Hi, I'm 26M. I am a "certified and registered" medical assistant (CRMA) since 2019 [pro tip, there is no difference between CMA and RMA, its literally the same]. I am certified and registered by the American Medical Technologists (AMT). I have always been fascinated by medicine. I was a very young child when I first got hooked, I have been seen every corner of medicine ever since. As it turns out, I'm pretty damn good in the field. I worked on this useless certification since before I was 18. In 2016, I graduated high-school and was a duel enrollment student my senior year. I went to my local community college during duel enrollment and was convinced by my superiors at the time that becoming a CMA was a great way to go.
I was told that by becoming a CRMA I would have bettehigher annual pay rates and higher probability of being hired for jobs. I was told that the credits I would obtain at my community college for this certification would be a great addition to many health related bachelor majors like Pre-Med and RN programs. Even contribute to a faster graduation much "like an associates". Only that I wouldn't have an associates which wouldn't be very "applicable" to the real world after graduation unless I continue to a bachelors. But a certification to get a "large head start".
Jesus fucking Christ, head start this, head start that, benefits here, benefits there. God, I want to vomit just listening to myself regurgitate all these words of affirmation said to me. Over the coarse of nearly 5 YEARS I am here to tell you that NOTHING of what I was assured or told was true.
Now here is the reality of what you will discover, post-covid, what being a CRMA really does for you.
- A CRMA certification grants you NO competitive benefits and NO reasonably competitive annual pay compared to anyone who gets hired with out a CRMA certification.
Literally no Benefits, none. I have been the lowest annually paid Technician, Medical Technician, Mental Health Technician, for EVERY JOB I EVER OBTAINED and WITH my CRMA certification. I worked at many extremely well known medical institutions from Childrens psychiatric residential care hospitals to where I am now working at one of the greatest health care institutions IN THE FUCKING COUNTRY of the USA and I am STILL one of the lowest paid compared to the majority of my fellow technicians. I currently get paid $18.20 an hour in one of the most expensive areas on the east coast. My co-workers laughed at me and then showed me their pay stubs at $24-26 per hour pay FOR THE SAME JOB. Then new hires that came after me getting $22 FOR THE SAME JOB, NO CRMA CERTIFICATION, NO BACHELORS, NOTHING. Yeah. Oh and good luck making that case to your manager. Getting any kind of raise is next to impossible no matter how long you work or how hard you work or how well you work at your position.
- A CRMA certification today will LESSEN your chances of being hired.
Yup, you heard it here first folks. Obtaining your CRMA certification means that you are of a higher education standard and can handle higher responsibilities, conduct more hands on care with patients, and even more universal in the world of medicine assistants for all kinds of levels of care. Yeaaahhh well after covid, that means that any and all health care networks are going to essentially hire anyone else to do those jobs. Qualified or not. According to my past managers, Nursing managers, and most business sides of health care networks, medical assistants have low level qualifications, little education, or education needs to even just become a CRMA. Furthermore, less urgent responsibilities, I guess? I was just doing CPR on a man in a 30 min code sweating my dick off but sure, I guess not. This means that from the business end perspective they don't need someone with higher qualifications to do the same job. It's simple economics. Why pay someone with proper qualifications $35-40,000 when you can choose the less qualified, less trained, and less educated person for $20-25,000 annually and still obtain the same results within a certain field of practice. It's the quantity over quality kind of mentality. Over my many years I have seen so many unqualified, uneducated, and relentlessly lazy individuals work beside me completely unaware of their responsibilities on the floors of the hospital. You WILL experience these people as your co-workers, guaranteed, now days more than ever.
- CRMA CERTIFICATION CLASSES DO NOT CONTRIBUTE JACK SHIT TO A BACHELORS
After all was said and done and I "graduated" (I guess..) from my community college I went on to my bachelors only to find out that 90% OF MY CREDITS I TOOK AT COMMUNITY COLLEGE WERE NOT APPLICIBLE. Literally 90%, I essentially was 21 starting at my 4 year university and at ground zero with barely anything to show for my efforts to get this CRMA certification. Then covid hit, everyone had to go home, and that really messed everything up. I couldn't focus at home and my grades started to tank due to my really awful home situation but I'm not here to talk about that. So I decided to take a gap year to get a night shift Technician job back at home as a float technician. Never the less, in academia I was majorly behind. Yes Yes Yes, I know. Life is not a race, it's a journey. Some of us struggle more than others. However, here I am at 26, I need to work to pay for an apartment (which I can barely pay for because I'm just a tech in a really expensive area), I need to stand on my own 2 feet, I need to pay for my car and car insurance, I need my own health insurance as per required by the state, and I'm LITERALLY JUST A JUNIOR AFTER ALL THIS TIME. I'm part time in school now so I don't burn myself out working and going to school (tried that, nearly 2 years of my life 7 days a week, no sleeping in, no breaks, fall-winter-spring-summer, just to try and catch up and I will never do that again.). So, at the part time pace I'm going I will graduate 3 years or more from now if I don't go full time literally NOW. I WILL BE BASICALLY 30.... If I do go full time in school I'll be able to graduate in about 3 semesters, I have no idea how I'll be able to financially do that even with loans.
- YOU WILL BE EXPOSED TO INTENSE, HARSH, HAZERDOUS, PHYSICAL, EMOTIONAL, AND MENTAL EXTREMES INVOLVING YOUR PATIENTS ALONG SIDE YOUR NURSES AND DOCTORS.
I have worked before, during, and after the worst of what covid-19 had to throw at us on Emergency department (ER), Intensive care, Progressive care, Medical-surgical care, Post Anesthesia care, Observation, hospice, and psychiatric care units/floors/facilities. I have seen families and children watch me as I do CPR on their Father before being shooed away so they aren't scarred for the rest of their life. I was forced to be sat on 1:1's with fully grown men with biceps the size of my face with the body build of a line backer having explosive and uncontrollable manic episodes, convincing themself that us health care workers were human traffickers, and somehow after hours of screaming what I can only describe as absolute madness, have the strength to bend the metal his restraints were tied too. I am 6'2", 220 lbs, consistently go to the gym and play lacrosse the majority of my life and for a moment I wondered if that was going to be my day. Furthermore, later in the day meeting said manic patients wife, I couldn't help but notice the bruises all over her face, her arms, legs, chest... everywhere.
I have witnessed patients with HSV-1 (facial/oral herpes), HSV-2 (Genital herpes) and HIV/AIDS fling various bodily fluids such as blood, spit, urine, excrement, and even ejaculate attempting infect someone with malicious intent. I had one patient admit that they tried to infect another purposefully because they didn't want to feel so alone. Patients will try to get to know you, you're going to be the one they probably see first or most through out the day when they use their call bell. Mostly, they'll want to have normal chit chat in normal ways but there is always that 1 or 2 with other intentions. I have my last name covered on my hospital ID because I WAS FOLLOWED. I am 26M, and all it took was some good and casual conversation talking about ourselves and our lives. I like to talk to my patients and get to know them so they know that I do care about their well being. Obviously, I'm not about to talk about crazy personal details of my life, separation of church and state n all that but that's all it took. Sad to say but even some of the insane have somewhat decent communication skills. A 12 hour shift and some conversation through out one shift, that's really all it takes. That was just one instance, my co-workers (the majority are female) have to many to keep tally.
You will encounter patients who are uncontrollably releasing their bowels and YOU are the one that needs to clean that up. House keeping isn't around the corner all the time and bleach wipes are there for a reason. You will encounter ALL bodily fluids on walls, floors, sinks, tables, chairs, beds, cabinets, and even on the ceiling (rare but yeah). You will be most likely responsible for your patients daily hygiene, dental, denture care, and shaving. If a patient is incapable of wiping after they released their bowls, and yes sometimes a little to early, got poop on themselves, their gown, socks, and down their leg... yup you guessed it, YOU gotta clean it up and in some cases re-wash the patient entirely. Most cases, your nurse or any help from fellow techs will be somewhere else probably dealing with another mess. Personal hygiene is ABSOLUTELY IMPORTANT for a patients health care while they are in your care. It's been proven that daily hygiene being done accelerates patient discharge rates. It matters. Which is why our position matters. If we don't wash our patients on a daily basis they will be more susceptible to infections and diseases. Especially if the patient is already immunocompromised. Depending on what unit you will be working on. You will also likely be responsible for checking equipment, making sure equipment is up to date, doing quality checks on defibrillators, refrigerators, and various other equipment that your unit uses every single day and for multiple times a day. I once witnessed two nurses go feral over a bladder scanner, I already bladder scanned both their patients by that time, both patients were fine. I could rant for an unfathomable amount of time about this position and all the essential things that we must do and provide with quality care and consistent accuracy. Don't get me started on Vaccinations at urgent cares, phlebotomy, obtaining samples for lab to do their mad scientist stuff, and the differences of technician/medical assistant responsibilities between different networks.
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Conclusion...
This is a small section of what it means to be a dedicated Medical Assistant/Technician. Do yourself a favor. If everything I said doesn't worry you much, go for it. If you want the experience or the desire for the experience and you are in a state where you can value the experiences more than the pay, go for it. I was like that once too, now I have no choice but to think more about how I will pay for myself and my future. Regardless, The Lord knows we need the help and I'll be happy to meet you and train you. However, you must know that you will always be appreciated. You'll hear the phrase "we appreciate you" or "Thank you for all your help today", from your nurses, fellow techs, managers, nursing managers, and doctors alike right before you leave to clock out. You'll just never be properly valued the way you should for the immense efforts you provide. You'll be just a tech. The health care field worker bee....

