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5. The Swimming Pool and the Quest by Elio Frattaroli, M.D. Man is made by his belief. As he believes, so he is. — Bhagavad Gita A Fix for the Brain Versus a Home for the Heart When I first gave the lecture that appears in Chapter 4, I had been working on this book for about a year and a half. But it was actually almost five years earlier—in the last week of March 1990—that the book first began to take shape in my mind. It all started when an issue of Newsweek appeared with a Prozac capsule on its cover—just where the picture of a person should be, I thought. It was not only the cover of that issue that got my attention, though. It was also the brief note, buried in its obituary section, announcing the death of Bruno Bettelheim. “If Dr. B wasn’t dead already, this would definitely kill him,” I thought ruefully. I knew how much Bettelheim had always deplored what that Newsweek cover was so blatantly glorifying: our drug culture and its quick-fix mentality. The ironic coincidence of Prozac’s much-heralded arrival on the cultural scene together with Bettelheim’s scarcely noticed departure epitomized for me the predicament of our society. It meant that everything Dr. B stood for—and everything I cared about as a psychiatrist and as a person—was being lost in our cultural frenzy for the quick fix. To me this loss felt very personal. You see, it was Bruno Bettelheim—“Dr. B” to his students—who first taught me about healing the soul and inspired me to want to become a psychiatrist. I had worked for Dr. B in the early 1970s at the University of Chicago’s Sonia Shankman Orthogenic School, the residential treatment center he created for emotionally disturbed children.1 Under Bettelheim’s guidance, the School was an extraordinarily loving and nurturing place, a place of healing and growth for the staff as well as for the children. In one of his books, Dr. B described the Orthogenic School as a home for the heart, and that’s very much the way I experienced it. It became my model for what psychotherapy should be: a place dedicated to fostering the inner life, a place of love and respect—an I-Thou relationship—in which we can feel what we truly feel, and so become who we truly are. The End Is in the Beginning One of Dr. B’s most memorable and useful teachings was that “the end is always in the beginning.” By this he meant that the assumptions, attitudes, and expectations with which we approach a therapeutic encounter or life situation define how that encounter or situation will evolve. Alfred Flarsheim, another of Dr. B’s students, reported a wonderful illustration of this lesson, taken from ethologist George Schaller’s book Year of the Gorilla.2 It seems that Schaller (whose writings inspired Dian Fossey) had been able to collect far more detailed observations of the behavior of free- living gorillas than any previous scientific observer. Schaller attributed his unprecedented success to the simple fact that he had decided not to carry a rifle. This forced him to be sensitive to the gorillas’ subtle behavioral signals and allowed him to get quite close to them without making them feel threatened. Earlier, less successful observers had gone into the jungle armed with rifles because they assumed (incorrectly) that gorillas were dangerously aggressive and would make unprovoked attacks. The end is in the beginning. Schaller ended up with different results because he started out from a different assumption. He assumed that the gorillas would not be dangerous as long as he treated them with respect. So he began without a rifle and ended up discovering that he didn’t need one. In contrast, the ethologists who carried rifles found that they did need them. In other words, they found exactly what they had been expecting: that gorillas were too dangerous to observe closely, and sometimes attacked and had to be shot. But these observers had created rather than discovered this confirmation of their preconceptions. It was not the gorillas’ innate aggressiveness that had prompted them to attack. Rather, the observers themselves had inadvertently provoked the gorillas to attack by their thoughtlessly intrusive behavior and bearing—influenced by the false security and sense of invulnerability they took from their rifles. Schaller’s experience is relevant for psychiatry. Just as the rifle reflects the ethologist’s preconceived assumption about gorillas, so medication reflects the psychiatrist’s preconceived assumption about symptoms. The end is in the beginning. The possibility of prescribing medication, like the availability of a rifle in the jungle, fosters the tendency to bring premature closure to an encounter. It affects the psychology of the psychiatrist in such a way that he is unlikely to get close enough to the patient to obtain an in-depth understanding of whatever symptom seems to be calling for medication. He is unlikely to learn more than what is necessary to confirm what he already assumed, that indeed this is the sort of symptom that requires medication. Psychiatrists today are far less tolerant of the unknown (and our fear of it) than we were when we had fewer pills in our therapeutic “arsenal.” We now cling to the security of the prescription pad, the white coat, and the Medical Model. We take the formal history and mental status, assign the diagnosis with its proper five-digit code number, prescribe the proper pill, describe its major side effects, and monitor blood levels, all based on the latest scientific data. This ritualized activity serves, along with its official purposes, to insulate us from our own anxiety by emphasizing the distance and the difference between us and our chemically imbalanced patients. It is worth comparing this dehumanizing I–It attitude with the humanizing I–Thou attitude taught by Bettelheim: Just as the patients have to learn that they possess all the necessary resources within themselves to get well, staff members must become able to comprehend that within them resides all the knowledge necessary to understand the patient.... [T]wo main principles ... were the essence of many staff discussions. The first is that “The patient is always right”—that is, nonsensical as his behavior may seem to us, it makes excellent sense to him—and the second, that an understanding of what this meaning to him may be can best be approached or directly derived from our own inner experiences. What we have to do is ask ourselves the question: What conditions would induce me to engage in exactly the type of behavior which seems irrational or otherwise deviate in the patient? Psychiatry and the Philosophy of Life Bettelheim’s approach is the very heart of the Psychotherapeutic Model. It understands symptoms as meaningful expressions of the self, in marked contrast to the Medical Model, which treats symptoms as dangerous and alien to the persons who have them. The difference between these two attitudes toward symptoms reflects a deeper difference in attitudes toward people. The Psychotherapeutic Model is grounded in the similarity—the common humanity—between physician and patient. The Medical Model is grounded in scientific research, in which the doctor treats the patient as an object of detached observation. How did psychiatry end up with two such radically different approaches to treating people and their illnesses? Because the psychiatrists who follow either approach start from radically different philosophical beliefs and values. The end is in the beginning, and what ends in the psychiatrist’s choice of treatment begins in his choice of philosophy. I don’t mean the kind of philosophy located in unreadable books written by dead intellectuals. I mean what philosopher Jacob Needleman calls “real philosophy”: a living organization of experience, a set of implicit assumptions, deep, often hidden, in the grain of our personhood, that is the basis both for our way of life and for our attitude about the meaning and purpose of life. Not that psychiatrists are generally aware of how their treatment decisions reflect their philosophy of life. In fact, most psychiatrists will tell you they simply use whatever treatment “works best.” They like to think of their treatment approach as strictly pragmatic, and would rather leave philosophy out of it. But philosophy is not like an American Express card. It is impossible to leave home without it. There is philosophy implicit in everything we do, though it remains, for the most part, outside of our awareness. What looks on the surface like a pragmatic choice of the treatment that works best is, at a deeper level, a choice of philosophy. What we think works best depends on what we are trying to accomplish, which in turn depends on what we think is worth accomplishing, which depends ultimately on our all too often unconscious philosophy of life. Philosophy and the Art of Bicycle Riding I learned this lesson the hard way one Sunday afternoon about fifteen years ago, when I tried to pick the method that would work best for teaching my son how to ride a two-wheeler. It was a beautiful crisp fall day, and the last thing on my mind was philosophy. Standing there behind Gregory, my hands on the back of his bicycle seat, I could almost hear the theme song from the old television show Father Knows Best playing in the background. “Okay, start pedaling and don’t look back,” I said optimistically. Famous last words. The bike kept tilting and Gregory kept looking back, complaining loudly that I wasn’t holding it steady enough. I snapped back at him that I couldn’t keep the bike straight if he wouldn’t look ahead and pedal harder. “But what if you let go and I fall?” he pleaded. “I won’t let go until I know you won’t fall.” “But how will you be able to tell?” “Just turn around and pedal!” Before long, I had a backache, Gregory had a headache, and we decided to pack it in and try again the next day. We slouched back to the house, Gregory grumbling reproachfully that he would never be able to ride without training wheels and I cursing Robert Young (the dad in the TV show) under my breath. Next evening when I returned home from work I was surprised to see Gregory happily pedaling his two-wheeler up and down the driveway. “Look, Dad, no training wheels!” He explained that Evan, an older boy who lived next door, had taught him how to ride the bike. “How did he do that?” I protested, aware that I ought to be sounding more pleased. “Simple! He told me that to ride a two-wheeler, the first thing you have to do is fall down a lot of times.” I