Existential Psychology Weblog by Louis Hoffman

A Brief History of Psychotherapy Outcome Research: How History Informs the Current Debate

An exploration of the history of outcome research controversy may help many gain a better appreciation for what is currently occurring, especially in the APS controversy. As this is a brief history, I will need to leave out many details for the sake of brevity, but this lends well to understanding the politics of outcome therapy research. For a more detailed history, I recommend David Elkins book, Humanistic Psychology: A Clinical Manifesto. 

Carl Rogers, to the surprise of many, is really the founder of contemporary outcome research. Prior to Rogers, there were many case histories, which could be seen as a form of outcome research; however, these were not intended so much to evaluate the effectiveness of therapy as to demonstrate or teach therapy. Rogers used multiple methods to evaluate the effectiveness of therapy, most of which involved intensive review therapy videos, audio recordings, and transcripts. To date, this is some of the most intensive analysis of the impact of therapy on a moment by moment basis that has ever been conducted. Ironically, the humanistic therapy that was consistently supported by this research, today is rarely considered "empirically validated" or "empirically supported." 

In the 1970s and 1980s, the field of psychotherapy had many problems leading to the emergence of managed care and contemporary outcome research. It is very important that therapists understand much of this was due to the abuses of therapy and third party payer systems by counselors, therapists, psychologists, and psychiatrists. There was extensive double-billing and over-billing, as well as unneeded long-term hospitalizations of clients and other unethical practices. Certainly, something needed to be done to contain the widespread abuses. 

The American Psychiatric Association was one of the first to respond by developing the "empirically validated therapies" (EVTs), most of which were medications. Division 12 of the American Psychological Association responded with their own version of the EVTs, then later the Empirically Supported Treatments (ESTs). The move from the EVTs to the ESTs is important. Although this did not reflect a change in the criteria or method for evaluating therapy, it represented a move toward a more appropriate philosophy of science. As most psychologists are taught in their graduate, if not undergraduate, research classes, psychological science does not prove anything, it supports it. "Validated" approaches were often understood as being a "proven" approach. 

The ESTs represented a very narrow view of science heavily biased toward quantitative research and what Elkins referred to as "short-term, linear therapies" (such as Cognitive-Behavioral, Interpersonal Psychotherapy, and other short-term, technique-based therapies). The representatives of many other types of therapy rightfully were very upset by this system and its biases, especially as it became political and many advocated that other types of therapy should be considered unethical.

There were several strong counter-movements. First was the empirically supported relationships, which advocated that it really was the therapy relationship accounting for most of the change in therapy. They looked at therapist and qualitative aspects of the therapy relationship connected to therapy change. Second, the empirically supported principles looked at broader features of the therapy relationship that contributed to change, including many relationship factors. Finally, Division 32 of APA (Humanistic Psychology) developed a set of standards of the practice of humanistic psychology rooted in a mixture of theory and research. While these approaches made some headway, the ESTs remained dominant. 

The introduction of Evidence-Based Practice in Psychology (EBPP) was the first significant challenge to the ESTs that began to really see some change. Ron Levant, who was the primary champion of EBPP, warned that if a broad definition of EBPP was not clearly established, it would regress to being another label for the ESTs. Many, it seemed, tried to push for this to occur, but overall it seems that the broader understanding of EBPP began to dominant in the APA. 

EBPP is rooted in three primary evaluative factors: 1) Research, 2) Clinical Experience and Expertise, and 3) Consideration for Individual Differences. For a therapy to be truly evidence-based, it should have support in all three categories. Here is where it is easy to demonstrate that the APS position, while claiming to be more rigorous, is actually much less. According to APS, only a narrow definition of criteria 1 is necessary for it to be "empirically validated," whereas the EBPP, increasingly supported by members of the APA, states this is insufficient in demonstrating therapeutic effectiveness. Let me briefly discuss each of these criteria before concluding with an illustrative example.

Research is understood broadly in EBPP and can include quantitative research, qualitative research, single-case design, public health and ethnographic research, and meta-analytic studies, to name a few. In this regard, it allows for a broad, in-depth analysis of therapy from multiple research methods to be used. This is much more rigorous than a narrowly defined research, or "scientific," agenda. 

Clinical experience and expertise adds that evidence-based practice also takes into consideration the perspective of expertise in the field and the peer-review process. It is not good enough to be supported by research, it must also be supported by clinical experience and expertise. Practitioners should regularly be reflecting on the therapy process and effectiveness, seeking appropriate consultation, and consulting the professional literature (including research and scholarship). Here is another place where the rhetoric of APS clearly falls short. In attacking the position frequently supported by APA, PsyD programs, and professional schools, they appear to be attacking the scholar-practitioner model, which is increasingly being associated with EBPP. Several articles in the public media and scholarly literature have claimed that this model advocates for clinical judgment over science. As noted in a previous blog, either they do not understand this model or are intentionally misrepresenting it for political gain. Instead, it is quite clear that the scholar practitioner model and EBPP advocate for clinical judgment and science. In their argument, they refer to a survey in which many therapists indicated they rely on clinical judgment more than science. Again, this is clearly a straw-man argument that holds no weight. Clinical judgment is always informed by science. Many who say they use clinical judgment over science are saying that just relying on science, without also including knowledge based in experience, is dangerous. Science is too often blind to context; this is where it needs experience and a broader understanding of clinical judgment. 

Consideration for Individual Differences is the final component of EBPP. This indicates that it takes into consideration individual differences, cultural differences, and other forms of difference. I would advocate that this also implicitly, if not explicitly, means different values systems. I have already regularly advocated that the APS position represents one value system and is antagonistic to other value systems. Its approach to diversity is to research the effectiveness for particular groups. For example, it examines whether Cognitive-Behavioral Therapy is effective in dealing with depression in African American males between the age of 20 and 30. However, it does not take into consideration the individual differences within this group (i.e., individual difference criterion of EBPP) and only considers effectiveness in terms of symptom reduction, not necessarily in consideration of common cultural values of this group. Clearly, this limitation is one that cannot be adequately addressed by a narrowly defined science, demonstrating its inferiority to an evidence-based approach. 

EBPP has become the most influential outcome research approach in professional psychology and for good reason. It addresses the limitations of the APS position, which clearly lacks sufficient rigor, and it also addresses the problem of psychotherapeutic free-for-all (i.e., allowing therapists to do whatever they want). It provides adequate containment against abuses of third-party payors and the general public while also allowing for sufficient flexibility to adjust to individual and group needs and differences. 

