PSYCHOTHERAPY AND MORALITY

PSYCHOANALYSIS & MORALITY--- THE LONGTERM PSYCHOANALYTIC TREATMENT OF A SOCIOPATHIC PHYSICIAN

Ali came to me 30 years ago. At the time he was a resident physician completing his training in obstetrics and gynecology. I was only a few years out of my residency. He was referred to me by the chairman of the department of psychiatry and the director of the clinic where I was junior staff, since he knew that I had a small private practice and was interested in psychoanalysis. He handed me Ali's letter, which was eight pages, written in longhand, showing obvious difficulty with the language and handwriting. However, the letter showed obvious intelligence and potential as it admitted to some knowledge of Freudian psychodynamics, including a brief experience with analytic psychotherapy and a wish for further work.

The first session showed an anguished human being with a very serious problem. He said, quite bluntly, "I am a gynecologist and I fuck my patients". Inwardly, I was taken aback, but outwardly I only demonstrated a detached, clinical interest. I asked him to tell me more. He had raped two patients in his first year of residency, an obese black woman and a pubertal boy. The woman had made a complaint, but it was his word against hers, and since there was no evidence, there was no prosecution, but he was dropped from the residency program. His letter of recommendation omitted mention of the incident and he easily gained acceptance to another residency. Eventually he came to my area and was subsequently referred to me, but he knew he was out of control and could easily get into serious trouble again, which meant that he could go to jail, lose his license to practice medicine, or even be shot by an enraged relative. Having read about psychoanalysis, he realized it was the treatment of choice for him. I had started my own analysis and thought that my therapy would help me deal with any countertransference I might develop. Of course, my initial reaction to Ali was that of shock and revulsion, but our professional code precluded my rejecting him or being judgmental. It was also considered part of our professional responsibility to help impaired physicians, and I believed, too, that psychoanalysis was the 'treatment of choice'

I referred to Otto Fenichel's book, "The Psychoanalytic Treatment of Neurosis" and found my patient to be in the chapter on 'perversions'. He was a fetishist, attracted to buttocks and anal intercourse. According to Fenichel, the principle of treatment was to interpret the 'castration-anxiety' underlying all the perversions and to 'convert' the perversion to a neurosis, by interpreting the defense of acting-out, and using suggestion and direction to stop the acting-out, which would then elicit the re-experience of underlying neurotic anxiety and depression. Then treat the neurosis classically. The basic plan seemed sound and simple enough, and it started with free-association and the reconstruction of the formative childhood influences. Ali's story seemed a classic case, as his childhood was one in which it was as if he were reared on the set of pornographic film-making. He recalled being very poor and everyone sleeping in one small room, on mats, and he would frequently hear his parents having intercourse. It was dark, but he could discern a rear-entry position in the primal scene, and heard certain sounds, which we euphemistically call those sounds of childhood anxiety, the sounds that go 'bump in the night'. He remembers his mother exclaiming, "you are a donkey" and "it hurts". He pictured his father as an animal and added that his father often had orgies in the home in which he invited his friends and a number of prostitutes and they would "drink and have a ball". During these proceedings, Ali, as a young boy, would wander about, occasionally witnessing sexual acts through keyholes and cracks in the doorway. The mother was in another room, lost in prayer.

Furthermore, the mother would attend to the patient's toilet hygiene by having him squat over a bowl of warm water, and after a bowel movement she would clean his anus and rectum with her finger, accompanied by Muslim prayers of purification and cleanliness. These would take extended periods of time which the boy would find pleasurable. His mother was described as a religious fanatic, ignorant, the daughter of a 'mullah'. She went to great lengths of purification and cleanliness with Ali, taking him to the communal baths and into the section for women, where he would describe gazing at hundreds of "naked ladies", some of whom covered themselves in his presence, but most took no notice of the small boy. Some would turn their backs to him in modesty, revealing their buttocks, which made him excited. He hid his excitement the best he could with a towel and he would not stare directly, but his mother would bathe him and herself for hours at a time, as often as she could spare the time from childcare, cooking, cleaning and laundry. When Ali was older his mother would tell him how, when he was an infant and very small, she would caress the skin of his breast, and tell him how it was the smoothest skin she ever felt. He became jealous and crestfallen when his brother was born two years after him and Ali would watch him being nursed, held, fondled, caressed and sung to. His mother developed an intense intimacy with this younger brother and neglected Ali except for these cleansing rituals.