knew immediately that there was something important in this little episode, but it was not until the third or fourth time I told the story that it dawned on me it was really a story about unconscious philosophy. Those who are unaware that they have a philosophy are condemned to act it out on their children. Gregory and I had come to grief over an unexamined and misguided philosophical assumption. When I stopped to ask myself why I had failed and Evan had succeeded, I recognized that my teaching had been guided by my anxiety—and by Gregory’s—that he would fall down. Our goal (implicit in this shared anxiety) had been not simply that he learn how to ride a two-wheeler, but that he do so without ever falling down. The end is in the beginning. We had failed because we started from the assumption that falling down would be bad. Evan had succeeded because his philosophy involved the opposite assumption, that falling down would be good. Perhaps most people would not ordinarily consider the assumptions “Falling down is bad” and “Falling down is good” to be philosophy, but in fact they are the central tenets of the two major philosophies of life and—not coincidentally—also the basic premises of the two major models of psychiatry. The Swimming Pool The first philosophy, according to which falling down is bad, I call the swimming-pool philosophy. Paul Stookey, of the folk group Peter, Paul and Mary, captured the essence of it when he said, “You know what swimming is to me? It’s staying alive when you’re in the water.” But what really brought the meaning of this philosophy home to me was a comment made by a classmate and close friend of mine one gray December afternoon many years ago, as we stood together at the edge of our college swimming pool, contemplating the twenty-five-yard lap lanes that stretched out before us. “You know,” Ron said, “life is a lot like swimming laps. You put your head down, you dive in, and you go back and forth and back and forth and back and forth. Every once in a while you bump into someone, and you say ‘Excuse me.’ Then you put your head down again and go back and forth and back and forth and back and forth.” According to the swimming-pool philosophy, the purpose of life is to stay afloat, to function smoothly, maintaining the equilibrium of the status quo. Bumping into other swimmers is to be avoided as much as possible. In other words, falling down is bad. The Quest The second philosophy, according to which falling down is good, I call the quest philosophy. Also known as the perennial philosophy, it is symbolized by the Arthurian myth of the quest for the grail. The quest is an adventurous seeking of a higher or better state. According to the quest philosophy, the purpose of life is to pursue this higher state—enlightenment, wisdom, self-actualization—by progressing through a series of difficult, dangerous trials. The successful mastery of each trial brings the seeker to the next level in his or her gradual ascent toward the ultimate goal, which, though it may be unattainable, is inherently worth pursuing. But the process of undergoing a trial inevitably involves some error. You can’t find your way to a higher level without learning from your missteps. Falling down is therefore good. The Swimming Pool and the Quest in Psychiatry From a child falling down while learning to ride a bicycle to a patient having a “breakdown” while learning to navigate the life cycle is but a short metaphorical step. Just as different attitudes toward falling down lead to different methods of teaching a child to ride a bike, different attitudes toward psychiatric symptoms lead to different models of treating a patient with mental illness. The Medical Model exemplifies the swimming-pool philosophy that falling down (disequilibrium) is bad. It views psychiatric symptoms as “chemical imbalances”—disruptions of neurophysiological equilibrium—that should be “fixed” quickly with medication lest they cause further disruptions of psychosocial “stability” and “adjustment” (i.e., bumping into people). In other words, the Medical Model considers symptoms as a kind of falling down that is bad: unfortunate and unnecessary spills from the cycle of life. The Psychotherapeutic Model, in contrast, exemplifies the quest philosophy’s premise that falling down is good. It views psychiatric symptoms as manifestations of inner conflict—unconscious emotions trying to become conscious against the internal forces of resistance—presenting opportunities for growth that should be facilitated in a psychotherapeutic process that respects the need to bump into other people (and thereby become more conscious) through transference. In other words, the Psychotherapeutic Model views symptoms as a kind of falling down that is good—necessary trials in our quest for self-actualization. Falling Down Is a Way of Growing Up Just as a father who believes that falling down is bad will try too hard to control his son’s equilibrium on a bicycle, and thereby interfere with the boy’s learning, so a psychiatrist who believes that symptoms are bad will try too hard to control his patient’s chemical and emotional balance, and thereby interfere with the patient’s growth. As Alfred Flarsheim put it, “In order to operate without trying to control a patient we must have confidence in his potential for spontaneous maturation and development.” Medical Model psychiatrists try to take control with medication because they do not have this confidence. They are aiming not to facilitate maturation and development, but simply to return the patient to his previous level of functioning. They view the patient as someone having trouble swimming laps, not as someone facing an important trial in his quest. You bump into somebody, you say excuse me, then you put your head down again and get back into the swim. Given this philosophy, it makes sense to try to remove the symptom as quickly as possible because it did derail the patient from his previous level of functioning and it interferes with his regaining that level again. But the end is in the beginning. If we start with a different philosophy, then we will end up with different treatment methods, and different results. Psychotherapeutic Model psychiatrists start from the assumption that symptoms are the very embodiment of the patient’s potential for spontaneous maturation and development. Their goal is to facilitate the maturational process that is already inherent in the symptom. They view disequilibrium, whether manifest in obvious symptoms or not, as a natural and inevitable result of the inner conflict that is intrinsic to human nature. Developing a symptom is a necessary step toward integrating that conflict, a way of focusing the disequilibrium and calling our attention to it, and thereby initiating or furthering a psychotherapeutic process. Seen from this point of view, symptoms are the place where growth happens, human nature’s way of waking us up and stopping the world so that we can get out of the pool and climb into the quest. Disequilibrium, falling down, and bumping into people are good. Indeed, from this psychotherapeutic perspective, they are not merely good but essential to a fully human existence. To Be Human, the First Thing You Have to Do Is Fall Down In describing this important difference between the swimming pool and the quest in psychiatry, I am writing in the belief that if psychiatrists and patients really understood that they were making swimming-pool choices and neglecting the very real alternative of the quest, many of them would want to reconsider their assumptions. But I am also writing as a person who believes that most of us, most of the time, live our lives in the swimming pool without quite realizing it. I consider the choice between the swimming pool and the quest in psychiatry therefore to be a special case of a much larger choice that each one of us must make about how consciously we want to live our lives. Here again, it is instructive to think about the story of Genesis, which tells of how consciousness was born in the very first falling down. From the perspective of a swimming-pool philosophy, Adam and Eve’s existence before the Fall was the ultimate ideal, an endless floating in the unconscious equilibrium of eternity. There was no disruption, no change, no desire, no choices to make, and no death, because there was no time. The impulse toward a higher consciousness—the desire for knowledge of good and evil—was disruptive to this blissful condition and therefore considered bad. From the perspective of a quest philosophy, on the other hand, life before the Fall, however blissful, was not a fully human life. Adam and Eve were in a state of limited, infant consciousness, without the freedom to choose, without responsibility for their actions, and without self-awareness. Their forbidden desire for the knowledge of good and evil then transformed their existence into a quest. It propelled them out of eternity into a world of time, marked by a new adult awareness of the restless, ever-changing dialectic of inner conflict: the uneasy conjunction between their joyful experiences of love and creativity and their exciting but disruptive experiences of lustful desire and self-aggrandizing ambition. If we think of this falling down and this quest as something Adam and Eve could have avoided by making a different choice, we have misunderstood the point of the myth. The Fall is not itself a choice, but rather the beginning of the possibility of choice—what Kierkegaard called “the possibility of possibility.” Adam is Everyman. Eating the forbidden fruit is growing up and becoming conscious. We all begin to do it sometime during our “terrible twos,” when by saying “No!” we reject the infant paradise of undifferentiated communion with mother. This “original sin,” our first act of defiance, is also our first act of self-definition and the beginning of our self-awareness as separate individuals. But it is only the beginning, because our first and enduring reaction to this “possibility” of self-awareness is to try to cover it up and then hide from it, as Adam and Eve tried to cover up and hide from God. To grow into full human consciousness requires not only the defiant awareness that we are willfully alienated from others but also the shameful awareness, and ultimately an acceptance of the fact, that we are naked—alienated from ourselves in a state of inner conflict. To achieve this level of self-awareness we need the repeated trials of the quest, falling down again and again until we