Several things can be quickly attained by the recent APS position by their language. First, they return to the language of "validated" and "proven" in their literature. This makes a strong statement about their philosophy of science, which is outdated. It is interesting to note that they are claiming to advocate for progress, a moving forward to a more scientific-based approach; however, in reality, they are advocating for a regression to an out-dated approach to outcome research that is less rigorous, not more. 

Let me close with an example to illustrate the important deficiencies of the APS approach. In a narrowly-defined scientific-based approach, the therapist appeals to science for their decision making, often lending to a step-by-step approach, or a system in which if A occurs, one does B. This sounds nice and simple, but how many clients want a therapist that appeals to their manual in how to respond? According to the APS position, expert therapists who have been successfully practicing therapy for many years should defer to narrowly understood research on clinical decisions. They would advocate that a technician who has mastered the techniques in the laboratory should be just as effective as the master clinician with years of experience. The weaknesses of this argument are evident. First, nearly all master practitioners still engage in the literature and are informed by science and their experience. However, the experience is critical in responding when what presents in therapy is not the typical, textbook client issue. When things do not go as they ought, this is when the expert clinician is able to adapt while the technician must consult more research, or maybe conduct more research. Clearly, most clients want the scientifically-informed expert over the scientifically-restricted therapist. 

History is an invaluable teacher. If we look to history to understand the current debate on outcome research, we can easily see the limitations, problems, and unfounded rhetoric in those who advocate for a narrowly-defined scientific approach. Even the narrow view of science should, and must, have a voice. But it should not be the only voice or the determinant of psychotherapy. EBPP at its best represents a truly rigorous and comprehensive evaluation of therapy outcomes. 

Why Diversity is Therapy's Strength: What the Outcome Debate

Many believe that it would make sense to have a unified psychology with all psychologists agreeing on pivotal issues. The APS position advocates this singular position should be determined by a narrow view of science. A number of limitations to this perspective demonstrate why this 'logic' does not fit psychology. 

First, psychology is not a pure science in the narrow sense of the term. Instead, psychology is based on a broader view of science similar to what was purported by Albert Einstein and William James. The non-scientists often idealize the degree of truth that can be attained in science; however, the true nature of science is progressive, recognizing the the belief in the attainment of truth is the greatest threat to true science. This was what Einstein and James believed. 

"The most beautiful thing we can experience is the mysterious. It is the source of all true art and all true science. He to whom this emotion is a stranger, who can no longer pause to wonder and stand in rapt awe, is as good as dead: his eyes are closed." ~ Albert Einstein

Einstein believed that science, much like religion, was best rooted in an appreciation of mystery and the limits of one's way of knowing. Science which no longer questions itself is a dangerous science. Much of psychology embraces this broad view of science. The only way for all of psychology to agree is to denounce mystery and have all psychologists embrace the same worldview. If this were to occur, psychology could no longer grow or develop; it would, because it could do no other, embrace the status quo and provide a solid barrier to progressive science. To tie this back to the outcome research controversy this series of blogs is about, what some associated with APS are promoting as science is, quite frankly, bad science. This is not because of poor research methodology and, for most of them, not due to bad intentions. Rather, this is due to a severely limited philosophy of science and a deficient understanding of the role of science. This narrow view of science serves social control, not progress. 

Second, these representatives of APS do not understand that psychology's diversity is its strength. They seem to hold this idealized vision of science, and psychology, as something that is purely objective and value free. Nothing could be further from the truth! Psychology is extraordinarily value laden. In arguing for a using a narrow view of science and extremely restricted epistemology for outcome research, they are implicitly stating that this value system is superior and all must fall in line with it. If not, there is something wrong. As Nietzsche would say,

"No shepherd and one herd! Everybody wants the same, everybody is the same: whoever feels different goes voluntarily to the madhouse." ~ Nietzsche

Psychotherapy clients have a broad, divergent set of values. For a psychologist to claim one approach to psychology and psychotherapy meets the highly diverse set of needs associated with these values is more than naive, it is ignorant. Similarly, the position advocated for by these individuals assumes that all want the same thing from psychotherapy, which, too, is dangerous. When one believes this, it gives them permission to impose a particular outcome upon their client; it allows them to impose their values on the client. 

When a client comes to me for therapy, the first thing I do is not consult a research-based matrix to determine which therapy is best for my client based upon gender, culture, and diagnosis. Instead, I inquire about their values, share some about my approach to therapy and other therapy alternatives, and then together with the client make the decision about if I am the right therapist. It is not that I reject science; instead, my approach to determining therapy fit is one rooted in deep appreciation for my client's value system. After we agree to work together, I draw heavily on science to inform my moment to moment decisions in therapy, but not to determine them. In my view, science should constantly inform clinical decisions making, but not determine them. 

Some advocating the APS position would say that I use clinical judgment over science. I am not sure if this is because they are uniformed, have trouble understanding the complex model many practitioners advocate for, or are using this simply as rhetoric and political leverage. I fear the later, but hope for one of the former. Instead, what I am advocating for is to use science and clinical judgment that is informed by science. Science and research is very involved in my moment to moment decision making process, but I do not allow myself to be blinded by the science or reduced to something akin to a computer, just allowing an unempathetic science to determine what I should do each moment.

In conclusion, the diversity of opinions and approaches to psychotherapy serves two main purposes relevant to this debate. First, it promotes a progressive view of science that allows for science to develop and grow instead of becoming stagnant. Second, it better allows therapy to meet the diverse needs and respect the diverse values of clients. 

What Consumers and Clinicians Should Know About the New Mental Health Controversy - Introduction

I'm guessing most people do not even know there is a new mental health controversy, yet for mental health consumers, this controversy could greatly change how psychotherapy is offered. A recent article in Newsweek even highlighted this. For many years, there has been a debate raging in the field of psychology about which approach to therapy is "the best." In response, many of us have argued that this debate makes little sense. There is good evidence from multiple sources that, with a few exceptions, all approaches to psychotherapy are effective; however, we didn't have the research to support it. Meanwhile, a number of individuals proclaimed that certain approaches to therapy were superior. Gradually, these individuals not only declared their approach was the best, but they tried to prevent others from practicing other approaches to psychotherapy. 

Then came Bruce Wampold and a host of other researchers who did very large studies examining all the research to date on psychotherapy effectiveness. The results were clear: all psychotherapies are equally effective in treating symptoms. Increasingly, the field of mental health, convinced by this research, began to change and become more accepting of the diverse approaches to psychotherapy that existed. 

