Reflections on Psychiatry, the Fear of Insanity, Trauma and Psychotherapy

Symptoms Reconsidered

I was fired from my first two jobs in psychology. Basically, I had made the mistake of talking to people. In the first case I was a senior in college and was working as a research assistant in a sleep lab. My job entailed placing electrodes on subjects and hooking them up to various machines to measure eye movements, respirations and muscle tone while they slept in the lab. I was to wake them during different stages of sleep and record their dreams. My training consisted of instruction in the use of the technical equipment.

One night the director of the study appeared while I was hooking up one of the subjects. I was chatting with the subject during this often-tedious process.

The next day the director called an emergency staff meeting. He was horrified that I had been talking to a subject. I tried to explain that I had never been told not to talk to the subjects but he cut me off. He proceeded to speak with two of the senior researchers as if I was not in the room. After the meeting I was summoned to the office of one of the senior people and fired.

I was, of course, devastated. Fortunately, the person who had been assigned the thankless task of giving me the ax was kind. He informed me there were many other areas of psychology that might suit me better. He told me that since I liked to talk to other people, clinical psychology might be a better fit.

My first job in the clinical arena went even worse. Shortly after graduation, I moved to Boston and got a job as a counselor in a program for the chronically mentally ill. The state hospitals were being closed and patients were put into apartments where they slept. From early in the morning until after dinner they came to what would now be called a day treatment program.

The psychiatrist who hired me was clearly afraid of the patients. He spent all of his time in his 3^rd floor office of the old brownstone that housed the program. To be fair these patients were not the most appealing people but they were not dangerous. Their lives were mostly sad and empty. Many had been lobotomized and all were heavily medicated.

Each morning one of the counselors would begin the day by convening everyone in a large meeting room. The counselor would orient the patients to the activities of the day and address any issues that may have arisen in the past 24 hours. When I arrived for work that fateful morning, I was informed that one of the patients had suicided the night before. As luck would have it, it was my turn to convene the daily meeting.

The patients needed to be informed so I started by saying that something sad had happened the night before. I told them of the suicide and went on to say, “All of us have experienced the kind of darkness that “Jane” must have known but it is not a solution.” I am not sure if those were my exact words but that captures the spirit of what I communicated. I had certainly known that darkness and I was trying to bring the community together.

That afternoon I was fired. The psychiatrist was clearly shaken and who could blame him. There was after all a dead patient. But what he focused on was what I said in the community meeting. He believed I had breeched the boundary between staff and patients and this could only increase the anxiety of the patients. The patients needed to view the staff as somehow invulnerable. In his eyes I had increased the likelihood that another patient would suicide.

I had enough sense to not buy this. The realization that people who are drawn to careers in the field are simultaneously fascinated and afraid of insanity was starting to dawn on me. For the most part the fear of the clinician expresses itself in conventions that have the effect of creating interpersonal distance between the therapist and the patient.

In the world of medicine symptoms are seen as evidence of some disease process. The practice of medicine involves diagnosing the disease and ideally curing it. In this way the symptom is eliminated. More often we find that the disease itself is not curable but the symptoms can be relieved. Consider diabetes where the disease process cannot be cured but by supplementing the diabetic with insulin the symptoms can be managed and the patient can be restored to far more optimal functioning than would be possible without the insulin. In attempting to apply a medical model to the psyche we attempt a similar approach. The use of psychotropic medications to eliminate symptoms has its merits and would be an end in itself if psychological symptoms were simply evidence of some disease process.

But what if psychological symptoms are very different than physical ones? What if psychological symptoms contain important information about the process of cure? Would it then be possible that the elimination of the symptom would undermine the likelihood of a cure? I would like to suggest that we reconsider symptoms by proposing that symptoms are the psyche’s latest best effort to preserve and heal itself.  In other words symptoms play a crucial role in both signaling that something is amiss and in restoring the psyche to optimal functioning.

To illustrate this consider the example of posttraumatic stress disorder. In this condition a person experiences distressing symptoms after a traumatic event. The symptoms can be divided into 2 categories, numbing symptoms and hyper-arousal symptoms. In treating PTSD one thing that is perplexing is that victims of this condition often adopt an interpretation of the traumatic event that isolates and/or demeans them.

One might reasonably ask why the psyche adopts an isolating and demeaning interpretation of events that “objectively” have nothing to do with the victim of trauma.

If we consider that symptoms are the psyche’s latest best effort to preserve and heal itself, a way of understanding this comes to light. It is my sense that in the world of the psyche isolation and stigma are preferable to disintegration. In other words when events are overwhelming and an individual is faced with psychological disintegration, the psyche protects itself by interpreting events in this way. The idea that “I am bad or shameful” is preferable to the dissolution of the self. Isolation serves the purpose a providing a sense of control to the victim and insulating them from a competing, though often more benign, interpretation.

The idea here is that any form of organization is better than the terror of disorganization. An isolating and demeaning interpretation is uniquely efficient in protecting a person from the threat of annihilation. To conclude “I am bad” does not require the endorsement of other people. One can arrive at this autonomously and, likewise, one can always feel alone. These interpretations can be reinforced by events in the life of trauma victims in that people with damaged self-esteem who feel isolated often behave in ways that further isolate and demean them.

This way of interpreting events is autonomous and self-confirming. When it goes on too long the very thing that was supposed to protect the self begins to choke the life out of it. We might think of the trauma response as a protective cast on a broken limb or sedation of a shock victim. It should be time limited.

One of the problems is that when you attempt to take the cast off or discontinue the sedation, the threat of the original experience and the threat of disintegration re-emerge, at least temporarily. When this structure is prematurely threatened paranoia may be the initial response. Again, any form of organization is better than none and paranoia has the advantage of concluding, “You are bad” rather than “I am bad”. But a more adaptive and potentially healing response would be to somehow access a sense of the deep spiritual connection that lies just beneath the surface of our personal suffering.