Medical coding is the process of translating medical diagnoses, procedures, and services into standardized codes that are used for billing and reimbursement purposes. There are two main coding systems used in medical coding: the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT).

Life comes in many flavours, and each day we face many questions. Some of these questions are judgements. And some of these judgements involve others in significant and meaningful ways. On the one hand, we seek to satisfy our personal needs -- self-determination -- while maintaining a sense of virtue -- compassion and justice. For many, there is too much injustice and suffering just to ignore. On the other hand, balancing the needs of us and them beckons honest appraisal of situations and people. But where and how should our finger be pointed?

Core psychology of blame

Among the very earliest struggles in a person's life is the process of ego development. In its simplest, ego is about separating good from bad, self from other. Various theories and models strive to explain the ego, or its development, from various perspectives. For the purposes here, I will be referencing object relations theory, which is part psychoanalytic psychology and deals with very early development, starting at birth. A few things will be slightly simplified to keep the text concise.
Within this theory, the first several months involve what is termed the paranoid-schizoid position. The "schizoid" aspect refers to a cognitive-emotional process known as splitting. This is where external objects, including people, are split into opposing mental parts -- to form part objects, or the "good object" version and the "bad object" version of each meaningful external object or phenomenon. For example, when the caregiver is gratifying to the infant, that part object is the "good caretaker"; and when not so gratifying, that caretaker is the "bad caretaker". At this stage of development and understanding, these two "part objects" are not seen as from the same source. Rather, each is a separate thing appearing and disappearing as circumstances and feelings change. The key word here is separation, which we will come back to later.
The other aspect of the paranoid-schizoid position -- the "paranoid" aspect -- refers to a curious side effect of splitting everything into "good" and "bad". Because each "part object" is either all good, or all bad, and because the appearance and disappearance of these mysterious entities is more-or-less out of control, the infant begins to resent and fear the bad objects that keep happening. That is, the baby hates the bad objects but loves the good objects. This is perhaps the very first stage of moral awareness -- raw, albeit mistaken judgement; love the good; hate the bad; pure, uninhibited attraction and repulsion. As a result, or side effect, of these negative or aggressive feelings toward "the bad", the baby may fear possible persecution, invoking paranoia. Strange though that may sound, there is a bit more to it.
Splitting, as between the mentioned "good" and "bad" objects, is only half the story. The other half of splitting is between "good self" and "bad self". That is, because in the paranoid-schizoid position, objects are temporary and impermanent, so too is the self temporary and fleeting. Moreover, the self is either in comfort, or in distress, giving either "good self" or "bad self" -- depending on circumstance. Since the "good self" appears with the "good object", and likewise the "bad self" with the "bad object", the child fears the appearance of the "bad object" even more. This is because its presence entails essentially collapse of the previous self-concept, as if to enter a realm of deserved persecution for being the "bad self" -- and hence the emergence of paranoia.
On an interesting aside, this manner of judging objects and selves as good or bad based solely on whether one is currently in comfort or pain is the essence of Stage 1 in Lawrence Kohlberg's stages of moral development. This is a theory on the progression of individuals throughout life in moral reasoning. Stage 1, termed obedience and punishment orientation, judges those in trouble or pain as inherently bad. In many cases, this view basically blames the victim. Further, this type of reasoning is essentially the basis for the "might makes right" mindset seen in some cases of antisocial personality disorder (ASPD). One thing to keep in mind is that we all start there, but not everyone stays there. In this way, having crude moral reasoning later in life is effectively a sign of delayed or regressed development, much like a disability -- ie. "morally disabled".

Completing the person

Eventually, the child will reach a point in development where objects become whole and persistent, able to have simultaneously negative and positive qualities. Objects or people may take on accounts, or balances, allowing for consideration of simple reciprocity, including guilt and reparation. Self and caregiver become distinct entities, where "good" self is no longer lost each time caregiver is absent or busy. Assuming successful progression, blame and judgement is no longer split dichotically between two extremes. Otherwise a new type of splitting is come, where objects and entities, though whole and persistent, are either idealised or devalued.
An important key trend exists between consecutive steps of ego development. This is the trend of expanding persistence and relatedness. In the part-object stage, objects appear and vanish -- some good, some bad. These raw appearances are neither persistent, nor related. In the whole-object stage, objects become persistent, although at first not really related. Because of this initial lack of relation, the secondary type of splitting -- idealisation and devaluation -- is still likely. Basically, since one person or object is fundamentally unrelated to another, including the self, there is "no harm" in seeing one as all good, and another as all bad. Without a stabilising relation, moral judgements can be whimsical yet extreme. A person or object may alternate between being embraced and discarded, depending on present feelings or arrangements. But what makes a stabilising relation?
In general, stabilising relations develop naturally through observation and reason. For example, a caregiver may through time be taken as an intrinsic part of one's need for support. Or a sibling may eventually be seen as fundamentally similar and related. But the building of these relations, or attachments, can be hindered by certain experiences or feelings. For instance, an unstable or unavailable caregiver may leave a child feeling resentment, shame, or guilt. These feelings may then get in the way of building an emotional bond. The resulting lack of security, mixed with possible shame or guilt for not being good enough, may lead to maladaptive and unstable boundaries and self-definition. Some common results are narcissism and borderline personality -- the former as an escape mechanism from feelings of inadequacy, and the latter as unstable border-lines between what is embraced, and what is rejected. These early childhood misgivings can then live on subconsciously, infiltrating the psyche and its future engagements.

Competition and judgement

While the capacity for blame and hate may emerge, as described above, from fundamental urges of attraction and repulsion -- mixed with innate capacity for making inference -- there is another powerful instinct at play. Complex social animals have a built-in game of gene-selection and mate-selection. This game relies on a simple heuristic, or objective -- form competitive hierarchies, and select those at the top. The evolutionary assumption is that competition filters out less desirable code. Without reflection, this pre-configured notion may be taken at face value, often in fact elevated -- whether spoken or kept silent -- to something of religious adherence. But is the argument sound?
In simple times, back in the tribe, individuals tended to grow up closely-knit and fairly uniformly. Regardless which parents one had, pretty much everyone had access to the same quality of food, healthcare, and education. Tools and other amenities could readily be made or obtained by any abled body, often with only modest effort. As a result, there was, compared to modern times, an extremely even playing field. Very little interfered with the above premise that those who achieved success in social hierarchy likely had something special inside. Sure, luck still played a part, but that part was not only far less significant than today, but also far more visible for those of simple tribes. In probably most cases, everybody knew when someone had encountered bad fortune, as individual stories were less hidden.
In the current age, however, personal merit is vastly more obscured and mangled by deceptive forces. The range of disparity in childhood resources and care, the long duration of schooling needed to be competitive, and the sheer price of admission into money-making pursuits, completely destroy any legitimacy the heuristic of selection by social hierarchy may previously have had. Luck may have played a part back then, but today the part played by the lottery of placement into a particular family, time, and place is riddled with inequity. On top of all that, the behaviours and exploits that set one person atop the next are lost from sight through the complex labyrinth of time, legalese, and the unfathomable size of modern society. Hence, the basis of soundness behind judging merit on personal outcome is no longer something that can be supported with any honesty. To praise or blame based on social status and wealth is to partake in folly.