Recently, the Association for Psychological Science (APS) came out with rhetoric a-blazin' declaring that psychology has lost its scientific roots and declaring a plan to restore the scientific basis of psychology and psychotherapy. In reality, even this statement is built upon a distorted view of history. So why should consumers care about this issue?? Here are just a few reasons:

1. If the APS approach becomes dominant, it would greatly restrict the consumer's choice in deciding which type of therapy they would prefer.
2. This approach suggests that science, not individual choice, should determine what outcomes are appropriate for therapy. 
3. It is possible that this would restrict the reasons why an individual could go to psychotherapy, making it difficult to seek treatment without having a diagnosed mental illness, which often comes with stigmatization. 
4. This could lead to greater restrictions on the number of therapy sessions consumers are allowed to seek. Recently, there has been a move toward more inclusive coverage of mental health; this could potentially be reversed leading to more restrictive coverage. 

The APS seems insistent not just on promoting a scientific approach to psychology, but declaring all other approaches to inferior, invalid, and possibly harmful to the general public. This is scientism that appears to be invoking a zealousness similar to religious extremists, instead of the temperament of science. In my view, it is the diversity of approaches to psychology that is our strength. It allows for us to honor various value systems, ways of knowing, and therapeutic approaches. To say there is only one appropriate route to mental health or only one appropriate understanding of mental health sounds like religious fundamentalism or extreme egoism, not science. 

My response will focus on several topics:

• Why diversity is psychology's strength
• A brief history of the examination of psychotherapy effectiveness
• A Response to APS Part 1: Research
• A Response to APS Part 2: Philosophical Issues
  
• A Response to APS Part 3: Rhetoric and the Marketing of One's Position
  
• A Response to APS Part 4: Diversity Implications
  

In closing, I must say that I am sad to be writing these blogs. For many years, I felt that the debate over "who's best" was a childish debate. Our time would be better spent focusing on working with individuals who are suffering or seeking growth, improving our current methods, and promoting conversations between different approaches so we could learn from each other. Instead, the building of egos appeared more important than the true mission of psychology and psychotherapy. This should be an embarrassment for the field. Yet, just when it appeared we were moving on, the childish ways return. Maybe some day psychologists will move beyond egotistical politics to focus on understanding the human condition and providing the service of compassion. 

Veterans Day Tribute: Understanding PTSD

This may seem like an odd way of paying tribute to our Veterans, to focus on PTSD; however, I hope that it quickly becomes evident how this is very much in the spirit of supporting our troops. 

Since the onset of the war on terror and the war in Iraq, I have been very disappointed what the idea of "supporting our troops" has sometimes meant. Soldiers were on extended tours, often under-equipped, frequently mistreated for acknowledging psychological distress, and not given adequate care when they were injured and no longer able to serve. Many soldiers were publically humiliated for acknowledging psychological problems resultant from their military service. Yet, for many, "supporting our troops" meant supporting the war, but not necessarily taking care of our troops. 

Posttraumatic stress disorder, or PTSD, plays a big role in the politics of supporting our troops. I am not a bit fan of diagnosis and believe mental health professionals should diagnose cautiously and only when necessary. Yet, I am very disturbed when mental health professionals in the military or professionals working with our troops and veterans in other contexts say they don't believe PTSD exists. These individuals are generally not engaging in the philosophical discussion on the nature of mental illness and diagnosis; they are discounting the suffering of the soldiers and, in essence, saying their problems is because they are weak. . 

Although PTSD is called a mental illness, the symptoms can really be understood as largely adaptive behaviors that have become maladaptive patterns once not longer in a combat setting. The symptoms of PTSD include 1) hypervigalence, or being excessively aware of one's surroundings, 2) exaggerated startled response, 3) poor trauma recall, 4) Intrusive thoughts and nightmares, and 5) avoidance of thoughts, feelings, people, and places that remind them of their traumatic experience. In this partial list, it is already evident that each of these symptoms can have a positive role in responding to a traumatic situation. Hypervigalence helped the soldiers survive when in combat through being attuned to the potential dangers in their surroundings. The exaggerated startle response is partially a learned behavior, but also serves to quickly activate the flight/fight response. Poor trauma recall helps individuals block out the bad experiences until they are in a place they can face them. The avoidance of reminders of past trauma serve a similar purpose. The nightmares and intrusive thoughts illustrate the other part of the paradox. Although it may be healthy to block out bad memories at times, it is also necessary to process them. Dreams often serve to help individuals process and consolidate memories; however, for many individuals with PTSD there is too much to process and the dreams become overwhelming. Some research suggests we dream more on vacations or other times when our unconscious recognizes we are in a safe and restful place that can allow the processing of the difficult information that had been contained in the unconscious. Therefore, dreams and intrusive thoughts can be a reminder that this information needs processing.

PTSD, then, can be seen as a natural response to a difficult situation; however, most people do not understand what PTSD is like or the purpose it serves. This includes many spouses who are bewildered when their spouse comes home a different person than when they left, or when they returned home without many problems after 1 or 2 tours, but after 3 tours begin showing PTSD symptoms. 

This is why we need to be very concerned when people use this diagnosis carelessly. Following the recent shootings at Fort Hood, many mental health professionals recklessly and irresponsibly began talking about the "likelihood" that Hasan, the shooter, suffered from PTSD without even gaining information about Hasan's background or direct exposure to combat or other trauma. Even though it is now understood that PTSD would not likely fit Hasan, the damage has been done. 

The message that this irresponsible use of invoking PTSD sends is that individuals with PTSD are dangerous. For individuals who know little about PTSD, this may cause them to fear people who have this diagnosis or, quite possibly, to fear people returning from the war in general. These veterans are often desparately in need of our love, support, and compassion, but irresponsible use of the label PTSD may instead cause people to fear and keep their distance from veterans. 

In truth, irritability and anger issues are connected with PTSD. However, it is a very small percentage of people with PTSD that become violent and, when it occurs, it is very rare for it to be something like what occurred at Fort Hood. When individuals with PTSD are violent, it is often connected with other issues - their own or systemic - that contribute to the violence. For example, many do not have adequate access to treatment. Many vets have repeatedly requested more frequent therapy sessions and other service options, but are told the services are not available because of the high demand. Others are concerned that if they seek treatment, this could jeopardize a promotion, their status in the military and ability to continue to serve, or are afraid they may be mistreated by peers or supervisors for admitting problems. Although many have sought treatment without these negative consequences, there are enough examples of this occurring to justify the concern. 