It would not be difficult to conclude that such a childhood would predispose to an anal fixation, so these intellectual insights were discussed early in therapy. Also, it was not long before Fenichel's analysis became a predictable truism. This over-stimulated boy often played with his penis, and when his father noticed this habit he became furious and threatened to cut his penis off, brandishing a knife. There was no telling what the father would do since he was temperamental and explosive and often raged while under the influence of alcohol. He did beat the boy mercilously at times, for touching himself and for stealing loose change around the house, and the father threatened to take him to the cemetery and beat him to death and bury him then and there. Ali was terrified of him and tried to stay out of his way. He would wander the streets of his village where he was noticed as a poor boy who would accept small tokens of money to be fondled by homosexual men. They would induce him to sit on their laps where he felt their erections near his anus.

He stole money because he was very poor and could not buy the treats that the other children would have. He also noticed that his clothes were ragged and that other children, especially those of wealthy parents, had beautiful clothes, wonderful things to eat and servants who would bring food to the school at lunchtime. So he stole money whenever he had the chance, including from the pocket of his schoolteacher, whose coat was on a hanger. He was once caught and humiliated in front of the class, and he was frequently the butt of shaming, as he was referred to by a Muslim expression of disdain, "he eats a lot, but he doesn't work" (fat and lazy). Ali silently bore the whips and scorns of his teachers, classmates and father, drawing into himself more and more, deciding that as long as he was always being punished, he might as well steal, as long as he could get away with it--- life was not fair. However, he was always terrified that his father would eventually carry out his threats and actually cut off his penis or kill him.

In high school he turned toward books and eventually achieved high marks. He did well on the national examination and was accepted to medical school. His father gave him some spending money above and beyond his national scholarship, but he was still among the poorest medical students. The other students with money had automobiles and girlfriends. He was jealous of his classmates who boasted that they would take out young women for a drive and then "fuck them in the ass". He claimed this was a common dating device to keep the girls virginal for marriage, as their hymens would not be broken. He was sometimes invited along to parties where he would watch the goings on, much as he did at home as a child, and was exceedingly envious and jealous. Everybody else seemed to be having a ball, and Ali was miserable. He was too shy to ask a girl out for a date, especially after rejections came from his awkward behavior and ill-fitting clothing. He finally went to a prostitute and promptly contracted gonorrhea. He was terrified, thinking he would lose his penis, and asked his father for money for a penicillin shot. The father promptly slapped him in the face and threw the money at him. The father's hypocrisy was not lost on Ali by this time and he wanted nothing more to do with him or his family, so he decided to emigrate to America, Land of Opportunity.

In the early months of the analysis, his free associations were constantly about his arousal while examining patients in the lithotomy position, their legs up in the stirrups, exposing their genitals. Every examination was simulated intercourse for him, and he would sometimes prolong the examination, observing whether the woman was getting excited or uncomfortable. At times it seemed that they were excited, and he would stimulate their clitoris, and sometimes he would whisper, "Is it all right to do it?" At times the woman responded, "yes", and he would take out his penis and insert it into their vagina or anus. He told me that many of these women who were in a poor, inner-city neighborhood, were prostitutes or promiscuous, addicted to drugs, and didn't mind a little sex with their gynecologist. For some, it was an honor. Others, who were uncomfortable or said, "no", he would leave alone. In these inner-city clinics the rule of having a nurse present was ignored.