Entity and arrangement defined

Entities are mental objects, and their social accounts, pertaining to people, groups, aggregates, and other moral agents. I say mental objects for two basic reasons. One, individuals and groups change through time. As the saying goes:

"A person never steps into the same river twice; for on the second occasion, one is neither the same person, nor is it the same river" (paraphrased) ~ Heraclitus of Ephesus.

Two, while we may posit that physical substance seems to exist out there, beyond the mind, we nevertheless must work within our mental model, or worldview, when considering those entities and other things of material or mental reality. Hence, entities and objects can be cognised, or considered, solely as mental objects. This phenomenon of the mental becomes even more apparent when we consider the nature of not only being, but identity, character, and personal story. None of these, from what I can tell, can rightly be said to exist outside the mind. Each has arbitrary, situation-specific, and continually shifting boundaries and connotations.
Arrangements, in contrast, are sets of objects; entities; their relative positions; their internal configurations; and their relations and interactions. Arrangements are hence the frameworks in place either materially or logically between and within entities and or objects. Common examples include law, culture, contract, education, and social hierarchy -- but also the physical placement of people and things.
Not surprisingly, the arrangements in place have substantial influence on the outcomes for individuals and society. The same person lowered into two different cultures and circumstances can be expected to have a different time. Education, ideas, values, struggles, and relationships may all be completely changed. The combinations of butterfly effect, disparity of opportunity, and idiosyncratic accident leave open the door for a wide variety of possibility.

Splitting and blaming the entity

Before talking about what to blame, or how to blame it, we might consider some phenomena which may influence one's ability to make sound judgement. As discussed previously, early development can play a big part in both the way one perceives and understands the world, and also the way one feels about, and hence reacts to, situations and challenges within the world. So let us look at some such phenomena.
Splitting, in the post-infancy sense, is the viewing of mental objects -- including and especially people -- as either idealised all good, or devalued all bad. The primary hypothesis goes something along the lines that a child who felt insufficiently loved or attended during infancy and early childhood may develop an internalised sense of unworthiness -- perhaps shame or guilt. In simple terms, the child may internalise a judgement of "not good enough". Since early, particularly pre-linguistic experiences tend to be deeply-seated and hard-conditioned, the person later in life may not only have little if any recall of such experience, but likely has little ability to reflect or challenge the resulting feelings or cognitive distortions. Basically, the only remnant clearly visible may be the feelings and intuitions themselves -- sense of shame, guilt, and never being good enough. However, as with other inescapable negative feelings, the child or later person is prone to forming habits of escape. Most notably here, the person may partake in defence mechanisms, or unconscious patterns of perception and thinking that seek to turn off or escape uncomfortable or stressful cognitions.
Projection is among the most used defence mechanisms. It involves taking an unwanted feeling or judgement, and throwing it upon someone or something else. The idea is to distance oneself from such negative connotations. In the case of internalised shame or guilt of being "not good enough" during childhood, the person is likely to begin casting this judgement upon others. Unreasonable or unattainable standards may be adopted. The world itself may be viewed as inherently broken or untenable. In the case of splitting specifically, black-or-white, all-or-none thinking may be employed to polarise objects or people -- including oneself -- into all good or all bad -- idealisation or devaluation. This type of projection sorts others into something of angels and demons. Furthermore, as in borderline personality disorder, these dichotic judgements may switch regularly depending on current affairs. The key thing to remember here is that projection is done to escape unfaceable feelings or judgements about oneself. Use of this defence mechanism may shift blame from self to another, often in a way that is difficult or impossible for the user to see.
More broadly, splitting belongs to a class of phenomena known as cognitive distortions. In addition to all-or-none thinking, cognitive distortions include overgeneralising, disqualifying the positive, jumping to conclusions, exaggeration, perfectionism, personalisation, always being right, and labelling of others. Obviously these all have significant implications for how one judges others, and indeed how one places blame. For the discussion here, let us talk about one more of these.
Personalisation is when a person takes the blame personally, regardless what external factors may be at play. This style of attribution is inherently self-deprecatory. Alternatively, blame may be placed entirely on another person or group. The distortion here is not that blame is occurring, but that the object is always a conventional moral agent, such as a human or AI. Essentially, an individual with this style of attribution may have an irrational tendency to place blame on agents, rather than circumstances. The trick is understanding why this happens.
As it turns out, the psychology behind placing blame disproportionately on people and other agents, rather than arrangements, is driven by the instinct of social hierarchy. Like brought up earlier, people have a tendency to compare and compete, judging one another into hierarchies of better and worse -- more or less worthy. The more insecure a person feels, or the more internalised shame or sense of inadequacy one has, the more the person may be compelled to cast blame on others. Put simply, insecurity activates the instinct of social hierarchy.
There are some noteworthy side effects to the habit of blaming the agent. One is scapegoating, or the projection of a group's fears and insecurities onto an external object. In scapegoating, the object chosen is often little, if at all, related to the underlying problem or dysfunction. Rather, the group seeks to unload its insecurity onto an unlucky target. This behaviour is much like that done in narcissistic personality disorder (NPD). One might say that groups too, not just people, can have NPD. One common target of scapegoating is minorities, of pretty much any type, who are often blamed for internal inadequacies of the majority regime. Another side effect of blaming the agent is kicking the dog, or chain reactions of blame shifting where each rung of the social hierarchy blames the next rung, all the way to the dog. Similar to scapegoating, kicking the dog picks a target generally unable to defend itself. This style of attribution, moreover, is contagious within organisations, hindering legitimate consideration of how the true underlying issues can best be resolved.

False object of blame

A curious distortion of interest is blindly taking the mental as fact. In the extreme, there is a phenomenon known as psychic equivalence. This is common in children, where the imagined monster under the bed is believed surely to exist. The line between mental and external is still thin. While most older individuals are beyond such explicit equivalence, we nevertheless have no other option for understanding reality than what our mind beholds. Whether for positive or negative, when we see or imagine someone, we are never seeing the real person. What we witness is our mental model, or mental object, of the other. The same goes for their view of us. When they behold us, they are really beholding someone else -- a construct of their imagination. Likewise, when we judge or blame another, we are really blaming someone else -- a monster of our own creation. Sometimes it can help to remember that in our mental, we are all mental.

Another defence mechanism

Aside from cognitive distortions, another key issue stands in the way of finding truth. In order to resolve deeply-seated emotional baggage, that baggage has to be opened. Yet doing so can be both painful and confusing. The mind has another trick up its sleeve to avoid facing the rain -- intellectualisation. Many have heard of rationalisation, or the making up of good-sounding stories to explain otherwise irrational or emotion-based actions and choices. Intellectualisation is related, but distinct. Instead of making up stories to seem more rational, intellectualisation makes up complex frameworks and red herrings to distract oneself and others from getting too close to the underlying feeling. Just like for splitting, the usual root cause is believed to be insecure attachment during infancy and early childhood. The result, especially later in life, is the excessive overreliance on logic and complex frameworks to avoid looking inside toward emotion. Reason becomes a comfortable hideout from hideous feeling. This disposition prevents proper reflection, making it hard or impossible to stop idealising and devaluing others. After all, one cannot stop spilling pain until one finds the source of that pain.

