You may not know Joseph Merlino, but he knows about you and what makes you function.  He knows what turns you on and he knows whether it is a problem for you.  Merlino, who is the psychiatry adviser to the New York Daily News, is one of the more accomplished psychiatrists in his field and he is the Senior Editor of the forthcoming book, Freud at 150: 21st Century Essays on a Man of Genius.  The battle over interpreting Freud's legacy still rages, a testament to the father of psychoanalysis and his continuing impact today.  
On the eve of the book's publication, Wikinews reporter David Shankbone went to the Upper East Side of Manhattan to discuss the past and future of Freud and psychoanalysis with Dr. Merlino, one of the preeminent modern psychoanalysts.  Shankbone took the opportunity to ask about what insanity is, discuss aberrant urges, reflect upon sadomasochism ("I'm not considered an expert in that field," laughed Dr. Merlino),  and the hegemony of heterosexuality.  
Dr. Merlino posits that absent structural, biochemical or physiological defects, insanity and pathology are relative and in flux with the changing culture of which you are a part.  So it is possible to be sane and insane all in one day if, for instance, you are gay and fly from the United Kingdom to Saudi Arabia.
DS:  How do we know what is normal and what is insane?
DS:  And that would be considered insanity?
DS:  So insanity is always relative to a society?
DS:  So eccentricity would be a form of insanity in principle, relative to whatever society found it eccentric, since it is a violation of social norms and mores?
DS:  —is 'pathological' better than 'insane' as a term?
DS:  So a woman who goes walking down the street naked in the middle of Manhattan, but fully cognizant of it and doing it to elicit a reaction, she has a pathology?
DS:  How often are people who are considered to have a mental disorder or pathology aware that their behavior is thought of as problematic by other people?
DS:  Such as a person who has an anger management problem?  The problem isn't that they are brought to anger, it's the external influences.  Even though that they know anger is not a preferable state to be in, they don't see themselves as the problem, even though they know that people get them there is a problem.  In other words, my anger is not good, but the real problem is that you made me angry.
DS:  The declassification of homosexuality as a mental disorder was a controversial debate in the psychiatric community, and it is still presented 30 years later as if it is this raging debate, and that it is just activism that was the impetus for change as opposed to any real hard science.
DS: If the issue was presented today, would it be 58% still, or would it be a greater number that do not believe homosexuality is a mental illness?
DS:  But it still has credence?
DS:  Did Judeo-Christian outlook infuse any of Freud's thinking, like it did Michel Foucalt in the The History of Sexuality?  
DS:  —but treated?
DS:  How did he discern whether a person's homosexuality was a problem with the person internally, or whether it was an external problem brought about by societal reaction to the individual?
DS:  Is his model of psychosexual development model outdated as to be useless, or is it still functioning?
DS:  How would psychoanalysis handle something like Obsessive-compulsive disorder?  It seems like the treatments that have been most successful are behavioral-cognitive and SSRI therapy.
DS:  How do you explain the exaggerated femininity of some gay men?
DS:  Chris Crocker, the YouTube celebrity known for his in-your-face femininity, perhaps falls in that category.  
DS:  What is the process by which a person develops a gender?
DS:  Do you think there are psychological distinctions between sadism and masochism in men?
DS:  Freud assumed sadism in men resulted from a distortion of an aggressive component of male sexual instinct, whereas masochism in men was seen as an aberration, completely contrary to the nature of male sexuality.  Is that still a function of psychoanalysis?
DS:  What is the motivation behind S&M?  Pain for sexual pleasure?  Gratification from cruelty?  Pleasure from power and the absence thereof?
DS:  —the missionary gets boring after awhile—
[A follow-up note from Dr. Merlino:  The above discussion assumes S&M is a consensual sexual relationship.  The gamut of behavior can run from healthy and normal to disturbed and pathological.  Clearly sadism in the context of the detached inflicting of pain on others based on the belief one has the right to do so and that others are there to be abused (e.g. rapists, batterers, etc) is pathological.  Similarly, masochistic behavior rooted in depression or a self-defeating personality make-up is pathological.]
DS:  What constitutes a paraphiliac?
DS:  Can a person be a paraphiliac and not have it be a problem?
DS:  When would cross-dressing become a disorder?  