Pain, Mental Illness and Spirituality

When we assert that symptoms are the psyche’s latest best effort to preserve and heal itself, the implication is that there are protective aspects of the symptom (preserve) and developmental aspects of the symptom(heal).  The numbing and low self esteem aspects of trauma victims can be seen as protecting the psyche while the hyper arousal symptoms can be thought of as effort at development. At the extreme the symptoms of psychosis and suicidality are distorted attempts at a kind of healing.

When pain is overwhelming, we break through the boundaries of our own personal grief to a suffering, primitive and undifferentiated, that informs human existence. At a personal level suffering can often feel isolating. At this more primitive level it somehow connects us to our humanness.

The boundary between this personal level of experience and the more primitive level is the personality that I define as who you know yourself to be. From this point of view psychosis involves the breaking apart of who you know yourself to be and suicide involves the extermination of who you know yourself to be.

Personalities formed in the context of trauma can be extremely fragile. Suicide and psychosis are more likely because the person’s attachment to their idea of themselves is their only defense against overwhelming distress. In order to experience their essential value, such a person would have to be able to tolerate shame to gain access to a more benign experience. Too often people cannot tolerate the pain and reference this in their suicide notes about wanting to end the suffering. They explicitly reference their shame and isolation when they speak of their families, friends and, even, the world being better off without them.

But even in their moment of despair there may be an intuitive sense of wanting a more primitive and benign connection to an aspect of human experience that eludes them. They seek in death not just an end to their pain and isolation but a sense of oneness with a transpersonal reality. The willingness of those who participated in the mass suicide at Jonestown is a testimony to this impulse.

The distinction between some of what we currently define as mental illness and spirituality is a function of a person’s capacity to tolerate distress. When Christ was being crucified, at the extreme moment of his suffering, he surrendered his idea of himself and in that moment was reunited with his father. His lament “Father! Why have you forsaken me?” can be thought of as the person, Jesus, letting go of his identification with his idea of himself. By surrendering his attachment to his uniquely human experience, he was delivered over into a more profoundly spiritual experience where his personality was of no importance.

The crucifixion/resurrection story is one possible form that psychic transformation takes. In the suffering on the cross Christ was tormented out of his human incarnation. The parallel psychologically is that the suffering of living tortures us out of our current version of ourselves. What is revealed in this suffering is how much our attachment to our idea of who we are is self-limiting, rigid and ultimately isolating. Our idea of ourselves is especially self-limiting, rigid and isolating when it is formed in response to psychologically painful events that need to be redeemed.

The resurrection of Christ represents a way of being that is unencumbered by the specificity of his human incarnation. The parallel psychologically is that in surrendering to our human vulnerability we become less attached to the specificity of our current version of who we are and more able to live unencumbered by the requirements of our personality.

Some version of this redemption story is at work in the process of hitting bottom. In an effort to fend off or alleviate distress people resort to substances or compulsive behaviors. Once the need for these substances or behaviors develops a life of its own in the form of addiction, the original suffering that created the context for the behavior is compounded by the distress associated with the addiction. In an effort to control their experience the addict helps create a situation where they have no control and their life becomes unmanageable.

This generic process is always informed by the addict’s specific version of himself or herself, which becomes progressively more dominated by the struggle for control and comfort. Only when they give up the fight and accept defeat are they delivered from the fight they cannot win. The relief associated with this process of surrender is one psychological explanation for the “gratitude” often referenced in AA meetings.

Injury and Trauma

In the normal course of human development the capacity to tolerate discomfort is essential. Delayed gratification is to some extent a hallmark of development milestones. Given optimal conditions the capacity to tolerate discomfort grows in parallel with the developing human being. More often than not, however, there are disruptions in the trajectory of development. When this happens the individual’s capacity to self soothe is overwhelmed.

In the simplest terms some sort of injury takes place in a person’s life and the response to the injury has important consequences for future development. In this connection it is important to distinguish between injury and trauma. Why is it that certain apparently minor injuries are traumatic, leading to developmentally retarding consequences, while other, often more dramatic injuries, are more easily incorporated into the flow of psychological development? Trauma arrests or retards development. It is my contention that the absence of benign meaning structures in the life of the injured predisposes the person to trauma.  A benign meaning structure is one where: the implications of the injury contribute to a benign valuation of the injured, and the meanings associated with the injury make a place for the injured in the community. (See Table Below)

Hierarchy of Painful Experiences

As a pre-adolescent boy I was extremely active.  I am sure I would have had a diagnosis of some kind had I been born in 1989 rather than 1949.  My trips to the doctor were not for evaluations for ADHD but to have stitches for yet another cut I had endured in one of my misadventures.  In those days people didn’t go to the emergency room for such things.  The doctor stitched you up in the office.

One particular incident stands out that helps illustrate the relationship between injury and trauma.  I was perhaps ten or eleven years old and was playing softball after school at P.S. 102 in Bay Ridge, Brooklyn where I grew up.  I was the second baseman and our field was the asphalt schoolyard framed by the el shaped building.  A Texas league pop fly was hit to short center field and I took off after it.  Running full tilt and keeping my eye on the ball, I dove for the ball attempting to make a backhand catch.  Schoolyard folklore has it that I made the catch.  I am not so sure since I momentarily blacked out when my head and the knee of the center fielder collided.  What I remember was the blood.

I had split my cheek open and one of the teachers was trying to staunch the flow of blood with those rough brown paper towels that were standard issue in the bathrooms of NY city public schools at that time.  After the blood flow had slowed, the teacher took a look at my face and informed me that I should avoid a career as a prizefighter since it was clear I was a real “cutter.”

I walked home holding the paper towel to my face and when my mother saw what happened, she told me we had to leave right away to get me stitched up.  I told her I needed to go to the bathroom and she said, “Okay, but don’t look in the mirror.”

I remember resisting the sidelong glance into the mirror on my way to the commode. On the way out I rinsed my hands at the sink and just could not help myself. I had to check out what had happened to my face. When I looked in the mirror I saw this enormous gash and the flap of flesh hanging down the right side of my face.  I was horrified and burst into tears.