What, then, does it mean to "support our troops." I believe supporting our troops mean showing them the respect and compassion they deserve for choosing a career based in serving and protecting US citizens. One can do this with or without supporting war efforts, with or without agreeing with the decisions made by our politicians about when to use military action. Our soldiers are not given the choice about which wars or in which combat situations they will participate. They enlist to protect our country, period. They must put their trust in our leaders to make good decisions about when to put their lives at risk. It is dangerous to collapse the idea of supporting our troops into the notion of supporting our political leader's decisions to go to war. From the vets I have worked with, some believed in the war efforts and some did not. Many reported they felt they had to support and believe in the war efforts when there was the possibility of being deployed; it was dangerous to be considering if it was a just war when they had to make life or death decisions involving when to pull a trigger. Yet, when the possibility of deployment was over, they began having to reconcile their beliefs and values with what occurred. I cannot imagine how difficult this must be for our troops. 

To conclude, nothing I could say would adequately express the gratitude I have to our troops. I am angry about some decisions that have been made to put their lives at risk when I didn't feel it was warranted, but I also am glad I was not the person who had to make these incredibly tough decisions about when to use our military. It is not an easy decision either way. I am also angry that our troops have not always been given the resources they needed when deployed and that they sometimes have been mistreated and neglected when they returned home. But supporting our troops is not about politicians or politics, it is about supporting the people who have enlisted in armed services because they are committed to their country and protecting all of us. This, I hope, everyone can agree upon. 

Understanding the Fort Hood Shootings: An Existential Psychology Approach

The United States has suffered another great loss with two of our citizens opening fire on fellow citizens. In the aftermath, we see the beauty of concern and compassion for those who are suffering. We also see the media frenzy trying to understand what happened and why. Striving to make meaning from tragedy is a basic existential concern; however, we also need to take a close look at the process of how we make meaning, which is the concern of this blog post. 

Withing hours, we heard psychological diagnoses being made, sometimes with appropriate caution, sometimes recklessly by mental health professionals happy to be in the national spotlight. I am glad that the media seeks to interview mental health professionals and there is nothing wrong with responding to this request. However, it bothers me when these professionals sensationalize their responses in exchange for 10 seconds of fame. It is unethical to diagnose these individuals without having known them, having access to the records, and being able to see the behavior in context. When Hasan is given the label PTSD, all of a sudden the many wounded warriors who suffer from PTSD become a threat instead of something deserving compassion. Compassion is replaced with fear for too many. I plan to write more on PTSD tomorrow in honor of veterans day. For now, I just want to highlight how this diagnosis can be used inappropriately. 

We also heard of people focusing on the shooter's last name, Hasan, and speculation that this could be because of his last name. In both the Florida and Fort Hood shootings, much was made of their ethnicity. Lost in much if this discussion is the basic reality that no cultural group in history has engaged in more mass shootings of this type than the White male. Few talk much of the role of ethnicity when the White male kills, but much seems to be made when a White person is victim. The dominant culture seems to feel safer by distancing the perpetrator from their personal identities. 

We also can use a psychological understanding of the impact of trauma and other factors to analyze what may have occurred. In doing this, the responsible mental health professional should always emphasize that this is speculation that may have nothing to do with the actual cases. Personally, I think diagnosing does not help this process most of the time, but using psychological ideas that carry less discriminatory power can be helpful. 

Most of the attempts to understand events such as the Ft. Hood shooting focus on wanting to distance ourselves from the killer. We attempt to categorize, label, and discount the individual instead of understanding him or her (almost always him in this type of event). Instead, if we truly want to understand what has occurred, we must be able to take a more sympathetic view of the individual. I understand this is not an easy idea to consider. Shouldn’t we focus our compassionate energies on the victims and their families? Yes, absolutely. However, if we want to prevent such tragedies in the future, we must take the risk of empathetically trying to understand the shooter. This does not excuse the behavior. I must stress this: empathetic understanding does not excuse the treacherous acts committed by the individual, it simply brings understanding. As James F. T. Bugental once said, he was convinced that if he had the opportunity to work with Hitler in therapy, he was confident that underneath all the anger he would find a hurt, suffering individual. This does not excuse Hitler or the holocaust; it helps understand it.

I imagine things were not easy for Hasan. To be of Middle Eastern ethnicity in the military must be difficult. I have heard many soldiers express concern about their immediate negative reactions to anyone who Middle Eastern, despite not wanting this to be the case. This is learned behavior. When deployed in Iraq or Afghanistan, they had many bad experiences with people of Middle Eastern origin shooting at them, trying to kill them, or otherwise intending harm toward them. It is basic behaviorism – learned responses. There has been some reports that Hasan did experience some blatant racism and mistreatment because of his race.

Additionally, I am sure he experienced many microaggressions. Microaggressions are unintentional, often well-intended forms of racism. A common example is when an individual of a particular skin tone or cultural group is asked to speak for everyone who shares that identification, or when an individual from a minority group is told they are articulate when a person of majority speaking the same way would be perceived as speaking quite normally. For Hasan, I’m sure he heard many stories like I have heard, of soldiers who have returned and struggled with their reactions against individuals from the Middle East. Most of the time, these soldiers cognitively realize that there is no just reason for their negative view of individuals of Middle Eastern origins. They speak of this because they do not like that they have this reaction, not because they embrace it. However, it still can be hard to hear these comments and others feel their reactions are justified.

We also need to consider the concept of vicarious trauma. Surely, in Hasan’s role, he heard many horrific stories, as do all of us mental health workers who work with soldiers and veterans. These are hard to hear; they are painful. When I hear soldiers talk of accidently killing a civilian and their guilt associated with this, or stories of being haunted by watching a friend get violently killed right next to them, it hurts. It traumatizes me.  I am sure that Hasan, as a psychiatrist, heard these stories, too. It is not as traumatic as being there, experiencing the violence and death, but it is still traumatic.

Last, I think it is important to realize that mental health professionals are people, just like everyone. There are checks to try to make sure that people entering the field meet certain standards of mental health. Yet, some individuals make it into the field that should not. Others are psychologically healthy when entering the field, but because of life experiences become unhealthy over time. However, ALL mental health professionals have their own struggles and issues. This is part of the human condition. Furthermore, some of the individuals most recognized in the history of the field as exemplar therapists were individuals who struggled deeply with their own psychological problems. Carl Jung, Harry Stack Sullivan, and R. D. Langs are just a few examples. If our expectation for mental health professionals is to have no psychological problems, then we might as well close down the professional.

In conclusion, I do not know why Hasan committed the terrible acts he did and I believe he should be held fully accountable for them. Nothing excuses his behavior. However, I do want to know why he did these things beyond discounting him as evil or acts of mental illness. He was a person who did a horrible thing. Discounting him will not help me be a better person or psychologist, but understanding him, finding ways to be compassionate toward him while holding him accountable, may just help me become a better person and professional.