overcome our need to hide from ourselves and learn to recognize, and so become, who we really are. Symptoms and Self-Actualization Under the Medical Model, then, symptoms are seen as a kind of fall from grace, unwelcome, destructive intrusions on the smooth course of day-to-day life. Under the Psychotherapeutic Model, symptoms are seen as necessary shocks that lead to recognition, important trials in a painful but rewarding quest for self-actualization that begins with our first “no” and continues through the entire course of human development. In this view, symptoms are manifestations of inner conflict: disguised expressions of forbidden unconscious emotions, uneasy compromises between our conflicting needs to hide from ourselves and to become ourselves. In that sense they represent an attempt, only partially successful, to integrate the conflict between the swimming pool and the quest—between our need to maintain stability by keeping ourselves unconscious, as if we had never desired the forbidden fruit, and our need to reap the rewards and punishments of Adam’s fall, as we grow into a more fully human consciousness. These very different attitudes toward symptoms imply correspondingly different ideals of mental health. The Medical Model’s attitude that symptoms and disturbing emotions are bad implies an ideal of mental health as a “steady state”: the capacity to be stable, to maintain chemical (and emotional) balance and social adjustment. The Psychotherapeutic Model’s attitude that symptoms and disturbing emotions are good implies an ideal of mental health as an evolving process: a capacity for growth, a lifelong progression of emotional and moral development, expanding consciousness through enriching new experiences of emotions that were previously forbidden (repressed). How Did Psychiatry End Up in This Muddle? It’s Freud’s Fault! This deep split in psychiatric attitudes toward illness and health has very real and potentially dangerous practical consequences—like the seemingly unbridgeable gulf between the Technocrat’s and the Cowboy’s approaches to Bill. It reflects psychiatry’s ongoing failure to resolve its own inner conflict, to integrate the opposing values of the swimming pool and the quest. It also illustrates quite vividly how those who do not remember the past are condemned to repeat it. For, you see, the rift between the Medical Model and the Psychotherapeutic Model is by no means a new one. Surprisingly enough, both models originated more than a century ago in the theories of one man, Sigmund Freud. Freud’s clinical understanding of mental illness was always that of the Psychotherapeutic Model, informed by a quest philosophy and framed in terms of inner conflict, but there was always a strong Medical Model current in his thinking as well—a need to explain his clinical observations in biological terms. In fact, his primary theoretical model during the first half of his career (1890–1915)—the so-called libido theory—was actually the original psychiatric theory of chemical imbalance. Like the Medical Model today, it pictured the soul or mind (Seele) as equivalent to the brain, and tried to explain anxiety and the symptoms of mental illness in swimming-pool terms as a disruption of neurochemical equilibrium. Freud’s Swimming-Pool Philosophy: The Libido Theory and the Constancy Principle Freud defined libido as a specific form of neurological energy belonging to the sexual drive. He hypothesized that increasing the amount or “charge” of libido in the neurons of the brain produced pain, whereas decreasing—“discharging”—it produced pleasure. Discharge could be interfered with in two ways: by inner conflict or by simple sexual frustration. In either case, when the quantity of undischarged libido reached a certain critical level—producing a chemical imbalance—it would either “spill over” in a toxic physiological process that was experienced as anxiety or be diverted into the formation of a neurotic symptom. In other words, anxiety and/or symptoms were by-products of a libidinal imbalance—an excess of libido in the neurons that could not be discharged normally. Freud’s neurophysiology was wrong, of course, because he developed his theory in 1897, long before anything was known about how neurons actu- ally work. We now have a more refined picture of chemical imbalance as a disproportion between “transmitter” molecules (serotonin, for instance) and “receptor” molecules in the synapses where nerve impulses are transmitted from one cell to another. But this great advance in scientific knowledge has told us nothing at all about how a chemical imbalance in the brain could possibly produce a disturbing experience in the mind or soul. In fact, the idea that chemical imbalances cause mental illness is no more scientific today than it was in 1897. In that sense, Freud’s theory had a distinct advantage over current neurological theories of the mind, in that he was well aware of his philosophical assumptions and never mistook them for scientific facts. He referred to the libido theory as a metapsychology precisely in order to indicate that it was a philosophy rather than a science. He explicitly defined its swimming-pool assumptions in the form of a hypothesis he called the constancy principle. According to the constancy principle, all psychological processes are designed (by evolution) to maintain a low-level steady state of energy (libido) in the neurons. The point of this evolutionary design—and implicitly the purpose of life and the goal of mental health—was to avoid pain and seek pleasure by maintaining a comfortable low-energy state of libidinal equilibrium. This meant avoiding external stimulation (which produced an unpleasurable increase in libido) and quickly discharging any internal excitation that arose directly from the sexual drive. In other words, “Keep swimming, but only hard enough to stay afloat. Try to stay in your lane and not bump into other swimmers, but when the inevitable collision does occur, make it a quickie and get back into the swim. Falling down (libidinal imbalance) is bad, so keep pedaling (discharging libido) and don’t look back.” Freud’s Quest Philosophy: The Principle of Eros The problem with the constancy principle—or pleasure principle, as Freud soon began to call it—was that the purpose of life it defined boiled down to the pursuit of the most immediate gratification. Freud’s mind could never come to rest in the amoral hedonism of such a philosophy. He began to ask himself, why, if the soul is really operating solely on the premise that falling down (unpleasure) is bad, did his patients have such an apparently perverse need to trip themselves up. Where did they get their relentless compulsion to punish themselves and otherwise subvert their own hedonistic purposes, to unnecessarily deny themselves pleasure and put themselves into painful high-energy states of inner tension? Then, too, why weren’t all states of inner tension experienced as painful? Why were they so often experienced as pleasurably stimulating and exciting? Why did people so regularly prefer the complex, high-energy state of love, for example, to the simple discharges of lust? Indeed, if it were not for the increased excitement involved, why would a person ever want to dive into a swimming pool or take the training wheels off his bicycle in the first place? Ultimately, just as Gregory and I discovered that the premise “Falling down is bad” was a misleading guide for learning to ride a bike, so Freud eventually realized that his libido theory was an inadequate foundation for a science of human nature. In order to explain all those motivations that violated the constancy principle, Freud had to introduce a second principle of motivation, the principle of Eros, which he borrowed from Plato’s Symposium. Freud described Eros as a kind of life force, essentially the opposite of the constancy principle: stimulus-seeking rather than stimulus-avoiding, tending toward higher rather than lower levels of energy and complexity. Where the aim of the constancy principle was to reduce libidinal tension through discharge, the aim of Eros was to resolve tension through integration. Where the constancy principle was a principle of stability, Eros was a principle of growth. Close but No Cigar As you might imagine, the path that took Freud’s thinking from the constancy principle to Eros was more convoluted than the brief outline I have just given would suggest. He found it difficult to give up the materialistic assumptions of the constancy principle and to embrace the spiritual implications of Eros. What he needed, and what psychiatry still needs today, was an integrated theory that includes both sides of human nature: the Flesh and the Spirit, the physiological needs of the swimming pool and the soul’s need for the quest. As I will discuss in Chapters 14 and 15, Freud spent his entire career trying to develop such a theory, and in the end came very close to achieving it. But the almost-integrated theory he ended up with gradually fell apart after his death, as different groups of his followers each began to emphasize a different aspect of his theory and almost everyone missed the overall point of what he had been working toward. Erik Erikson and the Eight Stages of Life Probably the closest anyone came to developing the kind of integrated theory to which Freud aspired was psychoanalyst Erik Erikson, whose model of human development is still the clearest, most comprehensive and accessible statement we have of the Psychotherapeutic Model’s overall quest philosophy. The one limitation of Erikson’s theory is that it doesn’t explicitly address the mind–body question—how the neurological and the spiritual are integrated in human nature. The great strength of the theory is that it does explain how our swimming-pool need for emotional equilibrium and social adjustment is integrated within our larger need for self-actualization through the struggles of the quest. Building on Freud’s mature theory of inner conflict (between the It and the I that stands above), Erikson pictured life as a progressive struggle to in- tegrate the conflicting needs of the swimming pool and the quest—the need for stability versus the need for growth, the need to remain unconscious versus the need for consciousness. These needs remain with us throughout the course of development, says Erikson, but the quality of our integration changes as we grow toward self-actualization. We may never fully become ourselves, but we do tend to get better at it as we