Relation to free will

The notion of free will comes in many definitions. These can get technical. But one fairly common theme is what they seek to support -- often some type of personal, or entity-centric, responsibility or blame. Regardless whether logically sound, the pursuit is in many cases a rationalisation of the instinctual and emotional urges of social hierarchy and ego defence. Essentially, many debates about free will are really struggles, or disagreements, on the nature of blame, and to where it should aim. In general, the belief in free will -- regardless the definition chosen -- is argued in support of some type of entity attribution. Likewise, the disbelief in free will is usually argued in support of system attribution, or blaming the way society or culture is structured. A person may choose a definition specifically to assert the desired end -- a psychological phenomenon called motivated reasoning. This text will avoid choosing a definition, as the underlying principles of behaviour are more important.
A less known paradox exists within the bounds of psychological agency. As is regularly discussed in certain circles of spirituality, there exists a spectrum of self-boundary between immediate, local, relative and timeless, non-local, absolute. This mental state of contraction or expansion depends in part on the grasping or release of fear and attachment. For those unfamiliar, the felt sense of personal agency -- sometimes called doership -- and one's associated beliefs about personal causation, are prone to change, or shift, depending on the present level of anxiety -- especially social and existential anxiety. There are two key aspects related to the sense of being in control.
The first aspect of interest is that of causal scope, or how far we trace the causes and influences behind any given event or decision. For example, as I type this, among the most immediate, or smallest causal scopes, is that of my finger pressing a key. Moving toward greater scope, we may consider that the arm is moving the finger. Further, of course, one might say the body is doing the typing. But the scope need not end there. We can trace back through the causal chains, finding all manner of influence. After all, why do I care about this? What social factors and life experiences influenced this cause? The more immediate the causal scope, the longer and more encumbered the causal chains. Hence, even though when afraid we may focus on the more immediate, hence feeling more in direct control, the more our felt boundaries of self and causality contract, the more short-sighted, distracted, and materially-bound we are. The paradox is in the inverted pyramid of influence atop our actions.
The second aspect relates to impulse and desire versus self-control and composure. Human desire may be divided broadly into basic animal instinct and social image. In Freudian terms, these would be id and ego. The former is often viewed as impulsive or animalistic; the latter as controlled and composed. A meaningful portion of pro-free will arguments seems to equate or compare the composure and planning of socially-conscious actions and choices as representative of the essence of "free will". That is, more "controlled" or deliberate actions were exercising greater free will than their more impulsive or animalistic counterparts. But is this assessment sensible?
On the one hand, being more socially aware likely helps to prevent being manipulated or impeded by others. Most would probably agree thus far. But on the other hand, the more we care about fitting in, or otherwise playing the game of social hierarchy, the more we submit ourselves to social norms and other hive behaviours. Essentially, the more we care about image, the more we let society control us. Despite this emotional tether, those with the biggest egos often proclaim the greatest sense of self-determination. Certainly one could argue that being on top of the hierarchy usually entails greater access to social amenities, some of which offering greater freedom. But there may be some right reservations here. Firstly, the enhanced freedom of high status often comes with enhanced fitment and scrutiny into the externally-defined social mould. This is not always the case, as for example with dictators. But secondly, the vast majority of those playing the ego game are neither in positions of status and power, nor emotionally secure enough to go their own way toward personal happiness. Perhaps most prominently, for most social animals, the hive provides only minimal amenity, and maximal loss of autonomy. Yet the internalised ego and self-concept obscure this reality by making cultural, emotional artifacts of socialisation -- especially during childhood -- appear as self-chosen. The person is thus a product of upbringing, but because these aspects of conditioning are so deep and unconscious, their effects are simply taken for granted as part of who one is. Hence, a second paradox exists in that what may appear as evidence for free will -- ego and composure -- is in fact the very thing enacting the long-seated will of the hive.
On a different note of the free will debate, there seems to be a phenomenon somewhat like "free will of the gaps", where any unknown of psychology or physics is received wholeheartedly as evidence for freedom. While no doubt one may never really know, particularly when stuck in the subjective mind-box, one might consider the effect of splitting, or black-and-white thinking. This habit may, without enough reflection, colour one's assessment of personal agency as either wholly existing, or wholly absent. This is not to say undue burden and other explicit interference is unregarded, but more that even the mere existence of randomness or unpredictability may be taken as sufficient reason to ward off the behavioural influences and effects known by modern psychology. Remember that splitting is driven by egoic insecurity, and that ego has vested interest in building the narrative which best places oneself in the social hierarchy of the mind. Impulsive or controlled, what we choose is there to satisfy instinct, whether animalistic, or socially-focused.

Blaming the arrangement

On the other side of inferred causation -- after instinct -- we have experience, conditioning, and circumstance. Experience and conditioning are carry-overs from past arrangement while circumstance reflects the present arrangement. For simplicity, I will place all three simply under arrangement. To borrow from earlier:

Arrangements ... are sets of objects; entities; their relative positions; their internal configurations; and their relations and interactions. Arrangements are hence the frameworks in place either materially or logically between and within entities and or objects. Common examples include law, culture, contract, education, and social hierarchy -- but also the physical placement of people and things.

With this definition in mind, what then does it mean to blame the arrangement, and what benefit does so doing provide?
First, let us consider the standard Western approach. When we blame the entity, we are accomplishing three fundamental ends:

1. declaring a point of causal significance;
2. downgrading social status;
3. offloading correction;

On the first point, blaming the entity cuts off past influences, including deficiencies and inequalities in access to essential resources like health, respect, education, and experience. One might wonder why respect is included here. But remember the types of issue that arise from internalised shame, guilt, and feelings of inadequacy. These live on subconsciously, causing non-obvious impairments in judgement and performance. Plus they harm health and performance through elevated stress hormones.
On the second point, blaming the entity lowers its public appraisal, thus cutting off access to the types of resources just mentioned.
On the third point, blaming the entity places the burden of correction squarely on the already broken component. For simple matters like enforcing social norms or decency, this type of blame is probably effective in most cases. But when we start looking at bigger matters, like health, education, intelligence, self-restraint, and general performance, the idea of forcing the suboptimal party to fix itself starts to break down. All these matters are heavily influenced by external circumstance through time. So telling the person to fix the resulting dysfunction is like telling them to rewrite their past environment, including their upbringing. Moreover, those from broken pasts are much more often the least supplied -- in both resource and knowhow -- to make things better.
And this brings us to blaming the arrangement. If instead of burdening and downgrading the unfortunate entity, we recognise the conditions of success and failure, we can apply legitimate effort toward enacting a better future. Obviously society as a whole is far better equipped to improve not only the outcome of tomorrow, but the conditions of today. Some of us, by chance, receive the winning hand. This may be in genetics, family configuration, area of schooling, or maybe just missing detrimental accidents and injuries. What sense does it make to hoard the helpings of fate, thus preventing the wealth of shared development and growth? In a world literally brimming with technological advancement, is it really better for the majority to live polarised as minority winners and majority losers?