Existential Psychology and Religion: A Response

As an existential psychologist interested in religious and spiritual issues, I have heard many interesting comments from people who have been taught inaccuracies about existentialism. Often, these individuals have been taught to be fearful of it. For example, I had one student who, while on break, mentioned to their minister that they took a class on existential psychology with me and really enjoyed it. Her minister quickly informed her that existentialism is atheism and that I was probably secretly trying to persuade her away from her faith. She was warned to be weary of me (that pastor had never met me and knew nothing about me except I taught a class on existential psychology). The student obeyed for a while before sharing with me what her minister said. Gradually, she began to trust, at least to a degree, that I was "safe" and that I respected her beliefs, but she always seemed leery. 

Recently, there was an article published in a peer-reviewed professional psychology journal on integrating a religious perspective into existential psychology. At first, I was excited to read this article; however, I quickly became disappointed. The article, to be blunt, was poor scholarship that does not meet proper academic standards in addition to misrepresenting existential psychology. The only references to existential psychology within the last 30-years were to Yalom. There were also two references to Frankl within the last 30-years, but one was inaccurately cited (it was published much earlier) and the other was a publication after Frankl's death comprised of revised articles he had written and published much earlier. There was not a single reference anywhere in the article about the numerous contemporary perspectives on religious/spiritual issues in existential thought. The journal should have been responsible enough to find an existential scholar to review the article and any contemporary existential scholar easily would have pointed out the many problems in this article. 

Both humanistic and existential psychology have had similar problems. Seligman, in the article that is considered the birthing of positive psychology, drastically misrepresented and discounted humanistic psychology. Both humanistic and existential psychology are frequently misrepresented in undergraduate and even graduate psychology courses. . 

So why are these perspectives so misrepresented? Well, there are many reasons. The primary reason is that they have not had much of a popular voice in the past 20-years. This is beginning to change and the last several years has evidenced a resurgence of existential and humanistic psychology. Most of the critiques I have run into are not even familiar with the majority of major contributors to these fields, yet feel confident in their critique. There is also the problem of history. Many will cling to one or two historical representatives of existential psychology, or maybe even mix in 1 or 2 contemporary figures, and then use this as their view of existentialism. Existentialism is a broad, complex collection of perspectives that share some common values and beliefs; however, there is not full agreement on any one issue. 

When it comes to religion, there a many different perspectives. Still, when existentialism is talked about from religious leaders and scholars they draw almost exclusively on Nietzsche and Sartre, occasionally recognizing Kierkegaard as an existential thinker. Using Nietzsche and Sartre, and maybe Yalom as the recent journal article did, as representatives of existential thought, they will often present a case against existential thought that condemns it as anti-religion, excessively individualistic, and morally dangerous, possibly even the same as relativism. 

Religion, in my experience, has been the biggest culprit misrepresenting existential thought. This often is a fear-based response. An example can be drawn from the popular bumper sticker, "Nietzsche: 'God is dead.' God: 'Nietzsche is dead.'" I find this quite humorous as it really demonstrates a drastic misunderstanding of Nietzsche's point. Never did Nietzsche intend this to be a metaphysical statement about the reality of God. Indeed, this would make no sense as Nietzsche did not believe in God (Nietzsche was more of a non-believing agnostic than a true atheist). Instead, Nietzsche was really arguing that faith, or belief in God, was no longer impacting how Christians lived their lives. This critique is not far off from what often is said in the pulpits on Sunday morning. To put it in theological terms, Nietzsche was really saying that Christian faith was no longer producing works or that Christians were not living in accordance with their beliefs. Most voicing an objection to this statement of Nietzsche have never read more than "God is dead" from "Thus Spoke Zarathustra" and, if they have, they often read it too defensively to ever understand Nietzsche's point! 

I would like to address one last issue related to ethics, relativism, and guilt. In the journal article referenced, it was essentially claimed that existentialists have had nothing to say about guilt and no moral ground for ethics. There are many problems and inaccuracies in this statement, which deserve a blog on their own, but I will briefly clarify. First, it is quite audacious to claim that existentialists have nothing to say about guilt. In fact, I doubt that any psychological orientation has spent more time talking about guilt than existential psychology! There basis for this, however, is different than many traditional religious views. 

From an existential perspective, guilt and ethics do not have to do with some external set of rules. Instead, morality is rooted in our existence, in being human (in theological terms, this would be a form of natural theology). To appeal to a set of external, concrete rules can only limit ethics. Instead, existential thought appeals to a set of abstract principles that can only be applied in context. In other words, ethics is always an applied ethics from an existential perspective. We can talk about ethics and morality, but detached from a context, it is meaningless and primarily just an intellectual exercise. 

Let's take an example of the most frequently cited objection to this: 'Thou shall not kill.' Some will respond saying that existential thought is unable to make a moral statement about murder. This is not true. First, drawing on a natural ethics, or natural theology, there is a basic principle of respecting life and human dignity that is part of an existential morality. How, then, does this fit in a view that murder is wrong if there is a claim that ethics are always applied and contextually understood? As an example, most ethics systems allow for different interpretations of what murder is. We differentiate between 'involuntary manslaughter' and 'murder' in the United States. Also, we do not consider capital punishment murder, even though it is taking someone's life. In other countries, our stance on allowing capital punishment is a form of state sanctioned murder and morally wrong.

Let me now return to the problem of guilt. What is guilt from an existential perspective? Existentialists distinguish existential guilt from normal guilt and neurotic guilt. However, in essence, most or all forms of guilt are rooted in an existential guilt. Camus is the true genius when discussing guilt, although he addresses it more implicitly than explicitly. For Camus, guilt is part of the human condition: to be human is to be guilty. This, although rooted in a natural theology as opposed to many Christian perspectives, has many parallels to the idea of original sin. But Camus, in contrast to Sartre, did not have just a pessimistic view of human nature. In fact, it was this issue that caused his separation from Sartre and his resistance to being called an existentialist. Camus, as many existentialists do, believed that human limitation should be balanced with human potential. The theological parallel could be cited as Luther's idea of the sinner-saint (Indeed, it is quite evident to see the influences of Lutheranism throughout much of existential thought, particularly through the influences on Kierkegaard and Tillich, who had Lutheran ties). 

To conclude, existentialism in it many variations -- philosophy, psychology, theology, and the many variations within each of these -- has always had a complex relationship with religion. Increasingly today, existentialists seem to be very interested in religion/spirituality through addressing religious and spiritual issues; however, there also remain some existentialists who take a very negative view on religion. Yalom is maybe the best known representative of this view. To pit existentialism against religion, or to discount the significant work existentialism has done with religion and spirituality, is really misinformed and based upon a limited view of the existential literature. Instead, there is a exciting realm of scholarship addressing spiritual and religious issues in existential thought with a long history that continues through today. 