progress through the eight stages of the life cycle. Here’s how it happens: As we move from infancy to old age, we face a series of “stage-specific” conflicts between what we aspire to—the goals of the quest—and what pulls us back—the swimming-pool fear of falling down or bumping into people. During the first year of life, the basic conflict is trust versus mistrust. During the toilet-training period it is autonomy versus shame and doubt. Then follow initiative versus guilt dur- ing the so-called Oedipal period (ages four through seven); industry versus inferiority during the grade-school years; identity versus diffusion during adolescence; intimacy versus isolation in young adulthood; generativity versus stagnation in the middle years of adulthood; and, finally, integrity versus despair in the years of maturity and old age. All these Eriksonian conflicts revolve around the common theme of desire versus inhibition—an ambivalence based on our (incipient) shame- ful awareness that good and evil are inherent in our own desire. Each of Erikson’s “goods” can become evil if the desire for it is carried too far. Each of his “evils” can in turn serve the good by protecting us from the danger of carrying our desire too far. But the danger is different at every stage. It changes as we grow, as does the level of consciousness required for mastering the danger. That is why, as Erikson observed, people tend to have different sorts of breakdowns—and different sorts of healing experiences—at different stages, depending on which of the eight stage-specific conflicts they are struggling with at the time and on how successfully they have mastered the previous ones. Even though a person might have superficially similar symptoms as a teenager and again as a forty-five-year-old, for instance, the symptoms will likely have a very different meaning in terms of the person’s quest. The symptom-producing conflict in each case will be different, reflecting the unique issues and emotions that belong to that particular stage of the person’s life. I have not yet had the opportunity in my career to see the same patient both as a teenager and as a forty-five-year-old, but I have seen the same symptom, with different Eriksonian meaning, in a nineteen-year-old daughter and a few years later in her forty-five-year-old father. My work with these two patients illustrates how symptoms serve to crystallize the conflicts of particular developmental stages, and how the Psychotherapeutic Model understands and treats these symptom-producing conflicts as trials in the patient’s quest. Example 1: Identity Crisis Anne was the young woman I described briefly in Chapter 2, who became suicidally depressed after being raped while in her first year of college. As you may recall, Anne did not tell me about the rape during the first two months of her hospitalization. Instead, she tried to keep up an image—what Jung would have called her persona, and psychoanalyst D. W. Winnicott would have called her False Self—essentially the image of herself as her parents would have wanted to see her. This in itself was not unusual. Each one of us has such a False Self, a mask we wear in our dealings with other people (and too often with ourselves) that reflects a tendency to comply with the needs and expectations of others—to live according to someone else’s idea of how we should live, the way a child lives according to his parents’ rules and needs. This orientation is sometimes called extrinsic motivation. To the extent that we are extrinsically motivated—as we all are to some degree—we are dominated by a swimming-pool need to hide in a superficial Eden of conformity, taking care not to bump into people, and not to make waves. But Anne’s need to hide in such a False Self conformity was extreme, to the point that she felt herself to be unreal, as if there was nothing to her except her False Self image. She felt this way especially after the rape. Her parents would never be able to accept her now, she believed, and she doubted that I would be able to accept her, either. Although she tried valiantly to present herself as she always had (and as she believed her parents would have wanted), she could not escape the devastating feeling that the rape had destroyed her image, and her “self” along with it, forever. Anne’s depression thus represented a failure or loss of identity, a feeling that she was nothing—and had never been anything—but an image, a mask now shattered beyond any possibility of repair. But that was only the swimming-pool meaning of her depression, and the identity she had lost was only her “conformist” identity. In terms of the quest, her depression was not only a loss of that old identity (a falling down that was bad) but also an attempt to find a new identity (a falling down that was good). After all, the inner person who actually felt Anne’s depression, who could be aware of herself as nothing but a false image and could feel depressed about that, must herself be more than that false image. No mere image can be aware of itself, or notice that it is missing something. In that sense, Anne’s depression was a new and genuine experience of her True Self—an inner self, born out of the ashes of her old image, that could discern the difference between image and substance. This True Self was intrinsically rather than extrinsically motivated, needing to live for herself rather than for her parents. She still felt the devastating pain of her depression—the mixture of anxiety, shame, and sadness over losing her familiar self-image—but in that pain she could recognize the sound of her innermost being crying out for something more real, more genuinely hers, to care about and live for. Anne became able to let herself feel and talk about both meanings of her depression as she began to experience the hospital, and her relationship with me, as a safe haven where she was free to feel whatever she felt and be whoever she was. This happened gradually once I told her (probably a week or two into her hospitalization) that I kept getting the feeling in our sessions that she was far away—emotionally disconnected—and seemed to be going through the motions of psychotherapy mostly to please me, rather than talking about anything that felt really important to her. In Eriksonian terms, Anne’s depression was a symptom of a classic adolescent “identity crisis.” It embodied the conflict between her swimming-pool need to lose herself in living to please her parents and her quest need to find herself by rebelling against them. In terms of the first need, Anne’s depression meant that her life was no longer worth living, because her parents could never again be pleased with her. In terms of the second need, it meant that she would have to change, because her life was no longer worth living as she had been living it. The first meaning belonged to her unconscious swimming-pool philosophy, the second to her unconscious quest philosophy. In deciding to tell me about the rape, then, she was not only taking a great personal risk but also making an important philosophical choice: to take her pain more seriously than her image, to think of her depression not as a sign of her failure to be the person she should have been, but as a sign that she needed to become who she really was. Depression As Rebellion Erikson’s concept of identity crisis has become so much a part of our cultural idiom that we now take it for granted that adolescents will need to rebel against their parents in order to find themselves. That such a rebellion can take the form of a clinical depression is less obvious, and seldom recognized when it happens, even by psychiatrists. What could depression have to do with rebellion, after all? If anything, it seems quite the opposite of rebellion. But to a psychoanalyst, that is precisely the point: depression seems the opposite of rebellion because it is a rebellion turned inward, a symptom of inner conflict between the impulse to rebel and the need to conform. We are nowadays so used to thinking of depression as a biological illness without psychological meaning (or, if we do think about it psychologically, as a problem of low self-esteem), that we have forgotten this older, wiser view of depression as anger turned against the self. Whether or not it is a disorder in the brain, in the soul depression is always an expression of unconscious anger toward someone else, repressed and turned inward against the self, creating a state of inner conflict that is experienced as self-hatred (which certainly does lower self-esteem). But in the process the depression provides an indirect outlet for that repressed anger, as a disguised, unconscious rebellion—a refusal to participate (disguised as an inability to participate) in the life that makes us so angry. People who are living with a depressed person, or trying to treat one, can often feel this disguised rebellion in the form of a subtle nonverbal reproach, an implicit complaint leveled against anyone who wants to help the patient “get over” the depression. I got a distinct impression of such a nonverbal message from Anne during the early weeks of her hospitalization. It was an emotional undercurrent that I could feel as part of my sense that she was far away and going through the motions. Trying to engage with this faraway person each day in our psychotherapy sessions, I would get the sense that, by staying depressed and distant, she was fighting me off. It was as if she felt my efforts to help her were intrusive and her depression was a way of saying, “I won’t go along with this. Don’t even try to get into my head. I won’t let you therapize me!” The Rage to Cure I realized that I could have been misreading Anne. My sense of her depression as a rebellion could have been a projection of my own subtle therapeutic frustration—my unconscious “rebellion” against her depression. Whenever a psychotherapist or psychiatrist has too great a need to cure his patients—in order to prove his own worth, for instance, rather than out of concern for what the patient needs—he will tend to become easily frustrated and intolerant of patients who don’t get better quickly. Freud called this tendency furor sanandi—“the rage to cure.” It is both an essential ingredient and a universal problem in the motivation of all who are drawn to the helping professions, and one of the primary reasons why all psychotherapists and psychiatrists need psychotherapy for themselves. Until they learn to recognize and come to terms with this rage to cure, therapists generally