That Sunday we visited my maternal grandparents and my mother must have told my grandfather the story because he made a point of pulling me aside.  There are twenty-five first cousins in my family and whenever we visited my grandparents there were always at least ten of us running around the house.  So, to get a private audience from Gido (Arabic for grandfather) was quite an occasion.

Well he sat me down and looked at my stitches, shook his head and said in his heavy Arabic accent, “That is very ugly.  It looks very bad.  You know when the stitches come out it’s still going to look ugly.  It will be all puffy and red.  There may even be some puss.  It will take a long, long time to heal.  Even then there will still be an ugly scar.”

I don’t remember what I thought or felt at this moment but I know I was completely entranced and I was hanging on every word.  He continued:

“In time the scar will begin to fade –very slowly. At first you won’t even notice.  Very slowly over many years it will become part of your face and when you grow up to be a man this thing will give your face character.  People will look at you and say, “There is a man with character!””

I am now a man in my mid-fifties.  I am completely bald.  In my late twenties I had basil cell carcinoma on my nose that required three surgeries.  Eventually a skin graft was done so that now the entire right side of my already crooked nose is a patch of skin that was removed from the back of my ear.  In short there is more than enough “wrong” with my face for me to be embarrassed and ashamed of my appearance.  Yet, it has never occurred to me that my face is in any way unappealing.

Now, I am not trying to claim that a single incident like this has inoculated me in this area.  I am sure other signs of love and esteem were part of the culture of my family.  The story does, however, illustrate what I am calling a benign meaning structure.  It gave me a way to think about what I experienced which helped to take the sting out of what I saw in the mirror without denying reality.  It put a positive connotation of me as someone who would one day be a man with character and it placed me in a favorable position within a larger community.

More importantly, the entire structure of this experience gave me a way of tolerating the inevitable adolescent discomfort over appearance. I could look in the mirror the day before the big dance and be alarmed by the emerging pimple on my chin and still go to the dance and have fun. I could continue to engage in the process of development.

Let’s consider another example from my own life to help illustrate the notion of trauma .I attended parochial school as a child and until the 6^th grade all my teachers were nuns. On the day I have in mind our entire classroom of perhaps 50 children were practicing hymns. This was the sum total of our music instruction for our 5^th grade class.

Sister Mary Adelle was a portly asthmatic nun who could not have been more than 4’10” tall. Her face had an incredibly pinched appearance as if it had been wedged into her habit. Her high pitched and squeaking voice communicated nothing but menace. If you closed your eyes and listened, you would swear she was a witch. This impression was reinforced by her custom of making an example of one of my classmates right after lunch each day by pounding his head into the blackboard. I can remember sitting at my desk in the far left row of the room and staring at the seam in the slate and watching the chalk puff out of the crack each time his head hit the board.

The afternoon of the particular day I have in mind began with this ritual and then it was time to practice our hymns.

All the children were instructed to stand up and Sister Mary Adelle would blow into a pitch pipe and raise her hand like a conductor and we would begin. I don’t remember which hymn we were singing but we got a couple of bars into it and Sister Mary Adelle clapped her hands violently and shouted “Stop!”

She peered around the room and said, “Someone in here is singing off key.”

You could have heard a pin drop as she once again blew into the pitch pipe, raised her hand and we began to sing. She was now pacing around the room tilting her head from side to side, listening intently for the offending 10 year old. Before we could get to the refrain she clapped her hands and shouted, “Stop! Someone in here is singing off key.”

She, then, instructed us to sound off from one through eight to create perhaps six groups of eight children each. She told us to move our desks so the groups could form circles. When she had completed her directions, there were several groups of eight children each with their arms on each other’s shoulders, facing into the middle of a circle. We were to sing into the middle of the circle.

Once again she blew into her pitch pipe, raised her hand and we began. Now, Sister Mary Adelle was stalking the culprit in a systematic way. She went from one circle to the next poking her head into the middle, looking and listening left and right for the offending off-key child. When she came to my circle, she once again clapped her hands and shouted, “Stop!” She pointed at me and said “You! Just move your lips.”

It should come as no surprise that for many years after this event I avoided singing at all cost. For the purpose of this illustration the effect of this event was to isolate me from my community of peers and lead me to feel inadequate.

Going back to the distinction between injury and trauma, this event led to a negative evaluation of the injured and isolated the injured from the community. Furthermore, it undermined any future development in this area because the discomfort associated with singing led me to avoid situations where singing was required. Instead of learning how to sing (developing) I learned to withdraw and feel bad about myself in this area.

Now the good news is that it was not critical to my development to sing and the avoidance this traumatic experience engendered was pretty much isolated. What becomes more problematic is where there are traumas that lead to more pervasive or complicated developmental disruptions.

When it comes to trauma, one’s response falls into two basic categories: avoidance or activation. When the effects of trauma block the road towards important developmental milestones, like forming a relationship, getting a job or appropriately disciplining a child, strategies to preserve the self like avoidance become more problematic. In my view avoidance strategies are designed to preserve the self.  Safety is the goal.  But life and the imminence of death push us forward inviting us to confront the next challenge.  When we feel safe enough, we take the next step and come face-to-face with the distress that led us to avoidance in the first place. Without an experience altering substance such as drugs or alcohol, people attempt to transform trauma into injury that can be healed. In other words they attempt to develop.

In my own situation there came a time in my 30’s when my wife and I sought out a Catholic church that did not require us to check our brains at the door. We wanted to expose our children to the traditions we had grown up in while protecting them from the excesses of a doctrinal approach to complex moral issues.

We were fortunate to find a very loving Catholic community at Saint Vincent’s parish in Philadelphia. The congregation and pastoral staff were making an honest effort to capture the spirit of Christ in the liturgy. They had a very active music program and at Mass the entire congregation sang.

I was naturally or should I say traumatically reluctant to participate. After many months of mouthing the words or singing in a whisper, there came a day when I was so moved by the spirit of the community that I just let myself sing.