Arguments

One might argue that blame and praise are natural and effective tools for motivation and modification of behaviour. Natural though they may be, these tools are premised on the limited knowledge and resources of tribal past. Like using a hammer to insert a screw, messy tools ought to be reserved for desperate times only. Modern medicine, psychology, and sociology offer a new toolbox, today readily available, for resolving problems with minimal collateral damage. True, not everyone has fair access to these modern amenities, and that is exactly why we need to stop blaming the victim. The technology is here. We simply need to open the gates.
Another common argument is that absent of pointing fingers, people would lose motivation, or stop caring. There may be some truth here. If we remove the whip from their backs, the slaves may begin to relax. But is that really a bad thing? Per-capita material output is already worlds higher due to automation and tooling. But artificial scarcity is brought in to "keep up the morale". This scarcity is largely in the form of wealth and income inequality, which ensure the true producers of wealth -- the workers -- are kept chasing their imagined carrot. The effect, in practice, is burnout and learned helplessness. The secondary effect is thus decreased performance, which is then "solved" with ever greater artificial scarcity, perpetuating the cycle of lies and suffering. Instead of entertaining a system of slavery with extra steps, why not more equally distribute the tools and technology of efficiency and success?
A darker argument that occasionally gets said out loud is that excessive competition and suffering help to weed out the less desirable traits. Often, it is proclaimed, nature wanted it that way. Ignoring the obvious lack of compassion, is this argument sound? The simple answer is no. The longer answer is not even a little. There are two main reasons. Firstly, the dirty game of filtering by social hierarchy was not only sloppy for its original environment of small tribes, but is completely unfit for modern, complex, abstract society. As explained previously, the legitimacy of individual merit is no longer known by fellow tribespeople. Wealth generation and extraction are too far removed and abstracted for proper outside judgement. And complex systems of power and propaganda further prevent equitable distribution of the fruits of labour. Secondly, the amount of time needed for such mechanisms of trait filtering to make an appreciable difference are substantially longer than the time from now before technology will allow superior selection of traits. There will be no need to compete in the sloppy ways of the past; nor any need to compete at all. The problem of selection is soon resolved. AI is entering the exponential phase. Petty and primitive worry about traits is irrelevant, for multiple reasons. If anything, those unable to understand this are unfit to be making policy decisions.
An argument which comes up enough to mention is that without blaming the entity, criminals would have free reign, able to do whatever they wanted without repercussions. This argument is missing something quite substantial about what is entailed by blaming the arrangement. Simply, if a certain person is believed to lack the self-control for certain situations or positions, that person will be kept away from those circumstances. A common example is driver's licensing, where one must earn the privilege by proving competence. And similarly to that, if someone is blatantly acting out and causing trouble, obviously they would be put somewhere safer. The key is rearranging circumstances as needed for best outcome while maintaining reasonable maximum personal autonomy -- without unnecessary harm, restraint, or loss of dignity. Yes, this is more involved in terms of resources and labour, but that is what technology is for. Naturally people prefer to have more privilege, and that alone is motivation enough to care.
And before someone accuses this approach of being or supporting a social credit system, we must make clear the difference. In social credit systems, blame is placed on the individual ! Sure, the factors used may involve family and acquaintance, but the burden of correction still goes to the person or small group. This is completely different from what is being proposed here.
A final argument relates to expense. On the surface -- especially from within the perspective of a system based on artificial scarcity and excessive wealth inequality -- the idea of having surplus means available for long-term planning may seem unfathomable. People's reluctance in this regard can be understood. But as mentioned above, we are presently, for presumably the first time in our recorded history, entering the age of exponential growth toward advanced artificial intelligence. Things are moving fast already, and both hardware and software are showing no slowing. If computational capacity continues to double regularly like it has for a long time now, we are probably looking at readily accessible post-human intelligence within five to ten years. Short of disaster or tyrannical interference, existing worries about labour and intellect shortage should soon evaporate. Yes, this time things are different. There is no known precedent.

Summary

Our natural instinct may tell us to blame the person. And Western culture may polarise this tendency to the extreme. But with a little understanding of why we feel the need to downsize others, we may be able to mend the splitting within us. Society may be designed around a game of hierarchy, but one need not partake. By knowing the factors that promote or inhibit wellbeing, and by using the knowledge and tools of modern, we can cast off the shallow assumptions behind us, to build something worth keeping. The first step is looking inside, to see the feeling that fears connection. Then we may look outside, to see that most are facing similar struggle. Situations are what make or break the person. If one should blame, blame the arrangement. The past may not be one for changing, but greater compassion today can find greater love tomorrow.

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As a PC gamer, I was disappointed by the announcement of Cities Skylines 2 using Unity as its game engine. I think Unreal Engine would have been a much better choice for this game, especially for the PC platform. Here are some of the reasons why Unreal Engine would have been a better choice for Cities Skylines 2 (keep in mind my thoughts are colored by my preferred platform):

• Advanced Graphics Capabilities: Unreal Engine is known for its advanced graphics capabilities, which can create stunning visuals and realistic lighting effects. Unity, on the other hand, often struggles to achieve the same level of quality and realism. For a city builder game that relies on aesthetics and immersion, Unreal Engine would have been a superior option.
• Modding: Unreal Engine has built-in modding support, a first party steam SDK, and Blueprints Visual Scripting, which would allow modders to create complex gameplay mechanics without having to write code. Unity does not have these features natively and requires third-party tools and plugins to enable modding. This makes modding more difficult and less accessible for both developers and players.
• Performance: On PC, Unreal Engine has better optimization and performance than Unity. This means that it can handle larger and more detailed cities without compromising on framerate or stability. Unity tends to suffer from performance issues and bugs when dealing with large-scale projects. This is especially important in a city builder game where players want to create massive and intricate cities without sacrificing smooth gameplay.
• Physics: Unreal Engine has more advanced physics capabilities than Unity. It can simulate dynamic environments and better wateweather effects. This would add more realism and variety to the city builder genre, where players could interact with their environment in more meaningful ways. For example, they could create bridges that collapse under stress or rivers that flood during storms.
• UI: This is subjective, but many players agree that Unity games tend to have bad UI design. They often look ugly and slow, with blocky text and graphics. Unreal Engine games usually have more polished and UI design that enhances the user experience. For a city builder game that requires a lot of information and interaction from the player, having a good UI is essential.
  
• VR: VR on mobile is better with Unity no doubt. VR with PC/High Quality graphics Unreal is the way to go here. Unreal Engine has more support and features for VR development than Unity. It can create immersive VR experiences that take advantage of high-end graphics cards and headsets. Unity is more suited for mobile VR development where performance and compatibility are more important than quality.
  

Ultimately, I understand that CO probably chose Unity because they are familiar with it and have used it for the previous game. However, I hope that the new version of Unity will address some of the issues and limitations that the old versions had. I still want Cities Skylines 2 to be an amazing game.

Hi all, apologies if this isn’t an appropriate place to ask, I will delete if so.
My three year old receives in office OT for some sensory issues and a fine motor skill delay. I contacted my insurance because his therapy office had been billing me for sessions he wasn’t at, and I needed the CPT codes to give to a new office so he can switch. He goes once a week for an hour.
The first two codes covered both a motor skill delay and developmental delay for not meeting milestones. Makes complete sense. The third was a diagnostic code for ‘neurological neglect syndrome’, when I looked it up this does not seem to be something my son at all has. He has no history of TBI or stroke. I contacted both his speech therapist and OT privately about this and they were shocked, and both say this isn’t something he has.
It’s a small office so I called the front desk who handles billing. They told me “oh that’s just what we put for any developmental delay” and not to worry. I’m not sure what to think so I figured I’d ask some people who’d actually know! I’m unfamiliar with a lot of medical billing so it’s 100% possible this is normal and I just didn’t know it! I’m just feeling weird since I had caught them billing me for two sessions we did not have scheduled. Any guidance would be so appreciated