have trouble distinguishing their own needs from their patients’ needs. In this case, however, I was aware of the danger and was fairly confident that I was reading Anne correctly—that it was her repressed rebelliousness I sensed in her depression and not a projection of my own frustrated need to “therapize” her. Any doubts I had on this score were quickly settled once I began to see Anne with her parents in weekly family therapy sessions. Unconscious Adolescent Rebellion In working with adolescent patients in the hospital, I have found that meeting regularly with the family—the patient together with the parents and sometimes siblings—is essential. It gives me a firsthand experience of the emotional atmosphere in which my patient has been living and allows me to identify and intervene in dysfunctional patterns of interaction that may be contributing to my patient’s illness. In my meetings with Anne and her parents, this definitely proved to be the case. What particularly struck me—and what convinced me that Anne’s depression was indeed an unconscious adolescent rebellion—was the great difficulty her parents had accepting that their daughter was sick. Simply put, Anne’s father and mother did not believe in mental illness, especially not for someone in their own family. As they saw it, being depressed was simply an excuse for being weak. They had both had very difficult lives themselves, they told me, and had always managed to cope. They prided themselves on being able to suppress or ignore all painful emotions, and to tough it out in the face of any problem life could throw at them. But their daughter’s unyielding depression and her inability to cope with it were now posing a formidable challenge to their whole way of life. When Anne was first hospitalized, their urgent mission was to get her back on her feet and back to college as quickly as possible. When this didn’t happen, they became frustrated, embarrassed, and increasingly angry—victims of a parental version of furor sanandi. In the family meetings they began to blame Anne for not pulling herself out of her depression, and became openly skeptical of my “talk therapy,” which to them seemed nothing more than another excuse for her to wallow in her problems. But when Anne finally told them that she had been raped (shortly after she told me), they were jolted out of this disapproving attitude and suddenly felt horrible—anguished for their daughter and furious at her attacker. They could now understand that she had been traumatized and were able, for a while at least, to stop blaming her and show their love by supporting her decision to go to the police and press charges against the man who had raped her. Initially, it was a great relief to Anne that her parents did not blame her for the rape as she had feared they would. She gradually came to realize, though, that their unexpected support did not really represent a change of heart for them. As loving as it was, their support remained predicated on their need for Anne to be strong—a fighter, not a quitter—and on their intolerance of what they perceived as weakness. They seemed surprised and dismayed when her decision to take action against the rapist was not enough by itself to relieve her depression. I explained to them that the rape was not Anne’s only problem; that the most important source of her depression was a deeper and older unhappiness within herself. I warned them that she might need several more months of intensive treatment in the hospital and that if she didn’t deal with this unhappiness now, she would remain vulnerable to repeated depressions and possibly another suicide attempt in the future. I told them, quite simply, that her life was at stake. Anne’s parents grudgingly accepted that she needed to stay longer in the hospital—I hadn’t left them much room to do anything else—but it went against the grain of everything they believed. Her father soon began to preach again to Anne about the necessity of being tough. “I know you feel like you can’t handle going back to college after what you’ve been through,” he would say, “but you have to try. Giving up is absolutely the worst thing you could do. Sure it’s hard to be depressed, but that’s the way life is, and the only way to deal with it is to tough it out. Hell, your mother and I are depressed every day of our lives. Do you think it’s easy for me to get up and go to work every day? Three out of four days I wake up in the morning and think I’ll never be able to put on a suit again, or look at another tax form in my life. But then I wash my face, have a cup of coffee, ask your mother to give me a good kick in the pants, and I’m out the door and on my way through another day. Do I like it? No. Is it necessary? Absolutely.” Conscious Adolescent Rebellion For weeks, Anne would listen to these exhortations and feel horrible about herself, unable to respond to her father. “He’s being so polite in our meetings with you,” she would tell me privately, “but I know what he’s really thinking—that I’m a worthless wimp. He has no clue that being honest about what I really feel—the way I’m learning to do with you—takes more strength than anything he’s ever done in his life! Oh God, I know that’s a terrible thing to say, and I have no right to say it, but it really is how I feel sometimes.” Being able to use her sessions with me in this way, to articulate the differences between her father’s opinions and feelings and her own, without fear of disapproval from me, was immensely helpful to Anne. It eventually led to her being able to risk her father’s disapproval by objecting out loud to the way he was lecturing her. She explained to him that the kind of depression she was struggling with was not something she could overcome with a cup of coffee and a kick in the pants. Nor was it simply a reaction to the rape. “You say I’m not being tough, but to me, what I’m doing is a lot harder than what you want me to do. I’m trying to face the fact that something has felt wrong in my life for a long time. It just doesn’t make sense to try to force myself back into a life that wasn’t working to begin with. Why do you think I became bulimic two years ago? It was because I couldn’t stand my life!” In thus confronting her father, Anne was able for the first time to feel the rebelliousness that had previously been unconscious in her depression. This was a tremendous sign of progress, but it also made Anne feel so anxious and guilty that she had a recurrence of her old symptoms of bulimia. Such a regression into an old pattern of illness is not an uncommon reaction to the danger of too much progress and is all part of an overall growth process—two steps forward, one step backward. In fact, it occurred to me that Anne’s “eating disorder” had itself been an early expression of the same impulse for growth that was now much more obviously embodied in her identity crisis. The alternation of binge eating and vomiting was a kind of bodily metaphor for an ambivalence that she was not yet ready to be aware of at a psychological level. The binge eating symbolically reflected her need to remain dependent by taking in all her parents’ goals and values as her own. The vomiting reflected the opposite need, to reject—spit out—her parents’ image and expectations of her and so begin the difficult task of becoming herself. This is the sort of inner struggle that every adolescent must go through in order to grow up. The struggle doesn’t always produce psychiatric symptoms as it did in Anne, but when symptoms do occur, it is important to remember that they are part of the solution rather than part of the problem. In Anne’s case, her bulimia had been the first thing that forced her to notice, at least briefly, how unhappy she really was. She had tried to ignore this warning, however, and to keep it hidden from her parents. She had even managed to suppress her bulimic behavior when her parents did discover it. But when the rape then shattered her already tenuous balance, instead of falling back into her bulimia she fell forward into a new symptom—depression—that actually represented an advance in her development. In becoming overtly depressed, Anne began to feel her unhappiness in a way that she could no longer ignore. In becoming incapacitated she forced her parents to pay attention, too. Thus, the shift from bulimia to depression brought the conflicts, both within herself and between herself and her parents, more clearly into consciousness. This was a sign of growth, a shift from acting out her conflicts toward experiencing them emotionally and so being able to talk about them in a way that her parents could begin to understand. As you would expect, the eventual result for Anne was by no means a complete rejection of her parents’ values, but rather an integration of what she had genuinely learned from them with what came more uniquely from her. This integration did not happen easily. In fact, once Anne began to disagree openly with her father in our weekly family meetings, not only did her bulimic symptoms return but there followed several unsettling months of sometimes bitter arguments, during which it seemed that neither of Anne’s parents might ever be able to appreciate what she was trying to tell them. But as she gradually became more effective at articulating and arguing for her own goals and values (around issues like how she dressed, who her friends were, when she would go back to college, whether she would live at home or on campus, what she majored in), her parents could not help but respect her for the strength of her convictions. Nor could they fail to notice that in standing up for herself with them, she was also gradually coming out of her depression. Although they continued to view her need to remain in the hospital as a weakness, they gradually discovered that they could amicably agree to disagree about this, with a sense of mutual respect and acceptance. Anne was then able to leave the hospital (after eight months altogether) and get on with her life. In fact, she blossomed. I did continue to work with her for another year of outpatient psychotherapy, but her growth very quickly became a self-perpetuating process in which I was no longer needed. Symptoms Are Part of the Solution, Not Part of the Problem It was an awe-inspiring privilege to be able to witness Anne’s healing and growth from such an intimate vantage point. I would like to think that I was important for a while in facilitating her inner process, but I suspect that the most important thing I did for her was