As he revealed these actions to me, I interpreted, from his early history, that they were defenses against castration-anxiety, that he kept having to prove that he had a penis and that it worked, and that he was not being castrated even though he broke the rules. It was a repetition-compulsion and a counter-phobic defense. I told him that his acting-out was preventing further significant memories from coming to the surface, that it was a resistance to further uncovering, which was necessary to work through his problems. He seemed to understand and accept what I was telling him, but was unable or unwilling to curtail his behavior. I tried to empathize with his feelings of being out of control and even suggested he was in the wrong specialty, considering his problem, but he would not consider changing it. I thought that in time he would either change it or work through his problem. When he continued to act-out and the sessions became monotonously repetitious, I told him I was no longer able to help him unless he stopped his acting-out. I gave him three chances and it was one, two, three strikes and he was out. I terminated him after two years of therapy.

I felt bad that I and/or the analysis was unable to help him and discussing the case in my own analysis, could not come up with anything that I was missing, not technically or emotionally. I could only wonder what Ali was doing, but he called me up again, six months later. He was now in solo private practice, still in the inner-city, since he preferred black patients and the fact that many of them were co-operative. At first the analytic fees were amounting to one third to one half his income, but now it was a minute fraction. I told him I would accept him back for therapy for double the fee, since the regular fee was now insignificant to him and there would be no financial inducement to complete the analysis, no real sacrifice. And there seemed to be an element of using the analysis as a 'confessional', and that the ventilation and catharsis were tension-relieving, and my relatively nonjudgmental and nondirective technique seemed to be condoning his behavior. I reminded him that what he was doing was wrong, that he was acting-out his fantasies, that he was violating professional standards and code of ethics, the Hippocratic Oath, all of which he acknowledged, but he claimed inability to control himself. He said he very much wanted to control himself, to live a normal life, free of guilt and fear, but he needed more of my help. He claimed he knew the consequences of his behavior, he didn't need my reminders. In his home country, if caught he would be summarily castrated.

I realized that analysis often took many years and also that this kind of case was very difficult. Fenichel said that the perversions were very hard to treat as patients were loathe to give up an intense pleasure, only to replace it by frustration, fear and guilt. This seemed to be the case for Ali, and considering my own conflict about the possibility of aiding and abetting a criminal, I justified in my own mind the extra fee because it was an unusually difficult case, the patient could afford it, and it was a sign of his commitment to the length, complexity and seriousness of the analytic work. I was impressed by the fact that he did a lot of extra reading on his own, seemed to understand the process of psychotherapy and dynamics of the unconscious, and was very bright, articulate and motivated for change. Also, I was given to understand that he no longer raped patients, always obtained their consent for sexual liberties, and so far there were no complaints against him. I also came to know that such behavior was not uncommon among gynecologists and psychiatrists, including analysts, most of whom escaped detection and punishment, and it was my responsibility to try and help an impaired physician. In other words, while Ali was disobeying the moral requirements of his profession, I was abiding by mine, and I hoped that over time my 'good behavior' would be a role-model for him. And he did seem to respect me greatly, displaying an attitude of deference and respect which I thought was sincere and genuine.

As we resumed the analysis, his errant behavior decreased and he worked harder to maintain the professional standards of his profession. When he took the OB-GYN self-assessment test, which was voluntary, the only other colleague taking the exam was the head of the department of obstetrics and gynecology. They both passed. Ali was doing many deliveries of high-risk pregnancies with a minimum of complications. His patients returned, time and time again, and his practice grew largely by word of mouth. The best gynecologists usually gravitated to the more affluent suburbs, but Ali stayed in the inner-city despite the usual dangers. He was considered an asset to the local community and so was well-protected from the usual break-ins and muggings. Most of his patients were on Medicaid and he accepted their low fees, sometimes less than half of what Blue Cross paid. However, he supplemented his income by doing many unnecessary tests and billing for procedures not done. After a few years, state auditors caught up with him due to his inflated income, and he was not alone. Many were doing the same, and it became a battle between highly paid private lawyers and professional expert witnesses, and the state's overworked, underpaid lawyers, their expert witnesses being retired general practitioners, so that Ali and many others retained most of their ill-gotten gains. Ali justified and rationalized his 'cheating' in that he was the object of being cheated, by auto dealerships, carpet salesmen, carpenters, plumbers and landscapers, some of which was true. I repeatedly interpreted his self-serving rationalizations and eventually the cheating subsided. In the meantime, he became quite wealthy and acquired the usual big home and expensive car. He continued, however, to wear shabby clothing and shoes.