5
From Mirror to Window: Curing Psychoanalysis of its Narcissism
The apparently individual conflict of the patient is revealed as a universal conflict of his environment and epoch. Neurosis is thus nothing less than an individual attempt, however unsuccessful, to solve a universal problem. - C.G. Jung (1912)
Narcissism is now the rage, the universal diagnosis. In Freud's world, the new attention was on conversion hysteria; in Bleuler's, on dementia praecox. Earlier we find all ills attributed to the English malady, to the spleen, to hypochondriasis, to melancholia, to chlorosis; in Paris, a myriad of phobies and délires. Different time and places, different syndromes.
Narcissism has its theoreticians - Kohut, Kernberg, Lacan - and modern Jungians are following the rage. The collective consciousness of psychology makes us collectively unconscious, much as Jung said when writing about the collective ideas in his day. Being "with it" also means being in it. The epidemic diagnosis Narcissism states that the condition is already endemic to the psychology that makes the diagnosis. It sees narcissism because it sees narcissistically. So let us not take this diagnosis so literally, but place it within the historical parade of Western diagnoses.
Eminent cultural critics - Karl Krauss, Thomas Szasz, Philip Rieff, Christopher Lasch, Paul Zweig, and the notorious Dr. Jeffrey Masson - have each seen that psychoanalysis breeds a narcissistic subjectivism inflicting on the culture an iatrogenic disorder, that is, a disease brought by the methods of the doctors who would cure it.
I shall continue their line of thought, but I shall use a method that Wolfgang Giegerich has so brilliantly exposed in many of his papers. If depth psychology itself suffers from a narcissistic disorder, then what we analysts need first to probe is the unconscious narcissism in analysis itself. Our first patient is neither the patient nor ourselves, but the phenomenon called "analysis" that has brought us both to the consulting room.
The term "Narcissism" is probably British . Havelock Ellis is credited with its invention, though Freud gave us its psychoanalytic meaning. What did Freud say? As I go through some of his descriptions, let us hear them narcissistically, as self-referents, descriptive of psychology and of ourselves in psychology.
1917: "We employ the term narcissism in relation to little children and it is to excessive narcissism of primitive man that we ascribe his belief in the omnipotence of his thoughts and consequent attempts to influence the course of events in the other world by magical practices." Does not analysis have this primitive omnipotence fantasy of influencing events in the outer world by its magical practices? The omnipotence of subjective reflection is attested to by many classic Jungians like Harding, Bernard, Meier, von Franz, Baumann, etc. As Jung himself says, we are each "the makeweight that tips the scales" that determine the outcome of world history." The rituals of self-engagement remove projections from the world so that, supposedly, the world itself is transformed by psychoanalysis.
1922: "... narcissistic disorders are characterized by a withdrawal of the libido from objects." The withdrawal of the libido from from objects - I ask you to remember this statement. We shall come back to it.
1925: Freud describes three historic blows to humankind's narcissism. These, he says, are the cosmological blow of Copernicus, the blow of Darwinian evolutionary theory, and the psychoanalytic blow (of Freud) which wounded the omnipotence fantasy, or narcissism, of the ego as sole self-willed ruler. Here, psychoanalysis becomes itself a giant omnipotence fantasy, a creation myth of our culture equivalent with astronomy and biology, promulgating itself with narcissistic grandeur.
This pronouncement appears in Freud's discussion on resistance to psychoanalysis. By means of this idea resistance, analysis brilliantly maintains its invulnerability to criticism. Questioning the validity of analysis is impugned as resistance to it. Even more: the very attacks demonstrate resistance and therefore help to validate analytical theory. As Freud says, "The triumph of narcissism, the ego's victorious assertion of its own invulnerability. It refuses to be hurt by the arrows of reality ... It insists that it is impervious to wounds dealt by the outside world."
Later Freud considered narcissism not to be rooted in love at all, i.e., as self-love, but to be rather a defense against aggressive impulses. Let us consider for a moment the value of "aggressive impulses," at least and at best they take the object, the world out there, into account: I feel enraged about societal injustice, nuclear danger, media crap, industrial callousness, the corporate mind, political ideologues, hideous architecture, etc. But, owing to my narcissistic defenses against the involving call of aggression, I go to the spa, work out, meditate, jog, diet, reduce stress, relax my body armor, improve my orgasms, get a new hairstyle, and take a vacation. And see my therapist: very expensive, very good for me, because he or she devotes complete attention to my problems, especially our transferential frame. Instead of the world and my outrage, I work on my analysis, myself, the Self. This Self, too, fits a narcissistic definition: "the incorporation of grandiose object images as defense against anxiety and guilt" or, as Fenichel puts it, one feels oneself in "reunion with an omnipotent force, be that force an archetype, a god or goddess, the unus mundus, or the numinosity of analysis itself.
Freud's paper "On Narcissism" states that both introspection and conscience or "being watched" derive from and serve narcissism. Yet, psychotherapy practices self-scrutiny as the principal method in its treatment and "being watched" or supervision as the principal component of its training. A candidate goes to hour after hour of institutionalized narcissism of watching and being watched.
The institutionalization of narcissism in our profession - the idea of resistance, the idealization of the Self, the practices of introspection and supervision, the omnipotence fantasies about its own importance in world history, its technique of referring all events back to itself as the vessel, the mirror, the temenos, the frame - bears immediately upon that central obsession of analysis today, transference.
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By transference, here, I mean that self-gratifying analytical habit which refers the emotions of life to the analysis. Transference habitually deflects object libido, that is, love for anything outside analysis, into a narcissistic reflection upon analysis. We feed analysis with life. The mirror that walks down the road of life (Flaubert) replaces the actual road, and the mirror no longer reflects the world, only the walking companions. They may as well have stayed indoors, less distracted by the trees and the traffic.
The principal content of analytical reflection as transference is the child we once were, a fact which accords with Freud's observation that the object choice of the narcissist is "someone he once was.” This helps account for the faddish popularity of Alice Miller’s writings. Her idealized children exhibit what Freud said: the narcissist is “not willing to forego his narcissistic perfection in his childhood” and “seeks to recover the early perfection.” The focus on childhood traps the libido only further into subjectivity, and therefore we must recognize that erotic compulsions in analysis are produced primarily by the analysis, rather than by the persons. Analysis acts itself out through them quite impersonally so that they often feel betrayed and ashamed by the impersonality of the emotions they undergo and are unable to recognize that what they are suffering is the object libido trying to find a way out of analysis. Instead, the narcissistic viciousness of our theory says that transference emotions are compelling the persons to go deeper into analysis.
Let us recognize that the other person - patient or analyst - embodies the only possibility within an analysis to whom object libido can flow. The person in the other chair represents cure of analytical narcissism simply by being there as an Other. Moreover, the patient for the analyst and the analyst for the patient become such numinous objects because they have also been tabooed as libidinal possibilities. Analyst and patient may not act their desire for each other. The narcissism of the situation makes them absolutely necessary to each other, while the taboo sets them absolutely outside of each other. This outside object however, is also inside the analysis. So, patient for doctor and doctor for patient become the symbolic mode of ending analysis by means of love.
Of course, the persons are often torn by what Freud calls the love dilemma of the narcissistic patient: “the cure by love,” which he generally refers to as cure by analysis. We must ask whether this neurotic choice, as Freud calls it, arises from the narcissisms of the patient or from the narcissism of the analytical system in which the patient is situated. After all, the fantasy of an opposition between love and analysis occurs within the prior fantasy of cure which has brought the persons together in the first place.
By elaborating ethical codes, malpractice insurance, investigations, and expulsions that blame the participants, analysis protects itself from wounding insights about its own narcissism. The vulnerability of analysis - that its effectiveness is always in question, that it is neither science nor medicine, that it is aging into professional mediocrity and may have lost its soul to power years ago despite its idealized language by growth and creativity (a language by the way, never used by its founders) - this vulnerability is overcome by idealizing the transference.
As well as transference love, there is also hatred. Perhaps the client’s hatred of the analyst and the hatred of the analyst for the client are also not personal. Perhaps, these intense oppressive feelings against each other arise in both to present both with the fact that they are in a hateful situation: the object libido hates the attachment of transference. Analysis hates itself in order to break the narcissistic vessel imprisoning the libido that would go out into the soul in the world.