simply to allow her human nature to take its own course, along a path that I knew had to pass through her depression. In thus recognizing the growth potential contained within her symptom, I was following another important precept I had learned from Bruno Bettelheim: Respect the symptom. Bettelheim taught that symptoms are adaptive, creative achievements, the best solution a patient has so far been able to come up with to the otherwise unmanageable problems of his or her existence. However painful or disruptive a symptom might be, Bettelheim assumed that the patient would not have gone to the (unconscious) trouble of creating that symptom unless she needed it. To respect the symptom, then, meant to recognize that it was serving an important purpose, and it meant also to respect the person who had (unconsciously) created the symptom to serve just that purpose. In this formulation, Bettelheim was himself following a much older teaching, part of the most ancient tradition of medicine. From Hippocrates to Freud, the wisest physicians have taught that symptoms are a manifestation not of a disease but of a healing process—what the ancients called the vis medicatrix naturae, or “healing power of nature.” In the Hippocratic view (about which I will have more to say in Chapter 13), disease was a disharmony of conflicting humors and elements, and symptoms were the organism’s attempt to establish a new harmony. Freud expressed the same idea by saying that symptoms are unconscious attempts to resolve inner conflict—the product of a “compromise” between the unconscious emotion trying to become conscious and the internal resistance that seeks to keep it out of awareness. In other words, as with Anne’s depression, all symptoms are attempts to harmonize the conflicting needs of the swimming pool and the quest—the False Self’s need for stability and conformity versus the True Self’s need for self-awareness and autonomy—in the overall service of growth. Unfortunately, in the Age of the Brain, psychiatrists try to cure patients by removing their symptoms, not realizing that those symptoms may be acting unconsciously to heal the patient. Most psychiatrists today would start Anne immediately on an antidepressant and discharge her quickly from the hospital, hoping to get her back on her feet. In so doing they would be unwittingly supporting her False Self, reinforcing her parents’ message that depression is a sign of moral weakness, and discouraging her from taking seriously her own inner life. She might never mention the rape, and would probably never become aware of the nature of her differences with her parents. Not only would she miss the opportunity to learn and grow from her illness, but her parents would miss an opportunity to learn and grow from it too. Example 2: Midlife Crisis Three years after I had last seen Anne, I got a call from her father, Joe. Anne was doing wonderfully, he assured me, but he now had a problem of his own that he needed to see me about. He had been having an increasingly difficult time at work for the last few months, he said, and on that morning something had snapped. He woke up feeling worse than he had ever felt in his life. The effort it had taken just to force himself out the front door had left him shaking, drenched in a cold sweat. He could not bring himself to get into the car and drive to work. In fact, he felt as if he might never be able to return to work again. So he came to see me. “It suddenly occurred to me that maybe my situation was not so different from Anne’s,” he told me. “I’ve never forgotten what you said back then about how sometimes having a breakdown is the best thing that can happen to you if it helps you recognize that your life is on the wrong course and that you need to change it. At the time—I guess you remember—I thought that was a pile of bull, but it certainly turned out to be true for Anne.... Well, I guess I’m not too proud to learn something from my daughter. You know she’s been on me for a while now about my drinking. She says if I’m drinking this much, then there must be something I’m not dealing with. Well, today I think I realized what that is. I hate my work. I’ve always hated it. All those lectures I used to give Anne about how important it is to keep functioning—I know I was really trying to fight my own temptation to give up. For years I’ve been trying to convince myself that things will get better, that the problem is this client or that client, or maybe my boss. But my clients have changed and my boss has changed and it’s never gotten any better. The fact is, I never really wanted to be an accountant in the first place. I don’t think I’m even very good at it. The problem is, I don’t feel as if I’ve ever been any good at anything, or that I ever will be.” It turned out that Joe did have a significant clinical depression, severe enough that it was not only impossible for him to work but difficult to motivate himself to do anything else, either. Just the process of getting to my office seemed to exhaust him. He wanted to try psychotherapy because he had seen it work so well for Anne, but it soon became clear to both of us that his depression, unlike Anne’s, was interfering with his ability to concentrate, so that he couldn’t focus his attention enough to make good use of psychotherapy. We therefore agreed to try an antidepressant, and within a few weeks he felt more at ease, was able to eat and sleep better, think more clearly, and make better use of his psychotherapy. But the antidepressant did nothing to change how much he hated his job, or to alleviate the sense of dread he felt whenever he tried to imagine himself going back to work. He continued to feel generally demoralized and down on himself a good deal of the time, and it was unclear to what extent this was an ongoing depression, not fully relieved by medication, or to what extent it was a natural psychological reaction to being existentially lost. Either way, Joe was still too depressed to work, so he took a temporary disability leave from his job and resolved to spend the next several months using his psychotherapy sessions to figure out what he really wanted to do with the rest of his life. Nel Mezzo del Cammin di Nostra Vita ... As Dante first described it almost eight hundred years ago, midlife crisis is like a “dark forest,” encountered “halfway through our journey of life,” in which we lose our sense of direction—the “straight path” that up until then we have followed. Something goes wrong that overwhelms us for a time, bringing us to a halt and forcing us to reevaluate our position. For most people, the jolt comes from such common calamities as the loss of a job, a sudden disability, the death of a parent, an extramarital affair, marital discord or divorce, the biological clock running down, or an empty nest. Or it may come simply from the dawning awareness of aging and mortality. In any case, the combination of the stressful event and our reaction to it—usually an episode of depression or anxiety disorder—makes us feel that we can’t go on any longer as we have been. We are forced to stop and ask ourselves whether the life we have been living is the life we truly want to live. And so it was that Joe, halfway through the journey of his life, was now forced to stop and consider the frightening question of whether he should change his career. Up until then he had always thought of his work simply as a job, a way of making a living, in which his all-important purpose was to achieve social and economic security and stability for his family. In this he had been following an unconscious swimming-pool philosophy, seeking primarily to maintain the equilibrium of a conformist, extrinsically motivated False Self. But Joe’s depression now forced him to consider the possibility that work could and perhaps should be an intrinsically motivated choice of his True Self. From the perspective of a quest philosophy, a career is not a job but a “vocation”—a life work to which we are called by our deepest needs, aspirations, and values, a way of actualizing our full human potential. In that sense, Joe’s depression and midlife crisis crystallized for him the universal conflict between the swimming pool and the quest. He felt torn between his need to maintain stability by returning to the security of the job he hated at the accounting firm and his need to grow by following his inner calling. This picture was further complicated by the fact that Joe had recently been promoted to a supervisory position, and in fact it was just at that point that his work had begun to feel especially intolerable. “Maybe I’m just being a coward,” he worried. “Or maybe I just don’t have what it takes to be a supervisor. I hate being in a position where I’m expected to criticize other people’s performances and then have to deal with all their flak when they don’t like being criticized.” It occurred to me that Joe might be suffering from a classic “success neurosis,” that the sudden increase in power and prestige of his new position had provoked unmanageable anxiety from which he then had to retreat by becoming depressed. If so, then his inner calling might actually be in the direction of being a supervisor, where he would have to face the fear of his own power and become more of a leader, learning to deal more effectively with people; whereas his psychological stability might be best served by returning to his previous accounting job, with its more manageable, predictable problems. As it turned out, neither of these alternatives really matched the way Joe felt. When he thought about it, he realized that even the responsibility of being a regular accountant—trying to satisfy the Internal Revenue Service, the clients, and the firm—had always felt quite oppressive and demoralizing to him. It reminded him of the way he had felt as a child, trying to satisfy the unreasonable and inconsistent demands of his parents. Being expected then to take on additional responsibilities as a supervisor had simply pushed an already intolerable situation past the breaking point. Joe realized further that most of the activities he had really enjoyed in his life involved using his hands—doing carpentry, plumbing, and painting around the house, for instance, and developing his own photographs. He liked working alone and he especially liked being his own boss—feeling responsible only to himself. He recalled that much earlier in his life he had dreamed of going into business for himself but had never permitted himself to take the dream seriously. He