A Re-Awakening to the Humanistic and Existential Movement

In the little over 10-years that I have been studying, writing, and identifying with humanistic and existential psychology, I have often been told that these are dying areas of psychology and intellectual thought. I resisted, but often it seemed the evidence supported their statements. Still, I persisted and never believed they would die off, even if they may never again be popular. But the story is beginning to change and maybe, just maybe, 2009 will be a historical year in that change. 

I first heard of humanistic psychology in my undergraduate program when taking classes from Herman Glaess. Dr. Glaess had been part of the human potential movement and, in actuality, embodied humanistic psychology as much as he spoke of it. Maybe this was because it was a conservative Christian College and, as I would learn, humanistic was often seen as a "bad word." Later, I was exposed some to the existential writing of Paul Tillich, but the label "existential" was never associated with these ideas. In retrospect, I again wonder if it was because "existential" was too threatening. 

As I continued in my studies, I supplemented coursework through the University of Nebraska. In this secular setting I was told repeatedly that these were ways of the past and if I wanted to be part of the future of psychology, I should not consider these approaches. In class, Rogers and others were openly mocked and, as I would come to find out, misrepresented. When I entered graduate school, I had put aside these theories and opted for what I was told I should invest in: cognitive-behavioral psychology. 

Over half way through my program, my roommate talked me into taking an independent study with him on existential psychology. Finally, in the readings for this course, there was something that really excited me. I began to immerse myself in existential psychology, but soon found this was a lonely path. I left California, where I did my graduate studies, for Missouri freshly 'converted' to being an existential therapist. Although there were some in Missouri that knew of existential psychology, and even dabbled in it, I still felt very alone in this path. So I moved back to California, partly in search of colleagues and hopefully even mentors. I soon found that being an existential psychologist was pretty lonely anywhere you went, except maybe the San Francisco area. I hoped maybe to find a job there, but no luck. I did, however, find a training group in the San Francisco area with James Bugental and soon connected, too, with Kirk Schneider. 

Gradually, I started to connect with more and more individuals drawn to this movement. Most had similar experiences to my own -- a lonely professional journey. Yet, everywhere I went, it seemed there was always a group of students who quickly became excited about existential psychology. It seemed the potential for renewal, even if only in a small way, was possible. 

Well, 2009 seems to have brought about such a renewal! And it should not be surprising that two books published this year have the word "awakening" in the title. It seems that existential psychology has re-awakened from its slumber. Here are five "book"marks of the renewal:

• Existential Psychology East-West by Louis Hoffman, Mark Yang, Francis Kaklauskas, and Albert Chan (March 2009). 
• Awakening to Aging: Glimpsing the Gifts of Aging by Myrtle Heery & Gregg Richardson (September 2009) 
• Humanistic Psychology: A Clinical Manifesto by David N. Elkins (September 2009)
• Awakening to Awe: Personal Stories of Profound Transformation by Kirk J. Schneider (September 2009) 
• Existential-Humanistic Therapy by Kirk J. Schneider & Orah T. Krug (September 2009, copyright 2010)   

There are other signs of renewed vigor in this movement. Recently, the American Psychological Association produced two videos on existential psychology by Kirk Schneider. The leading therapy outcome researcher, Bruce Wampold, gave his endorsement of existential psychology in his review of Kirk J. Schneider's 2008 book, Existential-Integrative Psychotherapy: Guideposts to the Core of Practice. Also, there are increased training opportunities and conferences being regularly offered:

• Society for Humanistic Psychology (APA Division 32) - Annual Conference
• Existential-Humanistic Institute (EHI) - Annual Conference  
• International Network for Personal Meaning (INPN) - Bi-Annual Conference  
• Existential Psychology East-West Conference - Bi-Annual, first meeting April 2010 
• Unearthing the Moment - Retreat Style Training Offered through the International Institute for Humanistic Studies 

My draw to existential and humanistic psychology was not because it was popular. Instead, as I began reading about these approaches I felt as if I found something that resonated deeply with my soul, with who I was and who I wanted to be. I found my passion with it. I still believe this is an approach to psychology that can, and hopefully will, change the world. 

The Truth, Stories, and Compassion

 

My career path has allowed me to combine two of my great passions: ideas and compassion. As a professor, I get to teach. Yet, teaching is rather stale and boring if it is just the dissemination of ideas. Instead, I see teaching as being about the exchange of ideas, testing how they fit in different worldviews and realities. As a therapist, my job is to listen, care, and love. It’s all about relationship and compassion.

 

From a young age, I fell in love with stories. I grew up being drawn to Bruce Springsteen, Tracy Chapman, and Gordon Lightfoot – some of the great storytellers. I was always looking for the meaning embedded in the lyrics and the meaning always led me to relationships. It should not be much of a surprise that today I write and teach that the deepest meaning is always in relationships – relationships with people, with God, with nature.

 

In our culture today, if we look closely we can often see a raging debate about ethics and truth underlying public and political discourse that is often missed. It is a discourse that combines this interest in ideas and compassion, if understood broadly. To use an overgeneralization, two positions underlie many debates: the view in an objective truth beyond people and the view that truth can only be understood in relationships and particular contexts. I think there is some place for a middle ground here, but I will stick with the extremes for the moment.

 

The best example of an objective truth is often religion. In the West, Christianity has long been the dominant religion, so I will mainly use examples from Christianity. Many people interpret most religions as maintaining a set of governing rules or laws that are truth. However, secular interpretations also exist. In this perspective, the highest ethical and moral calling is to understand and live by this objective truth. Religious individuals purport that their foundation is revelation, but then they use a lot of reason and logic to extrapolate from these basic truths. Some have developed their ethical system to including this, such as saying reason is a gift from God, while others do not recognize or acknowledge the introduction of reason into their way of knowing.

 

My beliefs are much different. I see everything as context, so to speak. In other words, I do not believe it is possible to separate truth from the context, time in history, and the complex relational matrix in which truth must always exist. Let me try to use a few examples to explain this position. Most people have had the experience where they had “the facts” about a situation and pronounced a judgment on it. Later, they heard the stories of the people involved and it changed their entire understanding of “the facts.” Context changed their understanding. Similarly, many will acknowledge that killing being immoral is subject to context. For example, most will say murder is wrong, but may allow for the idea of a just war, killing in self-defense, or maybe capital punishment. Few are completely consistent in saying killing other people is wrong in all circumstances.