During this time I was witness to a cultural variance for which I was not prepared. He was going to take a month's vacation, return home and come back with a wife. I was incredulous that he could do so, and gave him the usual advice that it was unwise during analysis to make a major life decision. I recommended an analytic consultation before he left for his home country, with which he complied, but sure enough, a month later he returned with a young wife, a virgin from a good family. In his country, marriages were arranged by the families, and it was thought that it would be a good catch for a doctor's daughter to marry a wealthy American physician, his home country being unstable and in political and economic turmoil. At first I would hear how this young woman was in culture-shock, separated from her family and neighborhood, and at first she was afraid to leave the house. She was inexperienced in sex and relatively unresponsive. Ali was not sexually attracted to her, but wanted a woman, a virgin, from a good family, well brought up, who would be faithful and a good mother to his children. He wanted a normal family life.

As time went by, this young woman who we shall call Rosita, made contacts, learned to drive a car and eventually developed friendships with other doctor's wives from her home country, and they helped her get the lay of the land. After a time, she became aware of and took advantage of her position, enjoyed shopping in the malls, gossiping on the phone, learning interior decorating and landscaping, and she started to have children. She had three children in nine years and was a doting, serious and scrupulous mother, seeing to it that her children had all the advantages. They went to private schools and took music lessons. Ali was a relatively absent father, a workaholic. Again it was interpreted that he was identified with his own father, afraid of his temper, resenting his wife's excessive discipline and demands, her complaining and controlling behavior. Part of the problem was her fear of the children being kidnapped, a residual of her own upbringing, and so she was overprotective and kept the children largely at home or well supervised. The presence of young children also stimulated additional painful memories of his own traumatic and deprived childhood, and so he came to envy his children. At times he could not control himself and beat his son, always with great remorse afterwards. With interpretations about this, over time, he became a more involved and compassionate father, who tried to moderate the strict discipline of the mother. Rosita complained that Ali was too permissive.

During this time I permitted some conjoint sessions to help mediate their disagreements over their children and growing marital discord. This was at Ali's instigation, and proved helpful. Also during this time, some of Ali's colleagues were also cheating Medicaid, becoming millionaires. They invested their money in tax-deferred retirement plans and made great profits from investments when the interest rates were very high. Gold prices were up and a good friend of his was so distrustful of banks that he carried around gold bullion in his attaché case. This friend became so fearful of discovery and worried about robbery that he had a heart attack under mysterious circumstances one day and died. Ali was convinced it was a psychic (psychophysiological) suicide and became terrified that the same thing would happen to him, so he said he would reform entirely, and no longer cheat or take advantage of his patients. At the time, I then agreed to lower his fee to my usual fee and hoped we would proceed to an eventual termination. After this the analysis took another five years.

At first Ali seemed to be totally reformed. He no longer took sexual advantage of his patients or made false claims to insurance companies. He seemed to be convinced, shocked at the untimely death of his friend and countryman, with whom he identified, that his greediness and unruliness would end in his own untimely death; he was literally scared to death. I thought this pathological over-reaction would promote the analytic goal of a change in his behavior, even as Freud admonished us to give up therapeutic ambition.