had been too afraid of failure. Unconsciously, he equated the idea of being his own boss—and becoming his own person—with repudiating the demands of his parents and so becoming a failure in their eyes. He had thus remained stuck in the mind-set of his adolescence, too afraid of displeasing his parents (for whom he then substituted the IRS, his clients, and the firm) to take the risk of doing what he needed to please himself. In that sense his depression was a kind of delayed but necessary adolescent rebellion, the beginning of a crucial developmental shift from the swimming pool to the quest, from the extrinsic motivation of living for his parents to the intrinsic motivation of living for himself. In terms of Joe’s old swimming-pool philosophy, his depression had meant that his worst fear had come true—he was a failure. But he now discovered that, in terms of his newly emerging quest philosophy, this failure felt strangely liberating. Having hit bottom, with nowhere to go but up, Joe no longer found it so frightening to think about starting his own business. He didn’t need to make much money at this point in his life, because Anne was about to graduate college and begin working, and his wife was doing well at her own job. So after weeks of deliberation and several false starts, Joe decided to follow his vocation. He put ads in all the local papers and set up shop as a handyman/jack-of-all-trades, hoping eventually to be able to specialize in cabinetmaking. Once he began to get his first small jobs, he discovered that he loved the work every bit as much as he had thought he would and that his customers were eager to refer their friends to him. With that, the last traces of his depression faded and he was able to discontinue the antidepressant. The Purpose of Symptoms Is Healing the Soul My work with Anne and Joe was informed by my Psychotherapeutic Model belief that falling down is good—that the crises of mental illness are like the trials of a quest, important opportunities for personal and spiritual growth. The idea is that there is a psychotherapeutic process inherent in the life cycle, a series of stresses that force us to reexperience and reintegrate our inner conflicts, sometimes in a way that produces symptoms of mental illness, always in a way that challenges us to confront ourselves as we really are. It is only in suffering and struggling with these challenges that the soul can heal itself and grow. As we reintegrate our conflicts at successively deeper levels, we become stronger, wiser, and in fact better people—better in the sense that we are more conscious of our own emotions, and therefore less driven by automatic reflexive (unconscious) personality tendencies (aimed at maintaining our swimming-pool equilibrium) and freer to react to other people with the empathy of the Golden Rule. For Anne this meant (among other things) overcoming her automatic mistrustful tendency to put a distancing wall between herself and other people and discovering the satisfaction of talking to people about (and trusting them to understand) what she really felt. For Joe it meant overcoming his automatic tendency to lecture Anne about the proper way to live and discovering that he actually had something to learn from her about the quest. From this point of view, both Anne’s and Joe’s depressions were necessary growing pains—crises of identity and of vocation that were integral to their struggles toward self-actualization. If, as I believe, all psychiatric symptoms are in the same way part of the healing/growing process, then the question of whether a psychiatrist should use medication or psychotherapy or both becomes secondary to the much more important question of what philosophy is guiding his overall approach to the patient. With Joe I had no hesitation in using an antidepressant. With Anne, following the same philosophy, I thought it was particularly important not to use one. However, if Anne were to have another episode of depression at some point in the future, I would be open to the possibility that her circumstances might be different and that an antidepressant might be helpful. In each case, I try to think about medication and the patient’s need for swimming-pool stability within the larger context of the quest—what the patient needs at this particular moment in his or her life to further his or her growth as a person. |
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by Elio Frattaroli, M.D.
The Value of Consciousness
I wrote Healing the Soul in the Age of the Brain because I believe that our society is in a state of moral crisis. Our lives are so consumed by the dehumanizing forces of materialism that we have lost touch with the deeper needs and values of the soul. Culturally, we value physical appearances, material possessions, creature comforts, and addictive pleasures, as if we really believed that the one who dies with the most toys wins. We then rationalize the emptiness of these materialistic values by invoking another kind of materialism—that of modern science, which gives credence only to what can be seen and measured and believes that only the physical is real.
Modern psychiatry typifies the shortsightedness of this scientific world view. Its theory that mental illness is a chemical imbalance and that all inner experience is a byproduct of brain activity—the so-called Medical Model—views human beings essentially as biological puppets, controlled by the strings of DNA and brain wiring, without free will or higher consciousness. Focusing exclusively on brain and behavior, it denies the spiritual element in human nature and treats the inner life of human beings — the essence of our humanity, the source of our joy, our anxiety, our despair, of our very culture itself, including our scientific theories – not only as if it didn’t matter, but as if it didn’t even exist. I believe that this materialistic way of thinking is hazardous to the health of our culture. It promotes the delusional expectation that we can eliminate suffering and achieve a state of contented normalcy simply by taking a pill. It subverts our ideals of moral responsibility by encouraging us to rationalize anything that disturbs us within ourselves as the accidental product of an abnormal brain state: My neurotransmitters made me do it.
Such dehumanizing beliefs reinforce a dehumanizing impulse that is already present within human nature. Like Dickens’s Scrooge and Disney’s Pinocchio, we are all tempted to ignore the inner voice of the soul in our pursuit of external tokens of happiness—not only because we are seduced by our culture’s materialistic values but because we are driven from within by our own materialistic passions and by our addictive need for quick, painless fixes for anything disturbing in our lives. The result is a kind of cultural mental illness in which we are, in effect, driven to dehumanize ourselves—to lose ourselves in materialistic illusions—in order to evade the fundamental anxiety of the human condition. To cure this illness requires an inner process of re-humanization—of our values, our science, and most importantly, our way of understanding our own experience.
Like Scrooge and Pinocchio, we need to wake up from our shallow materialistic illusions and reclaim what we know in our heart of hearts to be true. We need to turn inward, to listen to the inner voice of our authentic self. And we need a science that acknowledges the existence of this inner self; that recognizes human consciousness not as an electrochemical process in the brain but as an irreducible experience of the soul. In my book, I propose a new model of psychiatry and of human nature based on just such a science. This Psychotherapeutic Model understands mental illness not only in neurological but also in personal terms, as an inner emotional conflict —a disharmony of body, brain, mind and spirit—that is intrinsic to the human condition. Psychologically, inner conflict involves a disturbing unconscious emotion, threatening to become conscious, that triggers anxiety, shame, or guilt, and can lead to the development of a symptom.
Conflict is resolved and the symptom disappears when we can consciously feel and accept as part of ourselves the unsettling emotion that is generating the symptom. Although medication can be useful in relieving symptoms, it is important to remember that the symptom is actually part of the healing process. Since the time of Hippocrates, physicians have understood symptoms as a manifestation of the “healing power of nature,” the organism’s adaptive response to disease. Just as symptoms like fever and cough are not diseases but rather the body’s attempt to fight an infection, so too psychiatric symptoms like anxiety and depression are not themselves diseases but rather the soul's attempt to resolve an inner conflict —by forcing us to pay attention to the unconscious dark side of ourselves that we would rather ignore.
This understanding reclaims the true meaning of psychiatry: healing the soul. It views the anxiety and the disturbing symptoms of mental illness not merely as a chemical imbalance in the brain (though that may be part of it) but more importantly as a wake-up call for the soul. Healing—making whole the divided self—comes through experiencing, accepting, and taking responsibility for the dark side of ourselves in what I describe as the six phases of the psychotherapeutic process: an inward journey of self-discovery in which we allow ourselves to feel what we really feel and so become who we truly are.
By Stacey Burling Inquirer Staff Writer
Posted on Mon, Jun. 03, 2002
Like physical pain, these symptoms are signs that something is amiss inside. But, if approached correctly, they also present an opportunity for emotional growth. Making people better is not just about making that pain go away with a pill, says Frattaroli, who is in private practice in Bala Cynwyd. It's about facing inner conflicts that caused emotional pain and talking about them in a way largely out of fashion in modern psychiatry.
"The symptoms of mental illness," he said in a recent speech at the American Psychiatric Association meeting here, "can serve as a wake-up call, forcing us to pay attention to the deeper needs of the soul." Frattaroli thinks those deeper emotional needs are getting short shrift these days as most of his colleagues have embraced what he calls the "medical model" of mental illness, the view that psychiatric problems stem from chemical imbalances in the brain and therefore can be treated with chemicals.