 

Now, let’s try a more concrete example. Joey came in filled with anger, yelling at his therapist. His therapist remained calm and focused on applying de-escalation techniques to calm Joey. It didn’t work and Joey stormed out of the office saying he would never return. At this point, most would say that Joey was in the wrong and the therapist in the right, but let’s go further. The week before, Joey, who is 24, said that he felt like harming his parents. The therapist, following the clear ethical and legal imperative of duty to warn, called the parents after the session to tell them Joey had thoughts of harming them and also let the police know. Joey was then hospitalized. According to the legal and ethical codes, the therapist acted within their bounds. An objective assessment again supports the position that the therapist was in the right.

 

However, Joey is a young man. It is not uncommon for young men to express anger saying, ‘I’m going to kill you/them.’ Oftentimes, they do not mean they are actually considering this, but are just using it as a way to express themselves. Joey was mad because the therapist, like his parents, didn’t listen to what he was really saying; they stopped at the surface, literal meaning. Had the therapist followed up with a question about if Joey was going to follow through on this, he would have said that he never considered acting upon it. Although a fairly simplistic example, and one that could have been avoided with many clinical strategies rooted in different ways of knowing, this is also a common example that I have seen many variations of in my career. In knowing the rest of the story, many would say that Joey had a right to be angry and quit therapy, and that the therapist did many things that were not good clinical strategies, even if falling within a strict interpretation of legal and ethical codes.

 

The story changes everything. In my life and career, I have listened to thousands of stories. When I try to make sense of them from some supposed objective systems, whether it is a psychological, ethical, or political system, I can generally always make sense of the situation. However, when I take this approach, I am almost always wrong. Conversely, when I try to understand the story in the person’s experience, a whole new world of understanding opens up for me. This is a compassionate truth, or relational truth.

 

Some would maintain that this does not fit with religion’s claim of objective truth. I would disagree. Instead, it changes the way this is understood. When teaching a course on the history and systems of psychology, in which we basically trace the history of thought in Western culture, I will often make the comment, “How would Christian theology be different today if we had not had 1850 years of theology dominated by a White male perspective?” Most have never thought of this before. The dominant White male view is one embedded in rationality and objectivity. Conversely, many other cultures and more feminine approaches often are more rooted in subjectivity and relational ways of knowing.

 

If a more feminine or relational way of knowing was brought to theology, it would shift the center. Instead of applying laws to understand how relationships ought to be, maybe would be using an understanding of relationships to interpret laws in context. Maybe correct application of the laws always would have to consider the relationship first and different applications would be more appropriate in different settings or relational contexts. In returning to the example of Christianity, how different would the Bible be understood if instead of searching for pure application of the laws of the Bible, a relational imperative was used to understand the truth in the Bible. This more feminine approach has been advocated for by many feminist and postmodern theologians. Some would call this relativism, but this is too superficial of a judgment. It is not saying that all truths are equal, the more common interpretation of relativism, but rather saying truth can only be understood in cultural and relational context. Truth is less rooted in specific, objective truths and more rooted in abstract principles that may require different application in different context.

 

Similar applications can be applied with politics. Conservative politics often functions from a foundation of objective truth. This objective truth is sometimes seen as being reflected in the constitution, while other times it may be rooted in religion or rationalism. The confidence in having attained some semblance of this truth is basis for much of the conservative political theory and decision making process. Conversely, liberals often are more interested in the experience of the individuals they are representing and believe that individual experience is a moral issue. So conservatives appeal to grand metanarratives, or claims of basic ethical truths across time, while liberals share the stories of people they have met.

 

The United States, being largely centrist and occasionally leaning right or left, often has a bit influence on the way politicians present themselves. Particularly during times when the country is leaning left, conservatives are more likely to appeal to personal stories (thus the birth of Joe the Plumber). Liberals, conversely, especially when the country is leaning right, need to make appeals to religion and to upholding the constitution. While some may attribute other causes for these differences, I would maintain much of it has to do with one’s view of the nature of truth – objective or subjective.

 

I should acknowledge that in order to communicate without heavily over-burdening language with exceptions, I have made some overgeneralizations and some things are overstated. I do recognize the exceptions – how else could I be a contextualist!

 

So why is this on an existential blog? Well, existentialism is rooted in phenomenology, a fancy word that refers to a way of knowing rooted in subjective experience. In my view, existentialism is very postmodern and connected with social constructivist perspectives. Although there are differences, between existentialism and postmodernism, they fit quite well.

Zhi Mian: Facing Life as It Is

Several years ago Xuefu Wang started the Zhi Mian Institute in Nanjing, China to provide therapy services and training. Zhi Mian essentially means "face to face" or "facing life as it is." The Zhi Mian Institute has enjoyed great success over time. I am not sure a clinic bearing a name with such a meaning would have the same success here in the United States. Maybe I am wrong, hopefully.

In my limited experiences in China, there seems to be great openness to existential ideas -- both in being open to existential psychology and in the sense of just generally being open to existential issues. Maybe this is because, as we often heard on our trips, the people of China has suffered greatly. In the United States, we often have the luxury of escaping the existential issues that people in other countries have to confront on a regular basis. But sometimes I wonder if such protection, such little suffering, is such a good thing. After all, a little suffering can be quite a blessing at times and we often need suffering to learn some of the most important lessons of life.

But let me take a minutes to diverge and talk about how few in the West seem to face existentialism as it is. But let me note, I am not promoting the idea that there should just be one approach to existentialism, but rather that I am concerned about some of the distortions I see how how existentialism is understood as represented in some unbalanced and uninformed perspectives.

Many seem to think of existentialism as referring to this rugged individualism in which one's responsibility is only to oneself. This defies the existential reality of relationship and our relational nature. It seems to me that many of these individuals are really trying to escape responsibility to others and escape the pains of relationship and commitment.

Others want to make the focus just on responsibility and choice. They emphasize our ability to change our life situation. However, they too often deny what Rollo May referred to as destiny. Destiny, in this sense, refers in large part to the limits on our freedom. This viewpoint is much easier to maintain when one has access to certain privileges. This is not so easy for the underprivileged and those who have many limits on their freedom. This can easily turn into blaming people for life situations they cannot control, a lack of empathy for the difficulty of  many life choices, and a lack of understanding of the contextual forces. This often also serves to devalue suffering -- the suffering person is seen as suffering because of their poor choices and the implicit is to "get over it."

Yet, there is an opposite misunderstanding of existentialism and the human condition. If you do a search for "existentialism" in many popular forums, especially those geared toward the youth, existentialism seems to be associated with idealizing suffering and the concept of meaningless. Existentialists are seen as people drawn toward depression and who seeking suffering. But seeing the possibilities in suffering and not pathologizing suffering is not the same as immersing oneself in suffering for the sake of suffering.