As it turned out, Ali didn't die despite frequent chest pains, but a new element appeared in his external life which encouraged a partial relapse in his behavior, that of a malpractice suit. He was at the same time frightened and outraged; it was one of these frivolous suits, claiming damage that was clearly not his responsibility, and it was felt to be a betrayal by one of his 'loyal' patients. Inquiring into this case, it was determined that part of his going 'straight' was stopping giving diet pills, that is, amphetamines, to some of his addicted patients. It was one of these patients who was suing him. The medical record was subpoenaed, and before turning it in, Ali edited it, as it was previously sloppy and potentially incriminating. I reminded him that such behavior was dangerous and illegal, but he was determined not to go to trial with such an obvious disadvantage. During the trial, and while in the witness chair and under oath, cross examination exposed the updated changing of the medical record, at which time Ali fainted. This caused a commotion in the courtroom as it was thought he had a heart attack and CPR was administered. Ali recovered but this line of questioning was abandoned. The jury's verdict was that Ali was innocent. He then felt vindicated.

Thereafter, there were other malpractice lawsuits, some from patients with whom he stopped having sexual episodes. A few were settled for minor sums. Some patients had obviously been gratified with the sexual attention, tender words, and the gift of cash. We were also entering an era when malpractice and other torts in this county were given plaintiff awards in the millions, due to juries who found fault in 'deep-pockets'. This 'unfairness' stimulated Ali to return to some minor 'cheating' and to further sexual exploitation of compliant patients. It was an old pattern; if he was going to be 'punished' (by a suit) anyway, he might as well commit the crime. Also, after many years of avoiding outright adultery, knowing that his wife would divorce him and take the children if such a practice were discovered, he had an affair with a clerk in his office to whom he was attracted because of her 'large buttocks'. She allowed anal intercourse and he was in heaven. He found sex with her irresistable and gave her money, which she seemed to greatly appreciate. He was also tired of denying himself, since his wife, although by now sexually responsive, was 'skinny' and unappealing to him. He performed marital intercourse out of a sense of duty and release of sexual tension, and to convince her that all was well. The affair with the clerk gradually faded away and Ali was back to trying to be good again, no more cheating, no more running around, trying again to become a law-abiding citizen, a good husband and father.

He returned to psychology and philosophy books, reading Rollo May and Bion. He added studies of mythology, such as those of Joseph Campbell, and the male-bonding mythology of "Iron Man" by Robert Bly. He viewed "A Gathering of Men" a videotape narrated by Robert Bly, whose psychology emphasized the deficiency in a male's psychology and personality due to a loss of a significant father-son relationship. Through the years I had become a surrogate father to Ali, a contrast to his own father, who lacked many necessary virtues to properly bring up his son. Ali started piano lessons. He read such philosophers as Spinoza, Descartes, Nietzsche, Heidigger and Heine, the works of Danté, Goethe, Schiller and Rielke, and began to listen to tapes of Indian mystics and gurus, and to the poetry and music of his own country. In addition, he developed a love for and appreciation of the music of Mozart and Beethoven, music that one of his sons played on the piano, on a daily basis, a son with prodigious musical talent. Ali gave talks at his medical school reunions, talks which were roundly applauded and appreciated for its intelligence, depth and humor. His medical classmates were impressed with his apparent transformation, as he was shy and introverted in medical school. Ali was developing real self-esteem. He could think of no better way to pass the time while waiting for his patients to deliver, than to listen to philosophical tapes and music, to read poetry and philosophy. He was well-respected by obstetrical nurses who appreciated his presence throughout labor and delivery, compared to many obstetricians who would show up at the last minute or not at all, leaving the delivery to house staff. Ali was an experienced practitioner who was a good teacher and who kept up with the latest developments in obstetrical practice. He had only one fetal and maternal death during his practice, after delivering literally thousands of babies, a statistic better than most, and amazing, considering his high-risk population. The high-risks included physical abuse by husbands and boyfriends, malnutrition, chronic pelvic inflammatory disease, drug addiction and obesity.