The horned dilemmas of transference, including the analyst’s stare into the mirror of his own counter-transference, the feelings of love and hatred, this agony and ecstasy and romantic torture convince the participants that what is going on is of intense importance: first, because these phenomena are expected by the theory and provide proof of it, and second, because these phenomena re-enact what analysis once was in its own childhood in Vienna and Zurich, analysis in primary fusion with its origins in Breuer and Freud and Jung, in Dora and Anna and Sabina. The feelings are cast in therapeutic guise because this is the healing fiction of the analytic situation. In other words, transference is less necessary to the doctor and the patient than it is to analysis by means of which it intensifies its narcissistic idealization, staying in love with itself. We therapists do not sit in our chambers so many hours a day only for the money, or the power, but because we are addicted to analytical narcissism. Our individual narcissism is both obscured and reinforced by the approved narcissism of the analytical profession.
When one partner imagines a tryst or the other imagines resisting a seduction, or when either imagines that love is a solution to misery, then they are framed in the romantic conflicts of Madame Bovary, Wuthering Heights, and Anna Karenina, reconstituting the Romanticisms of the nineteenth century and the origins of psychoanalysis, not in your or my personal childhoods, but in its own cultural childhood. This means we have to locate the narcissism of contemporary analysis within a much wider narcissism: the Romantic movement.
*
Literary tradition differentiates at least four principal traits of this genre. We have already spoken of one, “idealization of the love object.” And indeed analysis idealizes the patient as an “interesting case,” “difficult patient,” “good patient,” “borderline personality.” Or consider all the literary fabulations that have made patients into eternal literary figures - Dora, Ellen West, Babette, Miss Miller, Wolfman, Ratman, Little Hands, all the way to Freud and Jung themselves in the novels The White Hotel and The House of Glass. Think of the Romanticism of our theoretical constructs: Love and Death, Empathy, Transformation, Growth, The Child, The Great Mother, The Mirror, Desire and Jouissance, and the Transitional Object. In the patient there takes place such idealized events as a hieros gamos, a quest for self-discovery and a journey into wholeness. Synchronicities outside of causal laws, transcendent functions, integration of the shadow and the realization of the Self on whom the future of civilization depends. We record our idealization of the love object, i.e., analysis, in taped and filmed analytic sessions, paying meticulous and expensive attention to trivial conversations and gestures. Analysis is in love with its idealized image.
A second essential trait of Romanticism is said to be the opposition between bourgeois society and the inner self that, with its dreams, desires and inspirations, tends to oppose, even contradict, the outer world of usual things. Psychoanalysis from its beginnings imagines itself fundamentally opposed to the civilization and its institutions of religion, family, medicine, and the political community disdained as “the collective.” Freud’s emphasis on himself as Jew and hence marginal, as well as Jung’s favorite position as heretical old hermit (despite the bourgeois lives they led and values they held) still shapes the imagination of the profession and distorts its relation to the ordinary world.
Third, imprisonment another basic theme in Romanticism, especially French and Russian. In Dostoevsky’s The Possessed, Maria’s song says: “This tiny cell suffices me, there I will dwell my soul to save.” The consulting room provides the confining physical place for the psychic imprisonment of analysis as such its devotion to the secret nooks and crannies of the private world, decorating with reconstructive rococo (i.e., psycho-dynamic intricacies) the narcissistic cell of personality.
Fourth, the Romantic genre has been defined as one that simultaneously seeks and postpones a particular end. This fits therapy. Its entire procedure seeks to restore the person to the world, yet postpones this return indefinitely. (Meanwhile, do not make major changes in your actual life. Don’t act out. The cure of analysis becomes more analysis-another analyst, another school - and the improvement of training becomes ever more hours.) The simultaneity of seeking and postponing an end occurs in the basic conundrum of every analysis, its contradictory two commandments: encourage the desires of the unconscious (Thou Shall Not Repress) and forbid gratification (Thou Shall Not Act Out). Our work is with the libidinous and our method is by way of abstention. The end is unforeseeable; there is no completion. Analysis interminable, as Freud said. This is the Romanticism of eternal longing.
There is no way out of Romanticism’s consulting room and the subjectivism of its eros, unless we turn to what is beyond its purview, turn to what narcissism and romanticism leave out: the objects, the unidealized, immediately given, actual world of dull and urban things . By turning psychological attention from the mirror of self-reflection to the world through the window, we release “object libido” to seek its goal beyond narcissistic confinement in analysis. For “object libido” is but a psychoanalytic name for the drive which loves the world, the erotic desire for Anima Mundi, for Soul in the World.
Perhaps it becomes clearer why I have been emphasizing John Keats’s remarkable phrase; “Call the world … The vale of Soul-making. Then you will find out the use of the world.” Also, you will understand why I have held myself back from that side of Jung which expounds upon meaning, Self, individuation, unus mundus, wholeness, mandalas, etc. . These large and introverted ideas envelop me and usually my patients with a grandiose, invulnerable aura. As well, I keep a distance from the current Kohut craze and Lacanian mystique. Although recognizing narcissism as the syndrome of the times (even if the groundwork for this was prepared long ago in the metaphysical catastrophe of Augustinian and Cartesian subjectivism); yet, Kohut attempts its cure by the same means of narcissistic obsession: an ever more detailed observation of subjectivity. And a subjectivity within the oppressive confines of a negatively reconstructed childhood. The child archetype dominates contemporary therapy, keeping patients (and analysts) safe from the world. For this archetype feels always endangered by the actual world, lives not in the present but in futurity, and is addicted to its own powerless infantilism. By so focusing on the child, analysis disenfranchises itself from wider realm of soul-making in the adult community of polis.
Nevertheless I must confess to a serious long-standing error on my part regarding Keats’s phrase. I always considered the world out there to be useful for making one’s own soul. Narcissism again. My soul, your soul - not its soul. For the Romantics, however, ensouling the world was a crucial part of their program. They recognized the traps of narcissistic subjectivity in their vision. Hence, they sought the spirit in physical nature, the brotherhood of all mankind or Gemeinschaftsgefühl, political revolution, and a return to the classic gods and goddesses, attempting to revivify the soul of the world with pantheism.
We must therefore read Keats as saying we go through the world for the sake of its soul-making, thereby our own. This reading suggests a true object libido, beyond narcissism, in keeping with Otto Fenichel’s definition of love. Love can only be called such when “one’s own satisfaction is impossible without satisfying the object too. If the world is not satisfied by our going through it, no matter how much beauty and pleasure our souls may receive from it, then we live in its vale without love.
There is a way out, or I wouldn’t be standing here. For my specific style of narcissism, my pose before the mirror, today is heroic. My style insists on resolution of the issues raised. The method I shall be using here follows the method which I usually empty for resolving issues. First, we look back into the history of psychoanalysis for a model; second, we turn to some peculiar bit of pathologizing for a clue; and third, we resolve problems by dissolving them into images and metaphors.
So, let us turn back to the first psychoanalytic case, Anna O., and her doctor, Josef Breuer, who, with Freud, wrote Studies in Hysteria. As you recall, after a year of almost daily sessions often of several hours, he suddenly terminated. You recall also the intensity of her transference, that she developed a hysterical pregnancy and childbirth, after Breuer tried to end the treatment. He, according to Jones, after a final visit to her “fled the house in a cold sweat. The next day he and his wife left for Venice to spend a second honeymoon which resulted in the conception of a daughter.” Whether fact or not, and Ellenberger says not, the fantasy shows a founding patron of our work escaping both cure by analysis and cure by love for the beauty of Venice and the conception of a daughter. His object libido returns from the oppressive narcissism of psychoanalysis to the Romanticism of the wider world.
This wide world remains merely that, merely a place of escape or acting out, so long as the world “out the window” is imagined only in the Cartesian model as sheer res extensa, only dead matter. To show more vividly how that world is, as Keats said, a place of soul, let us go straight through the window into the world. Let us take a walk in a Japanese garden, in particular the strolling garden, the one with water, hills, trees, and stones. While we walk, let us imagine the garden as an emblem for the peripatetic teacher or the therapeutic guide (psychopompos), the world itself as psychoanalyst showing us soul, showing us how to be in it soulfully.
I turn to the garden and to Japan because of insights given while in Kyoto gardens several years ago, and also because the garden as metaphor expresses some of the deepest longings - from Hesperides, to Eden’s paradise, and Maria’s hortus inclusus - for the world as home of the soul. So by entering into the Japanese garden now we shall be stepping through the window into the anima mundi.