After services that day, a woman who had been sitting in front of me approached.

She asked “Were you ever in the seminary?”

I said “No. Why do you ask?”

She replied, “Well your voice is so lovely I thought you may have trained in the seminary.”

You could have knocked me over with a feather. Now, I am not about to go out and cut my first CD, but I can tell you I am more inclined than ever to pursue a secret desire I have harbored for over 40 years to take voice lessons. Returning once again to injury and trauma, Saint Vincent’s helped to give me a community and this woman’s kind words moved me closer to a benign evaluation of my self.

People are continually engaged in similar processes in the natural course of development. The effort to transform isolating and stigmatizing events into more positive and relational ones is ubiquitous. Political events in the Middle East come to mind, as does our ongoing struggle over race relations. My own research on repetitive marital conflict reveals that marital conflicts are often fueled by each partner’s effort to transform their own early traumas into something positive in the relationship.

In its simplest form psychotherapy could be conceptualized as an experience where shame is transformed into esteem and isolation mutates into relationship. Intense emotional distress is part and parcel of the experience of shame and isolation. There are several possible responses to these experiences. Drug and alcohol abuse are especially dangerous because thy abort the development process.

Bias in Psychotherapy

If we can accept the premise that psychologically damaging events are isolating and demeaning, then it follows that the repair of the damage involves developing relationships and cultivating esteem.  Many people who are drawn to careers in psychology are both fascinated and afraid of madness.  Embedded in the way professionals think about mental illness are isolating and demeaning tendencies that inadvertently exacerbate the very problems the field is trying to correct.

The most obvious example of this is the simple act of diagnosis.  Thirty years ago while visiting my future wife during her surgical rotation in medical school I overheard two surgeons discussing their day in the Operating Room.  One was telling the other he had done “two gall bladders” and the other countered that he had done “three hernias”.

This struck me as an interesting way to talk.  I commented to some of the other medical students that it was as if these organs were not attached to human beings.  These students had all just witnessed their first surgeries and a conversation ensued about the surgical theater and how the area to be operated on was visually isolated from the rest of the patient’s body.  There are some antiseptic reasons for this but all the students agreed that this convention was useful in blocking out the momentousness of cutting into another human being.

Basically, it became apparent that in order to be able to cut into another’s flesh, it was useful to not think of them as a person.  The surgeons referencing “gall bladders” and “hernias” could be seen as an extension of the need to depersonalize the process, to isolate the offending organ from the human organism.

In the process of diagnosing a problem, the mental health practitioner is inherently isolating and demeaning the person diagnosed.  If mental illness were like diseased gall bladders there would not be an issue.  But what we call mental illnesses are conditions that change as a function of the way they are described.  When we assign a diagnosis we are moving in the direction of objectifying the person diagnosed.  This has the unintended effect of also making it less likely the person will experience relief from what we are calling depression unless we take pains to address the isolating and demeaning effects of the diagnosis.  No psychotherapist worth the title would ever chat with a colleague about having seen two depressives, three bi-polars and one schizoaffective before lunch. Yet today in the mail I received a brochure touting a CE program called “Assessing, Managing and Treating Personality Disorders: A Gathering of Experts”. I get at least three of these a month.

It is my contention that the tendency to think this way is a function of the same fascination and fear that leads people to a career in psychology in the first place.  By describing human psychic suffering in diagnostic terms we simultaneously create distance between ourselves and the suffering, comfort ourselves with the illusion of control over the suffering and congratulate ourselves with having figured something out.  But no one has been helped and real harm may have been done.

Case Illustration

Consider the case of one of the most deeply disturbed men I have ever had the pleasure of working with.  I was an intern in my final year of doctoral training working with school age boys in a clinic connected to a school for learning disabled kids.  My caseload was mostly boys between ages 8-12, but we also worked with people from the community.

My wife was in her final year of residency and my office was only a few blocks from our home in Philadelphia.  Every Thursday I would take my lunch hour to do the food shopping for our little family.  Eileen was pregnant with out first child and it seemed like we already had three mouths to feed.

On one particular Thursday in January of 1983 it was incredibly cold.  It was a point of pride with me that I could leave the clinic, do the food shopping, unload the groceries at our house and be back at the clinic within an hour.  So I had raced through the aisles and got myself on a short checkout line when a woman who seemed about my age got in line behind me.  I noticed she had on a lightweight wool coat and had one of those two-wheeled carts people use to walk home with their groceries.  It was perhaps five degrees outside and I began to wonder how far she had to go.

I felt somewhat awkward because I didn’t want her to get the wrong impression and I knew any side trip would cause me to be late getting back to work.  Still, the thought of anyone having to walk too far in that cold was disconcerting.  So I struck up a conversation with her.  Before long she told she “only” had eight blocks to walk and I had offered her a ride, which she gratefully accepted.  It turned out she had a car but it would not start because of the cold.

At some point she asked me what I did for a living and when I told her I was a psychologist, her eyes lit up.  She wanted to know where I worked and what kind of people I saw.  There was real urgency in her questions and, shortly, she was asking if I would be willing to talk to her brother-in-law.  This took place as I was driving to her home.

I found out he was living with her and her husband, was very disturbed but would not talk to a professional because of “what happened in New York”.  As we were driving the last half block I told her that if she could get him to me, I would be happy to talk with him.  At this point I pulled into their driveway and up to the rear of her car and was astonished by the sight of a young man dressed in shorts and a tee shirt attempting to wash the windows of her stalled car.

During this period of my training I was in a psycho-diagnostics seminar where we learned psychological testing.  In our discussions I often wondered about the need for these complex procedures in cases where a person was obviously disturbed.  These questions were tied up with my intuitive sense that something was wrong with the entire process.  We would watch videotape of the clients during their assessments and at one point I coined the term “the inter-ocular test”.  This referred to someone who was so obviously out of sorts that it hit you right between the eyes.

