Dr. Fritz Perls conducting gestalt therapy I saw during my early psychotherapy training in the 1970s.

The basic goal of the therapy was to help the patient become more of what he or she already was. Trying to be a changer--that is, a therapist who tries to persuade change--would not work, according to Dr. Perls. Personal change is an explicit goal of gestalt therapy but an implicit goal of other kinds of therapy. The heyday of gestalt therapy is over in the United States, but later work on the psychology of individual change has been applied to principles of social change.

Our knowledge about the psychology of change tells us that substantial, real change is not easy. Consider the failure rate of New Year's resolutions, which many of us are about to make for 2009.

In her acceptance speech at the Republican National Convention, Gov. Palin sneered that a presidential campaign should not be "a journey of personal discovery." Yet that's probably exactly what Dr. Perls would have said that a presidential campaign should be. I agree, and I think that serving as president also must be a journey of discovery. Campaigning and serving are certainly experiences that require ethics.

Ethical Development

We often think of morality, which encompasses our individual values, and ethics, which encompass our professional values, as being constant, fixed. That may be because we think these values should be basic and tested by time. But they are not. Our moral and professional values seem to change over the course of our lives, and sometimes the change is needed.

The pioneer in positing the stages of moral development was the psychologist Lawrence Kohlberg. …

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