At the age of 60 he retired and moved to another state. His children were in college or graduate schools and were relatively normal and successful. His relations with Rosita grew more harmonious and intimate as he realized how much he had ignored and abused her in the past, how her complaints to him were justified, and yet how committed she was to him and the children and their household. She had learned to use the computer and had increased his income by following up on unpaid bills, including those of Blue Cross and HMO's which were delinquent in their payments to him. He had ultimately confided most of his problems to her and convinced her that he was in the process of reformation. She accepted that and expressed some admiration for his persistence in therapy, knowing something of his childhood background, including his ongoing depression, nightmares, fears and misery. Now they enjoyed being together, shopping, travelling, watching movies, discussing books, going to museums and concerts. It seems that ultimately acting-out was replaced by sublimation, "where id was, there ego shall be".

The moral dilemma I experienced was the haunting possibility that in effect I was aiding and abetting my patient's unwholesome pathology. The outline of psychodynamics and prescription for cure which I found within Fenichel's classic book seemed appropriate and workable, given Ali's early history and how the repeated anal stimulation by his mother and castration threats by his father developed into a perversion and an impulse disorder. It seemed to me that psychoanalysis was a better, more civilized approach to such a problem, rather than the ineffectual penal system and mob justice which results from such a problem being discovered. I had seen in television and read in the medical journals of other gynecologists being accused of sexually exploiting their patients, and most 'got away' with their behavior due to lack of solid evidence or witnesses. It is interesting that no patient of Ali ever initiated a malpractice suit based on his sexual behavior. I assume the lack of such a response was due to his real charm and sensitivity. At the slightest hint of a patient's discomfort or lack of interest in his sexual predilections, he would desist.

An interesting aspect of Ali's psychoanalytic treatment was his participation on and off in my analytic group. This was a group of patients in psychoanalytic psychotherapy, like himself, in intensive individual and group therapy. Group members were for the most part highly functioning neurotics, character disorders and depressive and narcissistic personalities, deeply committed to longterm work. Ali's entrance to such an ongoing group was a shock, as he was disarmingly candid, open and vulnerable, and group members were not familiar with such behavior and pathology, knowing about it only by reading reports of similar behavior in the newspapers and increasingly on daytime talk shows. The initial reaction of the group was similar to that of audience responses to antisocial behavior and breaking of societal taboos on these now omnipresent television talk shows, such as "Oprah" and "Geraldo" and Phil Donahue. Some of the group members, especially the women, were shocked and outraged, hardly believing that a doctor could do such a thing, now wondering about their own gynecologist, recalling their own real and palpable discomforts on the examining table, and looking to me to punish Ali, report him to the police or the ethics committee of the medical society or the state department of licensing and regulation.

I had to remind the group that we were honor-bound to respect each other's confidentiality, that I had a professional relationship with Ali, and that my professional ethics required that I keep my knowledge of his errant behavior confidential. I would not even keep notes of his treatment, so there would be nothing incriminating that could be subpoenaed, knowing that there were irresponsible lawyers and judges who would want to use my records to advance their careers and not necessarily the pursuit of truth and justice. I vowed to remember well that President Nixon ordered the break-in of Daniel Ellesberg's psychiatrist's office, in order to get incriminating evidence to discredit him, one of his many 'dirty tricks'. As far as I was concerned, the government was not necessarily to be trusted. I trusted more the morals and values of professional ethics and standards, and of those members of my analytic groups who recognized the importance of confidentiality. Also I had consulted a colleague, a professor of Psychiatry and Law, who assured me that the privilege of confidentiality extended to members of a psychotherapy group; that they could not be legally forced to testify against a group member in the event of litigation or prosecution, except in highly unusual circumstances. The morals of the small group superceded the moral imperatives of the larger society. It was well known that the values of the larger society were not uniform or consistently fair, and that corruption invades government offices and judicial halls, as well as temples of worship.