It took him eight years and 434 pages to make the point in his book, Healing the Soul in the Age of the Brain, which had the unfortunate release date of Sept. 10. The paperback will debut in August with a new subtitle: Why Medication Isn't Enough.
Frattaroli, who gives medicines to about half his patients, thinks drugs should be used, not to stop psychic pain, but to dull it so that people can cope with their feelings and more clearly see their problems. Patients, he said, "deserve to be listened to and to be taken seriously. Having a 15-minute appointment, being given a pill and told to come back in a month for another 15-minute appointment, isn't adequate treatment."
While some psychiatrists say they do little long-term psychotherapy because insurance companies won't pay for it, Frattaroli contends psychiatrists developed this biological view of mental illness, giving insurance companies the rationale to cut back on talk therapy. And, he said, many psychiatrists no longer believe in psychotherapy. "Psychiatrists don't spend a lot of time listening to patients anymore because they don't think they need to," he said. In his view, people may be biologically predisposed to depression or mania or psychosis, but their symptoms are not merely the result of brain structure. Even schizophrenics, he said, are more likely to hear voices when under stress. And, while many people describe depression as a feeling that descends on them for no reason, he thinks that's never the case.
"Depression is always about something," Frattaroli said. "Anxiety is always about something. It's true that it often doesn't feel that way." The biological approach gives people an easy out. It "allows us to see anything we don't like about ourselves as a chemical imbalance," he said. "We don't have to take personal responsibility for things we don't like."
In the early '90s, Frattaroli, now 54, had a panic attack while giving a speech. He had heart palpitations. He felt lightheaded. His voice shook. Afterward, he was terrified it would happen again. Through analysis, he says, he realized that he had been conflicted about the speech. He was feeling competitive and had a "hostile impulse to show up" a good friend. Years later, though, he still takes anti-anxiety medicine before speeches. The therapy, he said, "changed my whole way of approaching that task, but it didn't completely take away the memory of what happened and the awareness that my neurophysiology was capable of producing that reaction."
The experience has made him more sympathetic to his patients and appreciative of psychiatric medication. Frattaroli thinks science would like to explain all of our thoughts and feelings, our sense of self, with chemical and electrical reactions in the brain. He believes that's impossible. "I think there are certain things that will never be able to be seen, touched or measured," said Frattaroli, a lapsed Catholic who believes in a "healing force" in nature and humanity. "There's more to our inner experience than can ever be explained with brain chemistry." He described the soul metaphorically as "the place where experiencing happens... the inner place where we feel our emotions and also the place where we feel connecting to other people."
Frattaroli, who studied Shakespeare at Harvard before going into psychiatry, uses Hamlet to illustrate his ideas. For 400 years, he said in his speech, millions have understood Hamlet's depression "as an emotional crisis in his quest for truth, love, and moral integrity; an expression of his noble struggle with the slings and arrows of outrageous fortune - i.e., a corrupt and dysfunctional family and society - and with an impossible combination of inner stresses: grief, righteous outrage, malicious vengefulness, unrequited love, disturbing sexual passion and existential anxiety.
"Even modern psychiatrists tend to think about Hamlet that way when we aren't wearing our psychiatric hats. But just let a patient like Hamlet come into our office and fill out a Beck's depression inventory, and suddenly his problem will be reduced to a chemical imbalance. That's how superficial and dehumanizing - how weary, stale, flat and unprofitable - our current psychiatric thinking has become."
Frattaroli has no illusions that his book will sell most Americans, or their insurance companies, on the kind of therapy he practices. "I'm trying to sell the importance of paying attention to what you're feeling," he said. "I think that's a message everybody is capable of hearing."
Towards An Epigenetic Biology And Medicine
Richard C. Strohman, Professor Emeritus Molecular and Cell Biology
University of California, Berkeley
But genomes are actually adaptive and conserved entities and are highly interactive internally and with the world. They are difficult to change and their complexity does not permit linear genetic prediction of health. or diagnosis of disease. The logic of health and disease resides not in genes alone, but in holistic, epigenetic regulatory networks in cells and in all organisms - networks that are coextensive with the external world and which require for a manifestation of wellness the presence of environments reflective of our inherited and conserved genetic and epigenetic capacities. Developments in the life sciences make it clear that the current genetic paradigm is too limited by mechanistic and deterministic models to accommodate new perceptions of the organism! Despite the successes of the currently accepted genetic paradigm in biomedical science, and the continuing pursuit of applied research using its models, basic research has revealed conflicts and inadequacies inherent in the assumptions supporting the paradigm [1]. What emerges from these challenges to concepts of genetic causality is the beginning of a new biological paradigm, an epigenetic view that embraces creative characteristics, fusion of genetic with environmental signals [2] and other aspects beyond currently accepted biomedical theory.
Epigenetic Biology Defined
The term epigenetic has been used in the past to describe organismal development as a nonlinear, complex process Usually it was used to distinguish developmental complexity from the theory of 'preformation' which claimed that the becoming of complex organisms was simply a matter of growth of tiny preformed bodies In modern form preformation is recreated in terms of DNA and genetic programs within which developmental instructions reside. Of course, this version of preformation based on DNA as the transcendent aspect of information is also wrong.
The new biological paradigm has an epigenetic basis. Characterized by enormous complexity and by phenotypic (behavior) possibility of great variability, biological systems actually occupy many fewer phenotypic states than are possible. Choice is then a scientific rather than a metaphysical concept observable at all levels of biological organization [3]. Because functional states evolved by biological entities (cells, organisms) are adaptive, creative choice also comes into a scientific focus. 'Choice' is no longer an anthropomorphic artifact, but an observable phenomenon. Organisms display enormous fidelity in their developmental and growth patterns. Memory, therefore, is an important characteristic of living things. Biological memory, however, differs from memory in physical systems (computers, other machines) because it does not reside in fixed predictable locations. Instead, it is distributed throughout dynamical system which themselves show enormous informational redundancy. Holistic memory must, therefore, be a primary characteristic of living systems. Four major features of living systems, down to the cellular level, are a. creative choice, b. dynamical information storage or holist) memory, c. non-linear or determinative chaos, and d. informational redundancy. These features are not currently addressed by the prevailing biomedical paradigm and consequent!, offer an opportunity to develop a new paradigm. The epigenetic features of life described here were formulated by the physicist, Walter Elsasser [3].
These features do not presently move beyond axioms or simple observables present in all life forms. They do not represent mechanisms but rather new starting points for thinking about relations between form and function. Since these features are not approached by the present governing paradigm of biology, they also provide a new opportunity at the level of biological epistemology and make insistent the need for biological theory that goes beyond reductionism. What is helpful in developing new approaches to biological systems is to make clear where our present thinking is, or might be inadequate; this analysis follows below.
Points of Departure between Biomedical Reductionism and Emerging Epigenetic Biology
Currently, biomedical sciences focus on what is predicted to be useful. Much work is in concert with ongoing basic research into fundamental aspects of cellular and molecular biology. For example, analysis of simple diseases with single gene causality is expected to produce new drugs based on molecular biology of cellular structures, receptors, and other molecules that mediate cellular function. However, this research bound by the reductionist model will not address the major human diseases. Because of the enormous complexity found in the simplest biological system and the inability of reductionism in general and determinism in particular to lead to new insights into these complex systems, the current paradigm fails in the areas shown in Table 1. These areas are discussed in the following paragraphs. Table 1. Areas confounding genetic determinism in biomedicine.
AREA CONFOUNDING ELEMENTS
Population Biology
Complex traits not accessible to linear genetic analysis.
Disease Natural History
Most common diseases are not genetic.
Evolutionary Biology
No relationship between genetic and morphological complexity.
Developmental Biology
There are no genetic programs.
Molecular and Cell Biology
Informational redundancy confounds linear genetics.
Population biology conflicts with genetic determinism
Genetic determinism in current biomedical technology is based on the general equation of uniqueness between genes and phenotype: Unique Genes --Unique Effects (unique phenotypes). Under this equation we may assemble the major assumptions of biomedicine as follows: Genes determine diseases. Genes determine aging. