Kavanaugh - Moving Forward Into the 90s With an Alternative to "Progress"
Moving Forward Into the 90s With an Alternative to "Progress" ©
by Patrick B. Kavanaugh, Ph.D.
With the declaration by the U.S. Congress that the '90s was the Decade of the Brain, psychology and psychoanalysis become more firmly situated in a culture of positivism; psychological understandings of people derived from a paradigm of biology, medicine, and the natural sciences; physiology underlies psychology and mind is a product of brain. Progress for the psychological community is defined as securing hospital and prescription privileges for the psychologist-psychoanalyst. Some of the far reaching implications for professional standards in the analytic community are considered. Moving Forward into the '90s with an Alternative to "Progress" consider a fundamentally different metaphysical position and paradigm for psychoanalysis, advances a psychological way of understanding people, and understands brain as a product of mind. From this perspective, the '90s are viewed as the Decade of the Mind... the U.S. Congress notwithstanding.
Psychologists currently see in their national professional publications an on-going debate which is giving final shape to the goals and objectives for the American Psychological Association's practice community for the 90s (see the APA Monitor's Letters: Opinions., Vol 21, No.7 - present). The three objectives with the highest priority for the 90s are: (1) Prescription privileges for psychologists; (2) hospital admitting privileges for psychologists; and (3) treatment of the "underserved," i.e., the chronically mentally ill and the elderly. "Making progress" in the 90s is for the clinical psychologist to be able to prescribe medications and to hospitalize. It is believed that it is necessary to achieve these objectives in order to treat those with "mental illness," most notably the "chronically mentally ill."
The attainment of prescription privileges has been described as the next logical and evolutionary step in the development of the profession of psychology as a science. Further, it has been argued that it would be unethical not to pursue prescription and admitting privileges. The reasoning is that not to pursue prescription privileges would be to needlessly prolong the suffering of patients, and not to pursue admitting privileges would be to abrogate one's professional responsibility to provide continuity of care. Indeed, given the social, political, and economic milieu of today's health care market place, such arguments can seem to be quite persuasive, if not compelling: More people could be seen less frequently for shorter periods of time. Thus, it is advanced, the psychologist with prescription and admitting privileges could provide services on a more cost-effective basis, which in and of itself would be seen as a progressive step into the 90s in that it would represent a further adaptation of psychology to the stated objectives of managed care.
The past president of the Division of Psychoanalysis (39) recently wrote in the Division's newsletter, quoting Richard Sterba, that the future of psychoanalysis rests with the psychologists (Vol. X, No. 4). If this, indeed, turns out be the case, then it seems that what is currently being heralded and advanced as "progress" for psychologists during this decade might carry considerable relevance for psychoanalysis as a way of thinking and as a treatment methodology in the years ahead. It would seem to be quite important to join this debate, and to actively call into question the first two objectives in this definition of "progress," Prescription privileges and hospital admitting privileges, which would include the hospitalization of individuals on an involuntary basis. This definition of "progress" would seem to require careful examination and consideration, since these proposed goals and objectives for the profession carry profound and far-reaching implications for all psychologists and, quite probably, for the future practice of psychoanalysis. Specifically, the achievement of these goals would eventually determine the "standards of training" in university doctoral and post-doctoral training programs, the "standards of practice" in clinical settings, and the "ethical standards of conduct" for members of the profession. The achievement of prescription privileges, in particular, would eventually determine and define what would represent the "treatment of choice" for particular behaviors or "diagnostic categories" of those individuals who consult with psychologists and/or psychoanalysts-not just those individuals identified as "chronically mentally ill."
During the 80s, the basic metaphysical position regarding the nature of people, which became prominent in guiding research and clinical practice, was that the ultimate nature of the human condition is be understood through biology, chemistry, and brain-behavior relationships. Biochemical imbalances, coupled with genetic factors, were believed to pre-dispose certain individuals to behave in certain abnormal ways--- diathesis-stress theory and position. During the past decade, behavior has subsequently become biologized, chemicalized, pathologized, and "medicalized." Each entity of behavior considered to be abnormal has come to be understood as a form of disease" or "mental illness." People and clinical phenomena have been conceptualized and explained in terms of chemical balances, aberrant synaptic firings, and defective cellular structures. Correspondingly, treatment has become more "medicalized" as certain behaviors have become more pathologized and "diseasified."
In July, 1989, President Bush signed legislation supported by the APA, declaring the 1990s to be the "Decade of the Brain." In July of 1990, the National Institute of Mental Health co-sponsored a two-day symposium, the topic of which was, "Frontiers in neuroscience and Brain Research." At this symposium, the neurosciences were proclaimed to be the basic sciences of mental illness; the goal of this, the "Decade of the Brain," was declared to be the gathering of more knowledge about the brain and the utilizing of that knowledge "...to find solutions to the major disorders and diseases that ravage the human brain." (APA Monitor, Vol. 20, No. 9, p. 8). The current, as well as the yet-to-be-discovered neuropharmaceuticals of the 90s were heralded to be the "treatment of choice" for these "disorders and diseases." This metaphysical position of a deficit-disease model not only holds that the "mind" is the product of the brain, it also holds that all behaviors that deviate from those which are acceptable are the actions of individuals who are in various stages of brain disease/dysfunction that is untreated, and that this is particularly true of the 'chronically mentally ill" individual.
It would seem that the formal adoption of this deficit-disease metaphysical position, by the profession of psychology through the securing of prescription privileges for psychologists, would involve the abandonment of a distinctly psychological way of understanding and working with people in exchange for a medical way of thinking about, understanding and working with individuals through biochemical technology. It would seem that the profession would also be formally adopting an implicit "clinical attitude" and "view of treatment," especially regarding the purpose and goals of treatment with adults who have been identified as "chronically mentally ill." This clinical attitude, view of treatment, and understanding of the purpose and goals of treatment might be something like the following:
One's view of the "chronically mentally ill" adult would be constructed around the idea that this individual is a helpless, passive victim---indeed, the victim of a disease process which is biochemically based. There follows from this conceptualization a "clinical attitude" that includes a number of basic elements: The individual is viewed as not being responsible for his/her behaviors, nor for the consequences of these behaviors. The individual is presumed to be incompetent, either due to history of hospitalizations or by virtue of the diagnosis itself, to make decisions about his/her life, and to live his/her life as he/she might choose.
The therapist who conceptualizes from this metaphysical position has two major functions in meeting with the patient: (1) Since the causative factors of psychosis/mental illness are understood to be biochemical, then the primary purpose in meeting with a patient is to monitor his/her medications and to persuasively maintain the patient's compliance with the treatment regimen; and (2) to monitor the patient's behavior, and to protect the patient from him/herself as well as to protect society at large from the patient.
In many ways the primary therapist is expected to function in loco parentis, that is, to take the place of the parent in doing for, making decisions for, or intervening for an individual presumed to be incompetent to do so for him/herself The central goal and purpose of treatment, then, is to ensure that the patient takes his/her medication; the central goals and purposes of psychological treatment are to reduce environmental stress, and "to improve reality testing" by selectively providing support and a "reality check" for the patient.
This view of the patient, these clinical attitudes, and this view of the nature and purpose of treatment with the "chronically mentally ill" individual are currently the most prevalent clinical attitudes and views held in the professional community. This, or some variation thereof, is what the profession of psychology would be making foundational in its conceptualizations and clinical practice, through success in the pursuit of prescription privileges and the formal adoption of this biochemical metaphysical position.
There is one final consideration related to one's clinical attitude and view of the purpose of treatment which derives from the psychologist/psychoanalyst's functioning within the larger social milieu. Within the larger social context, the philosophical point of view has been emerging in recent years that the community has a supraordinate position vis-a-vis the individual. Traditionally, there has been a struggle to maintain the equilibrium of tension between the rights and needs of society on the one hand and the rights and needs of the individual on the other. Recent years, however, have witnessed the swinging of the pendulum toward the rights of society, with a corresponding erosion of the individual's rights. Put another way, the rights of society have taken precedence over those of the individual, with society seeking the compliance and conformity of the individual to certain of its standards and norms. "Progress" for the profession of psychology during the 90s seems to speak to the same kind of tyranny of the majority over the individual, in that individual differences in behavior and thinking are not viewed as individual issues, but rather as legitimate concerns of society, and as such, are to be "treated" and "corrected."
With the formal adoption of the proposed deficit-disease model, the psychologist and the psychoanalyst move ever closer to taking on the role, in their minds, of becoming agents of society, as contrasted with being agents of the therapy. As an agent of society, the practitioner takes on a number of "therapeutic responsibilities" having to do with his/her patients' actions, behaviors, and thinking. These assigned responsibilities are applicable to all individuals who might seek consultation, but they are particularly apparent in the case of treatment with the individual identified as "chronically mentally ill." These therapeutic responsibilities are organized around the idea that the therapist is first and foremost a representative of society in the treatment. As such, one of the therapist's primary responsibilities is to organize the goals of treatment around the expectations of society as to what constitutes "normal" and acceptable behavior and thinking. Thus, the therapist is there to monitor, and to seek the patient's compliance and conformity with the requirements and standards that society holds out as being appropriate and acceptable in terms of how one acts and behaves. Within this milieu and context, the therapist is increasingly being held responsible to protect the patient, and to protect society from the patient's actions and behaviors. We currently see these responsibilities of the psychologist/psychoanalyst defined in the proliferation of legislatively-enacted "duties to warn" and "duties to protect."
From this biochemical metaphysical position, one's therapeutic responsibility also includes seeking the patient's compliance and conformity in how he/she thinks with society's standards of "normal thinking." Psychological treatment, then, has as one of its primary objectives the achievement of just such compliance and conformity with medication regimens and treatment plans, which invariably have as their stated purpose and goals the ability to change the patient's behavior, and/or to improve his/her reality testing. Those very characteristics with which most individuals present when seeking treatment are characteristics that are philosophically unacceptable to society at large. This is particularly true with the "chronically mentally ill" individual for whom expressions of noncompliance and nonconformity in thought, action, and deed have become pathologized. The metaphor of the "disease" of social noncompliance has undergone a process of reification, which has literalized the metaphor into a physical disease that now, it is believed, can be treated with chemicals. To the list of the various "duties" which spring from this deficit-disease biochemical position, one can anticipate if the individual is not "thinking normally", the "duty to hospitalize on an involuntary basis" and the "duty to medicate" emerging on the horizon in the not-too-distant future to join the other duties and responsibilities of the psychologist/psychoanalyst.
With the adoption of this metaphysical position as the basis for "progress" during the next decade, the profession goes far beyond being concerned with the functioning of the individual as an individual, and moves to how well that individual functions and adapts to the acceptable standards of thought and action in society. From this metaphysical position, treatment then has as its purpose the perhaps gentle and tactful, but nonetheless coercive and insistent, attempt to engender the compliance of the individual with the standards and expectations of society. It attempts to promote: (1) A reliance upon and conformity with the norms of society; (2) a dependency upon the collective; and (3) an acceptance of one's proper place in society, which has been determined in advance by one's diagnosis and set forth in a treatment plan. The question that remains to be addressed is "Is this the benefit or the price of ‘progress’?"
Moving forward into the 90s with an alternative to this definition of "progress" would involve moving forward from a fundamentally different metaphysical position regarding people and human behavior. There are at least two alternatives that could be proposed and considered as alternatives to the biochemical metaphysical position.
The first alternative to "progress" would be to continue to further the development of a psychological metaphysical position in working with people. This psychological alternative to the biochemical model would be based upon a psychological way of conceptualizing and attempting to understand human behavior. It represents a fundamentally different way of thinking about human behavior, and thus it would carry with it different implications regarding one's "clinical attitude" and "treatment." This contrasting metaphysical position would maintain that the ultimate nature of people is "something more"---something more than that which can be chemicalized, biologized, or even "scientifically" measured and calculated. One can, indeed, dissect the brain, understand its cellular structures and chemistry, and attempt to understand brain function and/or brain behavior relations. However, this is not the same as attempting to understand a person, with all the intricacies and complexities of the human experience. Currently, there are many different psychological theories and ways of thinking about the human condition that attempt to understand this "something more". An example of one such psychological theory would be that of a psychological conflict model, wherein all behavior would be viewed as the consequence of internal conflict and conflict resolution, even those very human experiences that are found in the psychoses.
This psychological model of the mind, conflict, and conflict resolution, would include at the very least several basic ideas regarding people: that all behavior has idiosyncratic meaning, purpose, and intentionality; that all behavior is related in a quite meaningful way to the individual's past experiences; that all behavior is quite adaptive, i.e., adaptive to that which is internal for the individual; that all behavior is the consequence of a complex compromising of various internal psychic actions and images; and that all behavior is in the service of expressing, protecting, and communicating various aspects of that individual, albeit aspects about which the individual might not be consciously aware. As such, all behavior can be viewed as representing, and as having many different experiential significances and meanings all at the same time. Finally, this model would hold that certain aspects of the individual are communicated in disguised representational ways that are of major importance in the attempt to understand a particular individual. Psychosis would be conceptualized, as would all behavior, as the consequence of a continuous interaction of internal psychodynamic processes, an intricate complex of compromise formations with a multiplicity of meanings and significances. Psychosis would be seen as serving a very necessary and adaptive purpose for the individual. The individual, in the service of this adaption to certain internal and contradictory conflictual experiences and images of self and others, attempts to protect him/herself from certain feared consequences, and in the very way of protecting him/herself also expresses that which is of major concern and distress. From this perspective psychotic symptoms are viewed as having great specificity, and as having exquisitely delicate precision, purpose, and meaning. Psychosis has both rhyme and reason. Psychotic symptoms could be viewed as a different form of thinking---in a sense, as a language substitute which would have its defensive, expressive, and communicative aspects. From this metaphysical position psychosis is understandable, and can he worked with interpretively by the therapist.
The further development of a psychological way of conceptualizing and attempting to understand behavior might receive a noteworthy contribution from an unexpected source, if psychology were to consider moving forward into the 90s by returning to its philosophic past. That is, psychology might do well to attempt to integrate contributions from philosophy with a revision of what currently is considered to be "scientific methodology." Psychology long ago left philosophy and joined the natural sciences. In doing so, it also adopted the methodology of the natural sciences, the experimental method. With this adoption of scientific methodology, it dropped and dismissed its interest and concern with problems of a philosophical nature, since they were considered to be "not scientific". However, as suggested by Eacker (1975), there are some very fundamental aspects of human behavior and experiences that simply do not lend themselves to experimental investigations, inquiries, and the methodology of the natural sciences.
For example, since so much of clinical functioning as a psychologist and as a psychoanalyst has to do with the concept of "reality," as in transference, countertransference, and reality testing, then one's view and understanding as to the nature of "reality" could have far-reaching implications for one's clinical work. Philosophy might make a contribution to this consideration as to the nature of "reality." There are two positions regarding the nature of reality that could be briefly considered, realism and phenomenalism. Each of these positions carries with it a different set of implications for the clinical situation, and for treatment of the individual identified as "chronically mentally ill." Indeed, to adopt one or the other of these two positions regarding the nature of reality would influence, if not determine, who would be seen in treatment, the very purpose one would have in meeting with the person, the goals in treatment, one's theoretical conceptualizations and clinical formulations, one's technique and interactive, if not interpretive, style and focus---indeed, what would even be considered to be clinical material itself.
The uncritical realist (realism), according to Eacker (1975), would hold that "reality" objectively and independently exists; it is obvious and self-evident: Indeed, for the realist, it is idle philosophizing to even question the nature of "reality". There is a factual world that exists independently of any observer---that's a fact! It is this world of indisputable and objective reality that the uncritical realist believes to be revealed through the application of the methodology of science. Truth is that which is revealed through science and the experimental method. With this understanding of "reality", certain of the therapist's responsibilities then become centered around the individual's current adaptation to this objective, independently-existing and verifiable world. The therapist, by virtue of being a therapist (assuming that it is a virtue), is presumed to be the authoritative representative of this objective "reality", i.e., the world as it "really is." From this metaphysical position the mind is a product of the brain. With this understanding as to the nature of reality, one's view of the "chronically mentally ill" individual, clinical attitude, and the nature and purpose of treatment are quite conceptually compatible with those that derive from the biochemical position considered earlier in the paper.