DS:  So pathology is almost always defined in relation to your interaction with the outside world?  If I lived on an island I could just do anything I wanted and nothing would be a pathology because I am a person unto myself and it doesn't affect anyone else?
DS:  What about autoerotic asphyxiation where a person engages in that activity that can be highly dangerous—fatal—yet they don't believe it?  Is it a 'smoker's denial'?  
DS:  With obsessions such as paraphilias, a person presents things to themselves in a series of questions.  What if I'm really gay?  What if I really want to seduce my patient?  What if I really was aroused by a picture of that child?  If someone comes to you and says, 'I just can't get out of my head the thought that I want to kill my baby', how do you handle such a challenging problem?
DS:  The difference is between having a thought occur, and actually acting it out in one's head?  It's "I thought about wanting to kill my baby," versus, "I'm picturing drowning my baby in the bathtub almost every night I wash her."
DS:  I have a personal example that makes me laugh.  There is a 60-year-old woman at work named Barbara who I have never met, but to whom I have spoken on the phone.  I don't know many Barbaras, but I remember the opening scene of Night of the Living Dead where the brother and sister are in the cemetery and to give the sister, Barbara, a scare, the brother starts going, "Baahbarah, Baaahbarah, they are coming to get you, Barbara."  It makes me laugh to imagine a scenario of calling this 60-year-old Barbara at work and saying that into the phone.  I have acted this out many, many times with my office mates, and it makes us laugh.  It's making me laugh now, the thought of doing something that bizarre—  
DS:  Behind it is the idea...I would never...
DS:  No, she's just another co-worker, who I've never even met.  We've just spoken on the phone once.  She has a kind voice.  But I have acted this out in my head often, as a way to give myself a chuckle.  To actually do it would be mortifying.  It might scare her and I wouldn't want to do that.
DS:  [Laughs]  But would that be a pathology, that I've acted this harassing phone call out in my head?  And if it's not a problem, is it because the act is relatively harmless, as opposed to wanting to drown my baby?
DS:  Such as, why do I find violating a social norm or more amusing?
DS:  Is there always a connection?  For instance, just that opening of the movie sticks in my head and I don't meet many Barbaras.  It was just something that popped into my head, synapses fired.  And that movie did play a role in my life, trust me.  But would it always signify something deeper than that?
DS:  Have you noticed any affect that the current political culture has had on your patients, in terms of the Iraq War?  Either in pathologies where the war is manifesting itself, or in just a general discomfort with the state of the culture and society as it is?
DS:  What do you mean when you say 'doing anything about it'?
DS:  We have been in this war for four years.  Is it important to discuss it?
DS:  Do you think people are putting their heads in the sand, or do you think it is too much for people to process what is happening?
DS:  But we respond to it.
DS:  How do you think that affects personality development, that our interactions today are so two-dimensional?
DS:  It seems a lot of pathology comes from people being isolated, living in their own heads and coming up with their own theories absent the interaction of other people.  They develop entire systems of beliefs and what they think motivates other people.
DS:  But it's not going to go back.  It's here to stay.

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Dr. Joseph Merlino is Director of Psychiatry and Behavioral Health at Queens Hospital Center.  He is Clinical Professor of Psychiatry at the Mount Sinai School of Medicine and Adjunct Professor of Psychiatry and Behavioral Sciences at New York Medical College, where he is also Supervising and Training Analyst.  He is a Distinguished Fellow of the American Psychiatric Association, a Fellow of The American Academy of Psychoanalysis & Dynamic Psychiatry, and a member of the Group for the Advancement of Psychiatry and the American College of Psychiatrists. Dr. Merlino is the immediate Past-President of the American Academy of Psychoanalysis and Dynamic Psychiatry, one of the nation's four major psychoanalytic organizations. He is Senior Editor of Freud at 150: 21st Century Essays on a Man of Genius, due to be published October 28 by Jason Aronson Press, and is co-editor of American Psychiatry & Homosexuality, recently published by Haworth Press. Dr. Merlino is also an expert consultant with The Forensic Panel in New York City.  He is the former director of community and ambulatory psychiatry at Bellevue Hospital Center, the oldest public hospital in the United States.  Dr. Merlino lectures and has published in the areas of applied psychoanalysis and medical ethics.  He is in private practice in Manhattan.

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Dr. Joseph Merlino on sexuality, insanity, Freud, fetishes and apathy