Well this woman’s brother-in-law passed or flunked the inter-ocular test.  Not only had he underdressed for the part of gas station attendant, but also he was dribbling massive amounts of mucus into his mustache and mouth that had frozen in place.  As we unloaded the groceries, Steve and I were introduced and arrangements were made for us to have a conversation the next day.

This young man fit the classic description for schizophrenia and had in fact been hospitalized at one of the most respected psychiatric hospitals in New York.  He had signed himself out of the hospital against medical advice because he objected to his diagnosis and stopped taking his medication.  Within days he was actually psychotic but unwilling to speak with professionals.  By the time I met him he had wandered from one family member to the next.

I had a sense that part of his willingness to talk to me was my lack of status as an intern and the fact that we had met outside of an institutional setting.  His defiance of the psychiatric authorities notwithstanding, or, perhaps, because of it, he was an excellent client.

He began our first session with the announcement, “I am not a schizophrenic!”

Fair enough, I thought, “I am not a noun either,” and we began.

Steve’s behavior in our sessions mirrored the reports I received from his family.  He would exhibit periods of lucidity punctuated by episodes of frankly bizarre behavior.  Sometimes the behavior would have some apparent connection to a shared social reality as in the case of cleaning the windshield, but often there was no apparent connection to the world beyond his psychotic truth.  The one constant was his somewhat bizarre and off-putting demeanor.  His speech was always pressured, his hair disheveled and his eyes bugged out of his head.

Often what someone says in the first few moments of the first encounter is crucial to the future course of the therapy.  What I learned from Steve was that as long as we did not refer to him as a “schizophrenic” we could pretty much talk about anything.

I noticed over time that there seemed to be some rhyme and reason to his bizarre outbreaks.  Once, when the subject of girls came up, he abruptly sat forward in his chair and began doing what appeared to be the backstroke while looking at the ceiling and humming to himself.  Often when we were having what I thought was a good conversation and I felt a certain warmth developing between us, it would be interrupted by word salad or strange facial contortions.  Attempts on my part to find out what he was experiencing were unsuccessful.

On one occasion we were engrossed in an intense conversation.  The form of our conversations would follow a predictable path where Steve would say something and I would respond.  Often what he would say would have some not quite normal aspect to it, but rather than confront the “not quite normal” I would respond to the part of it that would make sense.  Our very first exchange is a good example of this.  It’s “not quite normal” to introduce yourself by saying “I am not a schizophrenic”, but rather than confront him with “Hello?” or “Are you concerned about being called a schizophrenic?” I attempted to join him by saying, “I am not a noun either.”  I was attempting to relate rather than confront.

Intuitively I sensed that his illness caused him to behave in ways that isolated him and caused him to be demeaned.  My response was trying to communicate, “You and I are alike” – this cut into the isolation and “schizophrenic is just another noun” – this attempted to neutralize the demeaning quality of the word.

I don’t remember the content of our conversation or the occasion I have in mind, but I know we were connecting in a good way when suddenly, something like panic flickered across Steve’s face.  The next thing I knew he had jumped out of his chair and began a series of apparently bizarre movements in the middle of my office.  He was balancing himself on one foot with his arms extended looking like the human incarnation of a stork.

I asked him, “What’s that?”

He responded, “Tae Kwan Do!”

I said, “Show me,” and got up and stood next to him and began to imitate his movements while asking him to let me know how well I was doing.  The remainder of our session consisted of my first Tae Kwan Do lesson.

At the time I had no clear idea of what guided my behavior in this exchange. What I knew then was that I could not do a lot of things that my previous training had suggested. I could not make the observation that he had abruptly changed the subject when the conversation took on a certain emotional tone or inquire as to what was going on inside him when he jumped from his chair. I could not interpret that the closeness that was developing between us might be activating a homosexual panic in him as some of my psychoanalytically trained cohorts may have speculated at the time. I certainly could not have engaged in “active listening” since I was not dealing with spoken communication. A less disturbed client would have tolerated these kinds of interventions, but I am not convinced they would have done them much good. Steve could not have tolerated them and they would have driven him further into his isolation and shame. What I intuitively sensed at the time and have now come to understand is that Steve needed me to help him create a relational environment that would counteract his tendency to behave in ways that would lead to isolation and stigma.

By joining him in the practice of Tae Kwan Do and asking him to instruct me I was implicitly trying to stay connected to him and honoring him as someone with superior knowledge.

For the most part, Steve was incapable of articulating his own experience.  He was a follower of Baba Ram Dass, the former Harvard psychology professor turned Buddhist, and we could talk about Eastern religion.  I discovered that Steve had been told by Ram Dass himself that the pathway to Atman is through Brahmin.  I was, of course, skeptical that he was actually in touch with Ram Dass but I found out later through letters Steve showed me that he had in fact corresponded with him.  The pathway to Atman is through Brahmin suggests that the way to enlightenment is through mundane, everyday activities.

This turned out to be the perfect bridge between this man’s tortured experience and his ability to participate in what most of us commonly refer to as reality.  During this entire period Steve was unwilling to take medication and although he had stabilized to some extent he was unable to find a job or sustain any ongoing social relations with people other than his family.

Using the pathway to Atman is through Brahmin situation we addressed issues like personal hygiene, dressing appropriately and eating properly.  These all fit nicely into the traditions of Buddhism and I had familiarized myself with some of the classic Buddhist parables to help us with the work.

In one such story, the acolyte approaches the master after a long journey and says breathlessly, “Master, I have come to attain enlightenment.”  The master replies, “Have you eaten?”  The devotee answers, “No.”  The master instructs him to “Go and eat a bowl of rice.”

Somewhat frustrated the student leaves and returns shortly, a little more calm, and says, “Master, I have come to attain enlightenment.”  Again the master asks, “Have you eaten?”  The student replies, “Yes.”  The master asks, “Have you cleaned your bowl?”  The student answers, “No.”  “Then go clean your bowl,” the master says.

The student, obviously irritated, blurts out, “I came a long way and traveled through the night.  What does eating rice and cleaning my bowl have to do with attaining enlightenment?”