The phenomenalist (phenomenalism), according to Eacker (1975), would hold that "reality" is whatever it is that occurs when the senses experience. Reality is whatever the sense experiences reveal it to be. The phenomenalist does not assert that a real, objective world exists, with real objects and events taking place in it in the past or in the present. The phenomenalist simply asserts that what is known is sense experience. According to the phenomenalist, the world is constructed out of one's own sense experience of that world. Truth is whatever it is perceived to be by the perceiver; reality is always and only in the eye of the beholder. From this metaphysical position one could consider that the brain is a product of the mind. The phenomenalist's view of the patient, clinical attitude, and view as to the nature and purpose of treatment, are conceptually quite antagonistic to those that derive from the biochemical position. Indeed, this view of the nature of "reality," in conjunction with a conflict-conflict resolution theoretical position, introduces some quite far-reaching implications in terms of one's clinical attitude and the purpose of treatment in working with the "chronically mentally ill" individual.
With regards to clinical attitude: It quickly becomes apparent that a major aspect or element of one's "clinical attitude" is that one is not working with someone who is "mentally ill"---not even a "little bit mentally ill," much less "chronically mentally ill"---one is not even conceptualizing or thinking in terms of disease and illness. One is conceptualizing in terms of internal conflict and conflict resolution, with the individual being seen first and foremost as a person who is not only a co-participant in the treatment, but also as an individual who makes decisions affecting his/her own life. These decisions include ones that the therapist might not have made if he/she were in a similar situation, or might not be in agreement with, i.e., to take or not to take medication, or to come to, or not to come to, treatment. It is not the responsibility of the therapist to get the patient to conform nor to comply with society's standards and/or norms of behaviors or of thinking, nor to get the patient to conform to the much more subtle operative expectations of meeting certain theoretically anticipated outcomes of the treatment, such as "improved reality testing," nor to get the patient back onto a particular developmental track, nor to get him/her to give up a particular behavior or fantasy.
One's clinical attitude might begin to encompass some very central and basic ideas, for example, that the individual is not a helpless passive victim of the dreaded disease "psychosis." Rather, the individual might be come to be viewed as quite actively organizing the world around him/herself in orchestration with certain prevailing internal experiences. Indeed, there is both rhyme and reason. One might even begin to view the individual as both a master and as a teacher---a master of metaphor and symbolic representation, a teacher not only teaching the therapist about some of the various meanings and significances which go to make up the patient's world, but also teaching the therapist the best way for the therapist to teach the patient about that internal world. One might begin to view the person as an individual whose psychotic language is indeed different from what one might be accustomed to hearing. One might begin to consider that psychotic language is as sophisticated and as complex in its intricacies of meaning, idiom, nuance, and even humor, as is any other sophisticated language having its own rules of syntax and grammar. If one were to begin to accept the inner premises by which the individual organizes his/her world without regard for how things "should be," then there is a different purpose in meeting with the individual than the uncritical realist would have.
Purpose in meeting and the therapeutic task: The phenomenalist would not be there to correct the patient's perception nor to improve the patient's "reality testing." There is nothing to "correct" or to "improve." Reality is in the eye of the beholder. The only "reality" of any concern in the treatment hour is the patient's psychic reality, or (perhaps more accurately stated): the therapist's psychic reality of the patient's psychic reality. The therapist is there to attempt to see and understand how the individual sees and experiences the world, and to try to understand why it perceived in whatever particular way it is perceived; and to attempt to understand the individual's world of unconscious experience, of action and consequence that might seem to be so different from, and contrary to, one's conscious experience of intent and consensual meaning. The only purpose and goal of treatment, then, is to understand the patient's thoughts and communications; simply to attempt to understand "what is" and "why it might be" without regard or concern for what "should be," and to attempt to communicate that understanding to the patient in the most meaningful way possible. This would be the only goal and purpose of treatment in meeting and working with those individuals who have been identified as "chronically mentally ill"---nothing more. The therapist has no other therapeutic ambition or intent. A psychological way of thinking and working with people such as that just described would represent a viable alternative to obtaining prescription privileges and admitting privileges as prerequisites for working with those identified as the "chronically mentally ill."