I don't think these three misunderstandings of existentialism really "face life as it is." Choice and freedom, furthermore, is limited when we do not honestly face life and the human condition. It is just as dangerous to deny our limits as it is to deny our freedom. It is just as dangerous to avoid suffering and life's dark realities as it is to over-identify with these. It is just as dangerous to deny our relational nature as it is to become lost in community or conformity.If life is suffering, life is also beautiful. Maybe the only unqualified thing we can really say about the human condition from an existential perspectives is that it is paradoxical.

Xuefu is an individual that I have come to greatly admire for his knowledge and wisdom as well as his character and integrity. He hopes that "Zhi Mian" becomes a phrase that is recognized in the English language. This post, in part, is doing my part in promoting that, but I wonder if people in the United States are really willing to face life as it is. As I spend more time abroad and with people from other cultures, it seems to me that we in the United States engage in a great deal of distortion -- in defense mechanisms of sort. Our priviledge allows us to do this. But I worry that the longer we hide behind comfort and the delusions of superiority that the more this sets us up for difficult times ahead. I think that our unwillingness to face life as it is conencts to the failures of our education system, our lack of valuing of mental health, and our blind servitude to money. We can't seem to see beyond ourselves. Zhi Mian is not just a personal imperitive, but a collective or cultural one. We ought not deny life as it is on any level.

Freedom and Responsibility Singapore Style: Paradoxical Lessons

Singapore is an amazing country. It very packed into a little space, yet rarely feels cramped or crowded. It relies on high rises and a concrete jungle to create space for living and business, yet it is remarkably green and tropical. It is one of the most technologically advanced countries in the world, yet one of the most environmentally friendly. It is amazingly multicultural with people from both the East and West, yet remarkably devoid of many racial tensions. It is also remarkably religiously diverse, yet few tensions over religious diversity.

It seems there is much the rest of the world could learn from Singapore. Still, it is not a utopia. The way they have accomplished this includes taking away some of the precious freedoms we love in the United States. There are strict quotas for where people live. There is greater regulation over many behaviors, including it being illegal to chew gum or eat/drink in some public places. There are challenges and limits to the ability to speak out against the government and it does not seem the elections are really free. Yet, there seems to be very little discontent, little poverty, and few drug problems.

I'm sure most who read this will not agree with what I say in the next couple of paragraphs. Many may be angered and accuse me of being unAmerican. Some may want to encourage me to move to Singapore. But I hope people can understand where I am coming from. I like democracy and greatly treasure being a US citizen, but part of the reason I treasure this is because I am allowed to be critical of it and I am allowed to play with ideas that many would consider "unAmerican."

I do not think we have arrived at the perfect form of government. Democracy, for all its wonders, is not perfect. This is extraordinarily evident with many of the problems we face today in America. It is important to remember that many of the founders considered American democracy to be an experiment. They did not think that we had arrived, or discovered any perfect form of government. They knew we had much to learn and would make many mistakes along the way. Many areas that are very important for the future of the United States and the world are areas where we are failing. In many of these very places Singapore is excelling. In addition to the many other areas already mentioned, Singapore is much better than America at providing health care to those who need it and values education on a national level much better than we do in the US.

So what can we learn from this, especially from an existential perspective? Even politically, freedom and responsibility are always connected. Freedom is also connected to risk. Greater freedom means greater risk. In the US we've been arguing and debating this greatly since 9/11, but often missing the existential level of the question. Instead, the debate has been placed on the realm of ideals. When talking about ideals, freedom will almost always win over risk. But this is not reality. Post 9/11 we've taken away a great many freedoms in the name of protecting freedom. Interestingly enough, it is the people who have taken away the freedom that most often engage in the rhetorical speeches about freedom while accusing their opponents of being haters of freedom. Paradox.

On the trip, my colleague Jim Ungvarsky, presented on self deception. In this presentation he used a quote that basically stated if you say something often enough you will come to believe it. Maybe we have done this in America. Maybe we have said that "America is the greatest country in the world" enough to not just believe this, but also to believe it so blindly that we are unable to see the value in alternative perspectives; that we are unable to learn from the successes of countries such as Singapore. When we say, "America is the greatest country in the world," I think we need to ask, "By who's standards?"

I value my freedoms and the freedom of speech in particular is very important to me. But I can also see the value in the form of government that exists in Singapore. I don't think I would function well as a Singapore citizen as I would get myself into too much trouble speaking my mind. I can visit here and "be good," but I don't think I could live this way. But yet I can honor those that see this as a pretty good life. And I think by many standards, Singapore could be in the running for "the greatest country in the world." It is done what few, if any, countries have been able to do on many social and environment issues.

Some may be muttering under their breath now, "Love it or leave it" -- an American phrase that couldn't be more in contradiction to the values on which America is based. But let us not forget, America has its coersion, too. I know many colleagues and friends who have had bad experiences from being accused of being "unAmerican" for exercising their very American right of free speech. Our coersion is not the same as Singapore, but instead is a different form of social coersion. When people do not agree with the dominant view of American culture, they are ostrecized, made uncomfortable in their jobs, given diagnoses or other derogatory labels, or maybe event removed from their jobs or social circles. As Chomsky once said, "Rhetoric to a democracy is what the military is to a dictatorship." In addition to rhetoric, I think we could also add social pressure. Yet, we, in America, are critical of the focus on social harmony and not allowing for disagreement that is prevalent in different ways in China and Singapore.

I think my biggest criticism of the US is that we are blinded to the paradoxes that we live with on a daily basis. We are great, but not so great. We do many things well, but we have much to learn from countries very different from us like China and Singapore. In China, many scholars and social researchers have pointed out that they have done more to alleviate poverty and improve the standard of living for more people in a short period of time than any country in history. This has been accomplished during a period of great social change, which you would think would be a challenge to such social progress. China, too, is not perfect, but no country is, not even the US. And China is doing some amazing things in areas we have failed.

The more I spend time in various places around the world, and expose my worldview to many different perspectives, the more I can see value in the many different perspectives and governmental experiments in existence around the world. If we could lay aside the adolescent talk about "who is the greatest," maybe we could learn from each other. Maybe we could have greater respect for our differences. I am not advocating that we ignore the atrocities occuring in places like the Sudan, but I am saying that we should be looking more to what others are doing right and trying to learn from them. We also need to be more honest about the decisions we are making.

Freedom comes with risk, and freedom comes with responsibility. To ask for anything else is to deny basic existential realities -- politically and personally. I have long advocated that Americans too often naively seek after freedom with out responsbility, but they also often seek freedom without risk. There is no such thing. Americans like to claim to live in the greatest country in the world -- again, there is no such thing in my mind. American may be great, but it also may be that the most threatening challenge to our greatness is our insistance of being the greatest. Once again, paradox.