When the student looks to the master for a response, he sees the master has fallen asleep and peevishly goes off to clean his bowl.

So in this way Steve and I talked about enlightenment as something that could only be attained in submission to the day-to-day requirements of living.  And it is not as if he were the only one needing to learn these lessons.  I had recently married and with a pregnant wife I was getting a crash course in the requirements of living.

At some point we were able to discuss his brain in the same way we could talk about his hair.  Both required basic hygiene.  If he went for too long, his hair would become greasy and matted and his bangs would fall over his forehead.  This could contribute to the acne, which made it difficult to attract girls.  Of course, the way you begin to smell when you haven’t washed doesn’t help either.  So, the idea was that your hair has requirements that you need to attend to if you want to be able to attract a girl.

Likewise, your brain has certain basic requirements which you need to attend to in order to help it function in the optimal way.  I explained that Steve was born with a unique sort of brain that gave him the capacity to experience things that most people could not experience but it also had a fragility that made it difficult to experience the world in more conventional ways.  For this reason Steve had less room for error in his life.  He could fight the demands of his special sort of brain or he could submit to its requirements by doing the kinds of things that would make it possible for him to function.  In addition to enough sleep, proper diet and respect for his brain’s unique sensitivity to stimuli, I suggested that every other week injections of Prolixin D, an anti-psychotic medication, would make it profoundly more possible to pursue “right practice”.

Once Steve agreed to the medication, things progressed more rapidly.  The bi-monthly injections increased the likelihood of his compliance and made it unnecessary for him to have to deal with the potential indignity on a daily basis.  But as far as I know, he never experienced the medicine in this way because it was embedded in a more benign way of thinking about himself and his unique requirements for living.

From the point of view of what has been called the medical model, the apparent success of Steve’s treatment is a simple matter of persuading him to take medicine to correct the chemical imbalance in his brain.  I have no problem with that description as far as it goes, but it is a description that is bereft of any unique or nuanced meaning in the life of the patient.

That way of thinking brings to mind a conversation I once had with a fellow while playing golf.  Lou and I were introduced on the first tee at Kimberton golf course in Phoenixville, PA in the spring of 1988.  After playing the first hole, he informed me that he had just retired from his position as Assistant Principal of the local high school.  He let me know he was a Veteran of the Korean War and was a “no-nonsense” kind of guy.  As we walked up the second fairway, he asked me what I did for a living.  I said, “I’m a psychologist.”

He asked, “You mean like a school psychologist?”

I replied, “No, I am a clinical psychologist.  School psychologists do a lot of testing and evaluation whereas I mostly talk to people.”

Lou continued, “Well, what do you talk about?”

“All kinds of stuff,” I answered, “but for the most part you could say I talk to people about their problems in living.”

He inquired, “And you get paid for that?”

I responded, “Yes.  As a matter of fact, people generally pay me when I see them and often get some reimbursement from their health insurance.”

“Oh,” Lou replied.

I could tell he was pondering these revelations as we approached the second green, but the whole subject seemed to have dropped over the horizon, as we got absorbed in the game.  So I was a little startled when, two holes later, as we left the tee of the par 3 fifth hole he approached me and said, “You know what you do for a living?  Where you talk to people and they give you money?”

I said, “Yeah.”

“Well,” he continued, “I know it’s not illegal or anything, but isn’t it kind of like stealing?”

To which I replied, “You know it’s really more like selling water by the side of the river.  It would be wrong except for all the people dying of thirst on the banks.”

For people like Steve it’s obvious that taking the proper medicine helps enormously in controlling his symptoms.  But the question is what way of thinking about these things maximizes the likelihood that medicine will be seen as an act of self-love and esteem and not as something demeaning and isolating.

We have come so far in the area of developing our pharmacopeias.  But most physicians will tell you the biggest problem we have in getting the therapeutic benefit from these wonderful medicines is what pharmaceutical companies call “compliance”.  This is especially the case when it comes to mental illness.

Bias in Favor of the Past

Another bias that is built into the structure of psychotherapy is a pre-occupation with the past. One of the basic discoveries of psychoanalysis was the observation that a person’s current problems bore a striking resemblance to difficulties in their past. This insight has been refined over the years and my own research into repetitive marital conflict focused on the similarity between couple’s current unresolved conflicts and the early life experiences that seemed to fuel these struggles.

Some of the disaffection with psychoanalysis and psychotherapy in general is based on the perception that therapy is an endless rehashing of the past or the occasion to continually blame one’s parents for current difficulties. Indeed entire schools of psychotherapy from Gestalt to cognitive behavioral specifically challenge the focus on the past. The argument within the field has focused on the issue of insight leading to change. The fact is that simply seeing the connection between painful early life experiences and current difficulties does little good. Anyone who has had these correlations pointed out repeatedly can attest to the debilitating effect of such observations. The comic relief of a character like Woody Allen draws its pathos from the discouragement that accompanies this sort of preoccupation.

The fact is that painful life experiences tend to exercise a regressive pull on a person. There are basically two responses to painful events, avoidance and attempts at mastery. The wish to avoid the pain in the future leads us to overgeneralise from the painful event. We end up avoiding situations that we experience as similar and opportunities for development are missed. Alternatively, we attempt to master the threatening situation. But because the threat of the painful event is now embedded in our experience, we bring an emotional charge or edge to the situation, which can paradoxically lead to a re-enactment of the painful experience.

It was Freud who coined the phrase the “the narcissism of small differences”. This phrase aptly expresses the bias built into psychoanalysis to treat perception of differences between past and current events as unimportant. What was considered important was the similarity between the past and the present. The bias in favor of the past has been one of the unintended consequences of the fascination with this fundamental insight. But if we can accept that painful experiences create an experiential bias, a therapy that is itself biased towards the past exacerbates an already regressive process.

When a person is suffering from PTSD and is having a flashback, the arousal they are experiencing is driving their perception. They feel as if the traumatic event is happening again. What is potentially healing is that the current situation is in fact different. To point out whatever similarity there is between the current situation and the traumatic past without also noting the differences would be cruel indeed. But this is precisely what is done in a lot of well meaning psychotherapy.