A second, but no less seriously intended, alternative to "progress" would go much further than simply suggesting a psychological way of conceptualizing and working with the individuals identified as "chronically mentally ill." This second alternative is that psychology, as well as psychoanalysis, reconsider and rethink the whole idea of having allied themselves with the health care professions. Over the years, the close identification of psychology and psychoanalysis with the "health care professions" has led to the rather wholesale adoption and transposition of certain medical concepts and ways of thinking, and of values and attitudes towards issues and processes that are uniquely and distinctly psychological. While proceeding from the premise of disease and health might be quite appropriate for understanding and treating the physical diseases, it is quite inappropriate for understanding psychic functioning and psychic reality. This second alternative would involve stepping away from a very comfortable and familiar conceptual framework that is provided by the metaphors of disease, treatment, and cure. This second alternative would be to consider, and to adopt, a new metaphor that would be closer to, and more reflective of, psychology's philosophical beginnings.
It is certainly recognized that the therapeutic reliance upon a psychological position, such as a phenomenalistic conflict position, in one's clinical work lacks the authoritative certitude that accompanies the biochemical deficit-disease position. Furthermore, it involves the therapist's willingness to exist in a state of not knowing---a relatively continuous state of uncertainty. It also involves the willingness of the therapist to be involved in a continuing process of questioning his/her own cherished beliefs, attitudes, values, and their own foregone conclusions, which would include the questioning of one's "theoretically reality". The alternative, however, would be to continue to wrap psychology and psychoanalysis in the cloak of medicine and a disease-deficit model, which might provide this longed-for authorative certitude, and might also meet certain social, political, status- and power-oriented, and economic objectives for the profession, but, it would seem, at a tremendous cost to the public and thus, ultimately, to the profession itself.
Psychology has reached a critical juncture in its evolution as a profession, as it prepares to move forward into the 90s. The major issue to be considered is not the merits of a conflict resolution point of view as an alternative to the merits of attaining prescription privileges. The major issue to be considered is the viability of metaphysical positions, biochemical or psychological, and the impact of each upon the future course and evolution of the profession of psychology and the practice of psychoanalysis. The metaphysical position from which one proceeds is the difference between the declaration of the 90s as the "Decade of the Brain," with the focus of inquiry upon brain-behavior relationships, with future courses in pre- and post-doctoral training programs centered around the study of psychopharmacology and neuropharmaceuticals, and the methods of treatment being further developed within a medical conceptual framework---OR---the declaration of the 90s as the "Decade of the Mind," with the focus of inquiry upon the intricacies of the person and motivational causalities, with future courses in pre- and post-doctoral training programs centered around the study of philosophy, poetry, and psychology, and the methodology of treatment being further developed within a psychological, conceptual framework.
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Dr. Kavanaugh received his doctorate in philosophy (psychology) from the University of Windsor in Ontario, Canada. Since the completion of his doctoral studies, he has been active in the academic, organizational, and practice areas of the psychoanalytic-psychological community. In the academic area, he has served as Director of Clinical Training and member of the core teaching and supervisory faculty in the doctoral program in psychoanalytic psychology at the University of Detroit; as a member of the teaching and supervisory faculty in the Program for Advanced Studies in Psychoanalysis in Wyandotte, Michigan, an interdisciplinary program for the study of the analytic discourse; and, as a member of the teaching and supervisory faculty in the pre-and post doctoral educational programs at the Detroit Psychiatric Institute, the Wyandotte General Hospital, and the V.A. Medical Center in Detroit. In the organizational area, he is the founding and current president of the Academy for the Study of the Psychoanalytic Arts; past president of the International Federation for Psychoanalytic Education; the Michigan Psychological Association, and the Michigan Society of Clinical Psychologists. In the practice area, many of his professional interests during the past 35 years are directly related to experiences in the discourses of various residential treatment facilities.
Dr. Kavanaugh is a recipient of The Distinguished Psychologist Award from the Michigan Psychological Association and the Master Lecturer Award from the doctoral students at the University of Detroit.
Currently Dr. Kavanaugh is in the private practice of psychoanalysis in Farmington Hills, Michigan:
Office: 31805 Middlebelt, Suite #305
Farmington Hills, Michigan, USA 48334
Phone: (248) 626-6460
Fax: (248) 626-4808