In effect, we were a society of analytic patients which had a more utopian morality, one based on understanding, compassion, sympathy, empathy, tolerance, and a certain faith in the validity of this method of treatment. What invariably happened when Ali entered a group was an initial period of outrage and demand for punishment, which subsided when he told the group his childhood history. And this history was so consistent and delivered with such sincerity and depth of feeling, that it was clear that this man was no remorseless sociopath. True to Fenichel, as the acting-out subsided, the anxiety, fear, guilt and depression rose to the surface. Hardly anyone in the group encountered an individual in such anguish and despair. Of course it was argued at times that Ali was extraordinarily clever, and might be the ultimate 'actor', but these misgivings subsided in time. Ali became as being interested in everyone else's problems as well as his own, and he used his intelligence and sensitivity, his own clinical perceptiveness, his readings, his developing insights and his growing articulateness to interact with others in a positive direction. He addressed everyone by name and had a startling memory for the key events and basic conflicts in the lives of other group members.

Ali used the group as a microcosm of society, which it became. Group members personalized their concerns about and feeling toward him. Women would say they did not want their gynecologist to take advantage of their professional position and exploit them sexually. They confided how vulnerable and uncomfortable it was to be examined by a male gynecologist. Some of the women group members actually switched to a female gynecologist. Men would ask Ali, what if this were your daughter, or your wife? Of course, he would have no answer and he would hang his head. After such confrontations he would report that he would think of the group reaction if he did anything wrong, and how he would feel, and that would inhibit his impulse to act out. He would admit to the group that he knew that what he was doing was wrong and that he was trying to stop, trying to use his understanding, his analytic insight to stop, to change his behavior. He wanted to please them, he did not wanted to displease them, he craved their approval.

It was clear that there were many other group members who also had intellectual insight, but who themselves resisted making changes for the better, changes that would appear simple and obvious. The group as a whole empathized with the problem of resistance, the tendency to avoid, deny, postpone, negate, dissociate, split. It was quite a task to work through the conflicts at a deep enough level to accomplish the integration which was the prerequisite for change.

When Ali announced in group that he was ready to terminate, that he had achieved what he believed was maximum benefit from therapy, that he was retiring and moving to another state, most group members were accepting and glad for him. They felt he had made significant gains and were no longer worried about him or his patients. They were tearful and hugged him and wanted to keep in touch. He brought delicious 'bakhlava' that his wife had made and a bottle of champagne. People were tearful and smiling as they bid him farewell.

I present this case as a difficult one and a long one, manifesting the ultimate problem of morality and psychoanalysis. Psychoanalysis has been accused of being amoral, in being overly scientific and nonjudgmental, nondirective, eschewing direction and suggestion, especially moralizing. Some people believe psychoanalysts should be agents of society and proponents of cultural norms, but Freudians have, for the most part, resisted the pressure to submit to societal requirements. Freud, in his book, "Group Psychology and the Analysis of the Ego" related the tendency of groups to anxiety, contagion and regression. All those who have worked with groups and studied the behavior of larger groups, know all too well how individual behavior can deteriorate in the face of mass emotions. Nazi Germany and lynch mobs are only the obvious examples of large group behavior allowed and encouraged to sink to the basest level, with unscrupulous and evil leaders. In psychoanalytic groups, a mentally healthy and well balanced leader, the analytic therapist, can encourage and work toward the highest human potentials by his own example and utilizing the insights of his training and personal analysis.

In this case, I would say the treatment was successful and vindicates not only the deep understanding and recommendations for treatment by such an analytic giant as Otto Fenichel, building on the work of Sigmund Freud, but demonstrates that moral behavior can be developed through insight and psychoanalytic theory and technique, which really stems from a highly moral position which is intrinsic and intuitive. What is demonstrated is that following the ethics of our profession, we are in a better position to help a sociopathic person who seeks help, than from other quarters of our society, such as the penal system. Hopefully this case will illustrate that the morality inherent in our profession works better to help individuals impaired by a traumatic environment, than punishment and incarceration.

Victor Bloom, M.D. is Clinical Associate Professor, Department of Psychiatry, Wayne State University School of Medicine and Lecturer in Psychoanalytic Psychotherapy at the University Psychiatric Center, Detroit, Michigan.

1007 Three Mile Drive

Grosse Pointe Park, MI 48230