First we notice that the garden has no central place to stand and view it all. We can but scrutinize a part at a time. Instead of overview and wholeness, there is perspective and eachness. The world changes as we move. Here a clump of iris, there a mossy rock. Instead of a center (with its etymological roots in the Greek kentron, “goad” or “prick,” and being compelled toward a goal by means of abstract geometric distancing), there are shifts of focus relative to the body’s location and attitude.
Second: as one strolls, each vista is seen again from a different perspective. The maple branching down to the pond edge, the floating leaves appear less melancholic after the path bends. These shifts of seeing again are precisely what the word “respect” means. To look again is to “respect.” Each time we look at the same thing again, we gain respect for it and add respect to it, curiously discovering the innate relation of “looks” - of regarding and being regarded, words in English that refer to dignity.
Third: when the garden, rather than the dream or the symptom or the unconscious, becomes the via regia of psyche, then we are forced to think anew about the word “in.” “In” is the dominant preposition of all psychoanalysis - not with, not from, not for, but “in.” We look in our souls, we look in a mirror. "In” has been utterly literally, as an invisible, spacelesss psychic stuff inside our skins, or meanings inside our dreams and symptoms, or the memories locked in the past. Interiority of the garden, however, is wholly present and wholly displayed. “In” holds the meanings of included, engaged, involved, embraced. Or, as Jung said, the psyche is not in us; we are in the psyche. This feeling of being in the psyche becomes most palpable when inside the ruins of a Greek temple, in an Egyptian tomb of a king, in a dance or a ritual, and in a Japanese garden. Jung’s phrase “esse in anima” takes on concreteness then, as it does in a clear-cut forest, a bombed city, a cancer ward, a cemetery. Ecology, architecture, interior design are other modes of feeling the anima mundi. Instead of the usual notion of psyche in body, the body strolling through the garden is in the psyche. The world itself is a psychic body; and our bodies as we move, stand, look, pause, turn, and sit are performing an activity of psychic reflection, an activity we formerly considered only mentally possible in the mirror of introspection.
Fourth: the idea of individuality also changes, for in the Japanese garden trees are trimmed at the top and encouraged to grow sideways. Rather than an individuality of the lone tree, towering (and Jung said the single tree is a major symbol of the individuating Self), these trees stretch their branches toward others. Individuality is within community and, takes its definition from community. Furthermore, each tuft in the soft branches of the pine trees is plucked by gardeners. They pull out needles, allowing emptiness to individualize the shape of each twig. It is as if nothing can be individualized unless it is surrounded by emptiness and yet also very, very close to what it is most like. Individuality is therefore more visible within the estrange separateness and close similarity, for instance, of family than in trying to be “different” from family.
Fifth: not only are aged trees supported with crutches and encouraged to flower - blossoming belonging therefore not only to youth - but also the garden includes dead trees. What more wounds our narcissism than these images of old age, these crutched, dependent, twisted and dead trees? < “At least Aurora didn’t reject Tithonus, old, didn’t allow him to lie there lonely in the House of Dawn. She often fondled him, descending into her waters, before she bathed her yoked horses with care. She, when she rested in his arms, by neighbouring India, lamented that day returned too soon.”>
Sixth: the Karesanui gardens, or Zen-inspired gardens, present mainly white sand and found stones, rarely trees. In this bare place the mind watches itself making interpretations. The nine rocks in the raked sand are a tiger family swimming through the sea; the nine rocks are mountain tops peaking through white mist and clouds; the nine rocks are simply rocks, aesthetically placed with genius. One legend after another, one philosophy, theory or literary criticism, or psychological interpretation rises to the mind and falls back into the white sand. The garden becomes wholly metaphor, both what it is and what it is not, presence and absence at once. The concrete koan of the rock garden transforms the mind itself into metaphor, its thought transient while image endures, so that the mind cannot identify with its own subjectivism - narcissism overcome.
“This Open happens in the midst of beings. It exhibits an essential feature which we have already mentioned. To the Open there belong a world and the earth. But the world is not simply the Open that corresponds to clearing, and the earth is not simply the Closed that corresponds to concealment. Rather, the world is the clearing of the paths of the essential guiding directions with which all decision complies. Every decision, however, bases itself on something not mastered, something concealed, confusing; else it would never be a decision. The earth is not simply the Closed but rather that which rises up as self-closing. World and earth are always intrinsically and essentially in conflict, belligerent by nature. Only as such do they enter into the conflict of clearing and concealing.” - Heidegger, The Origin of the Work of Art.
‘“Hegel introduces this notion of ‘oppositional determination” in his logic of essence, when he discusses the relationship between identity and difference; his point there is not only that identity is always the identity of identity and difference, but that difference itself is also always the difference between itself and identity; in the same way, it is not only necessity that encompasses both itself and contingency, but also - and more fundamentally - it is contingency itself which encompasses both itself and necessity. Or, with regard to the tension between essence and appearance, the fact that essence has to appear within the domain of appearances, as a hint that “appearances are not all” but are “merely appearances.”’ - Zizek, Less than Nothing>
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Finally, I shall insist that the garden is not natural; nor is psyche natural. The garden was designed and is tended to maintain an artificiality that imitates nature . In Fort Worth, Texas, a large and marvelous Japanese garden was constructed years ago. But since adequate funds were not set aside for gardeners from Japan, nature slowly destroys that garden. Without the pruners’ perverted twist to each inch of nature, the garden declines into merely another part of the forest. A garden’s elaborate display of soul-in-the-world is an opus contra naturam, like alchemy. Like alchemy, the garden is a work of intense culture. Unlike alchemy, its matter, its body, is out there, rather than inside the glass vessel.
Because the garden is artificial, as the alchemist was called artifex, all conceptions of soul must be plucked of naturalistic fallacies. The soul as opus contra naturam will not be served adequately by fallacious comparisons with organic growth, cyclical process, and myths of nature goddesses. Nor does the garden shelter the child from which grows the creative person as psychotherapy is found to believe. By insisting upon the artificiality of our work with soul, I am trying to keep us from the Romantic error of confusing the ideal (Eden and the Elysian fields; Horaiko, in Japanese) with the natural. The garden as metaphor offers a romantic vision that saves us from Naturalistic Romanticism by twisting and sophisticating nature through art.
This twist to nature that wounds idealizations of garden is presented in our culture, as in Roman culture, by our ancient god of gardens and gardeners, Priapus. Priapus is neither young nor beautiful. Unlike lovely Narcissus, unlike the semi-divine figures of Adam and Eve, Priapus is mature, bald and paunchy, and so distorted that his mother, Venus, deserted him at birth. His very presence repels romantic idealizations and the gaze into the mirror of Venusian vanity as well as Narcissus’s rapt reflection. Priapic reflection starts the other way around; his preposterous swollen condition reflects the vitality of the world. The same force displays in him as in the buds and germinating pods. By means of distortion which deceptively seems “only natural,” Priapus invites the grotesque pathologized disproportions of imagination - and imagination, says Bachelard, works by deformation.
So, when I invoke Priapus, I am not speaking of priapismus; I am not speaking of machismo; and I am not anti-feminine. Let me be quite clear. I am speaking of the generative artificiality that is the essence of the garden and of the psyche. Each dream, each fantasy, and each symptomatic complication of natural health and normative humanity bears witness to the psyche’s libidinal pleasure in exaggeration, its fertile genius for imaginative distortion. If this god of gardens is also a god of psychoanalysis - and from Charcot through Lacan the priapic has been invoked - he brings to its work an archaic reflex beyond the romantic or baroque, a rousing urgency forward and outward. (Priapus was not permitted indoors in Hestia’s closed rooms where his presence becomes only violent and obscene.)
Moreover, this god needs no mirror to know himself, for his self is wholly displayed. His nature cannot be concealed within, so he is quite free of hidden meanings and subtle innuendos that keep psychoanalysis hopefully addicted to one more revelation, one more transformation, interminable. Priapus knows no metamorphosis, no transfigurations. Priapus is without ambiguity; metaphor is forbidden to him; he displays all, reveals nothing. Like the garden, all there. The rocks are the rocks.
<"And I also say to you that you are Peter, and on this rock I will build My church, and the gates of Hades shall not prevail against it." - Matthew 16:18>