One of the arguments for the belief in the existence of the “repetition compulsion” is the observation that people seem drawn to circumstances that are likely to re-injure them in ways similar to the past. Clearly, if we can learn anything from PTSD, it is that one of the consequences of painful events is a bias in the direction of experiencing similar events as painful. All things being equal people who have been hurt will end up in hurtful circumstances until whatever pain they have experienced is resolved. A more optimistic view of this tendency is that there is a bias built into the human organism toward healing injuries. As it turns out in the world of the psyche, in order to fully recover from an injury a person often must risk re-injury to discover that the feared painful event does not recur, but is truly in the past.

Cultural Bias

What is it about mental illness that leads us as a culture to treat it in such an isolating and demeaning way?  What is it that causes the symptoms?  Some failing of upbringing or character has been thought to be the culprit, but now that a description that focuses on brain chemistry has been put forward, the culture seems no more inclined to embrace the afflicted.  Diabetes is okay, for example, but mental illness is not.

It seems to me that things like mental illness and addiction strike at the core of our collective and individual illusions about control.  Addiction and mental illness threaten the illusion and the sense of coherence that goes along with it.  I believe it was Escher who maintained that a system of ideas can either be internally consistent or it can be complete, but it could never be both.

For example, the idea that 1 + 1 = 2 is perfectly internally consistent.  It applies in every situation and at all times.  But it is profoundly incomplete in that it addresses only a tiny fraction of what could possibly be described.

As a culture we are reflexively biased toward internal consistency at the expense of completeness.  As a consequence we initially attempt to exclude anything that threatens the sense of internal consistency.  To the extent that belief in control is central to our way of thinking, things that expose the illusion associated with that belief are unwelcome.  Experiences like “hitting bottom” are liberating precisely because they relieve us of the futile struggle of continuing to fight for a control that is not possible.

Of the two protagonists in the vignettes I have related, Steve and Lou, Steve’s world is far richer and more complete.  Lou’s “no-nonsense” approach suggests a world where there is no place for whatever he does not understand.  It’s either crazy or criminal.  Steve comes from what I would call “the broken world” and Lou is a citizen of “the unbroken world.”

The “broken world” includes “the unbroken”.  It is the larger world.  The unbroken lack access to that which becomes apparent in the broken world.  People of the broken world are too often saddled with shame or feel in some way diminished by their brokenness.  This is reinforced by the fact that people from the unbroken world trivialize, marginalize, demonize or pathologize much of what the broken bring to the table.

No one volunteers to be broken and the unbroken act as if they want nothing to do with it.  The challenge for the broken is to honor and make a place for all that has become accessible because of their brokenness.

I am not talking about building a monument to it or getting involved in some sort of social cause.  Part of fully honoring one’s brokenness is compassion for those whose world lacks the richness that only becomes possible in the context of one’s world having been broken open.  When a person’s world breaks, what is lost in coherence is gained in possibility.

There are so many ways our culture expresses its fear of whatever it does not understand.  This general attitude, however, finds a unique expression in the fascination with and fear of madness as revealed in one of our own classic psychological procedures.

The classic posture of the psychoanalyst and the patient is one where the patient is reclining on a couch while the doctor is sitting upright in a chair.  The doctor is positioned in such a way that the patient cannot see the doctor but the doctor can see the patient.  The patient is instructed to say whatever comes into their mind.  A procedure called free association, which is designed to elicit the non-logical, non-rational contents of consciousness; in other words, the potentially mad musings of the patient.  The doctor, sitting apart from and above the patient, expresses his fascination through close attention to the ramblings of the analysand.  The fear of this “madness” is expressed through the interpretation of whatever the patient says in terms of predetermined set of psychic structures and central myths.

This procedure produces some pretty interesting experiences for the patient who is well functioning and has a reasonably intact personality structure but it can be pretty unsettling for people with a whole host of treatable conditions.

One of the justifications for this process is the idea that the therapist must remain a blank screen.  In the tradition of psychotherapy with psychoanalysis being the original prototype, the notion of the therapist as a blank screen was thought to evoke the transference reaction of the patient.  The idea being that the transference is the way the patient will distort their experience.  By definition patients distort and therapists clarify.  Whatever the patient says is a projection on to the blank screen and reveals the inner life of the patient.  The important dilemmas that the person comes to the process with can only be brought out through a blank screen because any stimulation will contaminate the transference.

I always thought that was a convenient vehicle for the therapist to remain hidden.  The danger of the structure is for the therapist to maintain a one-up position with the patient.  It seems like an extraordinarily unnatural relational context or dynamic.  What I have concluded over the years is that if something is really potent and a person needs to address it, it will express itself regardless of whether the therapist is transparent or opaque.  The point is that there is no such thing as a blank screen or uncontaminated relational environment.

Most people intuitively sense that there is something slightly absurd in this classic psychoanalytic structure.  A not very sophisticated friend of mine used to tease me about what I did for a living.  He was cut out of the same cloth as Lou, who thought what I did was a little like stealing.  But at least this guy, whose name was Tony, had a sense of humor.

He said, “You have the most amazing job.  All you do is sit there all day listening to people.  One after another they come in and spill their guts and all you do is sit there saying, ‘Uhuh, uhuh, uhuh, your mother.  Uhuh, uhuh, uhuh, your mother.’  Then after forty-five minutes they get up and give you money.”

Embedded in the entire structure of psychoanalysis is the idea of the doctor who knows and the patient who has yet to have the distorting effects of their personalities sufficiently analyzed so that they can also “know”.

One of the most revealing examples of this kind of hubris occurred during my doctoral training, when one of the consulting psychiatrists approached me.  He knew that I played golf and he was puzzling over how to interpret the dream of one of his analysands.  He wanted to know whether the par 4 holes were in fact the “special holes” on a golf course.  I explained that in fact the par 4 holes were the most common holes and that the par 5s and par 3s were the more unusual or “special” ones.

I queried, “Why do you ask?”

He answered, “Well, I had a patient report that he dreamt about putting on a par 4 and I had interpreted it as an indication of an incestuous wish to have sex with his mother.  To putt the ball into a special hole.”

I then asked, “Well, now what do you think?”

He responded, “What you have told me is very helpful because now I realize that my patient’s dream reveals his defense against his incestuous wish to have sex with his mother.”

“How so?” I inquired.

He continued, “By dreaming about the common holes he was defending against dreaming about the ‘special’ hole.  He is not yet able to tolerate the idea of wanting to have sex with his mother.”

To this I deadpanned, “I’m glad I could be helpful.”

Of course at this point only die-hard classic psychoanalysts continue to use the couch and the supine patient, but the bias embedded in that structure continues to express itself in the current practice of psychotherapy. Furthermore, even without the classic psychoanalytic structure, there is a bias built into the encounter between therapist and client in favor of the wisdom and sanity of the therapist. As a colleague once quipped, “Part of what I love about this work is that for 50 minutes at a time I get to be the designated sane one.” However, what I am most concerned about is not that there is bias, but the effect of the bias.

Simply stated the idea of therapeutic neutrality and the structure of the psychotherapy relationship run the risk of further isolating and demeaning the client. Because the client brings to the therapeutic encounter problems that have their roots in traumatic experiences that have been incompletely resolved, they are predisposed to feel isolated and demeaned. If the therapist brings “neutrality” to the conversation the bias of low self-esteem and isolation embedded in the client’s problem will shape the relationship.

Perhaps an example from my own life will help illustrate the bias the patient brings to the encounter. When I was in my early twenties, I had already been through an extraordinary amount of psychological turmoil. I had barely survived my adolescence and as I was embarking on what I hoped would be a fruitful adult life, I was still pretty confused. I was living with my High School sweetheart in Boston and things were not going well, so we volunteered for couple’s therapy with a co-therapy team who were in training.

It was not long before we broke up and shortly thereafter my mother died suddenly. I sought out the help of the woman in the co-therapy team, Joan Blatt, who seemed sufficiently non- threatening. I saw Joan for a little less than a year on a weekly basis and tried to work through the loss of the two most important women in my life.

Joan was very kind and thoughtful and always seemed to listen very carefully to what I said. I had a number of remarkable experiences in her office. At the time I did not realize how profoundly therapy was affecting me. I was used to a lot of chaos from my childhood and my work with Joan was much more quiet. She helped me to turn more inward.

As the summer approached she informed me that she spent her summers in Colorado, so we would not be able to meet for some time. After some discussion, we mutually agreed to end the therapy. At our last session she gave me a special gift.

Because Joan was being closely supervised, she had made a series of audiotapes of our work. As her parting gift to me she wanted me to have these tapes. I was, of course, grateful and was sure I would make good use of them. But the truth is I put them in a safe place and did not revisit them for many years.

At some point during my clinical training, as I was wrestling with questions about therapy and its effectiveness, I remembered the tapes. I decided to listen to them but quickly realized how daunting it would be to listen to well over 30 hours of material some of which was hard to hear due to the quality of the recording and the softness of Joan’s voice.

I decided it would make sense to listen to one of the very early sessions and one very near the end to see if there was any noticeable difference. This is about as scientific as I ever get. What this little experiment revealed was pretty interesting.

Three changes were readily apparent. First the pace of my speech had slowed down. In the early session my speech was pressured and had a breathless quality. In the later session my speech was more measured. There were pauses, as I would complete a thought and periods of silence.

The second difference was that my tone of voice had changed. In the later tape my voice was perhaps a half octave lower and more resonant. On the early tape there is a high pitched, thin quality. I sounded older on the later tape.

The last change I noted was more closely associated with what is typically thought of as psychological. In the early tape I introduced much of what I said with the phrase, “This must sound crazy but…” or end what I said with the question, “Does that sound weird?” In the later tape this phrasing had fallen away. For the most part I simply said what I had to say without editorializing.

At the time I did not understand what these changes meant except that they were positive. Now I can see that embedded in the way I spoke and the content of my speech was a sense of isolation and an expectation of being demeaned. As I look back on a career that now spans 33 years I have witnessed a lot of debate over the how and what of psychotherapy. At the end of the day psychotherapy is effective when it ennobles the client and fosters a sense of connection.

It is worth noting that in my work with Joan she never called attention to the pace of my speech or tone of my voice. I am sure she encouraged me through her calm demeanor or even with a gentle suggestion to slow down. I don’t know whether she observed the pattern of my speech but she never commented on it or in any overt way tried to get me to think and speak differently about myself.

What the pace of my speech, the tone of my voice and the editorializing of my early sessions reveals is a person who feels bad about himself and doubtful about his place in the world. By exuding acceptance, gentle tolerance and intense interest Joan created a relational atmosphere that was the antidote to the bias I brought to the encounter.

Had she pointed out the things I later observed, I am sure I would have inwardly cringed and recoiled in shame and embarrassment. Unfortunately, this kind of observing is a staple of most psychotherapy as it was practiced in the mid 1970’s and, for the most part, today.

When my work with Joan was over, we agreed that future therapy would make sense for me. Given the violence I suffered at the hands of my father and the powerfully conflicting feelings this engendered in me, it was suggested that I continue my work with a male therapist.

In my view there are no truly right or wrong techniques in psychotherapy. The use of the psychoanalytic couch, my criticism not withstanding, can be enormously beneficial in some circumstances. Some people who have been badly mistreated feel so threatened by any interpersonal encounter or so unworthy of relationship that the couch and its anonymity are a great comfort. Pointing out someone’s behavior in the right circumstances and in the right way can help foster a better sense of self or help develop an awareness necessary for healing.

It is the relational environment that is crucial. In this area there is no equivocating. There must be a bias built into the relational position of the therapist to counter the bias of the client. However this bias is achieved, it must incline in the direction of esteem and connection in the face of stigma and isolation.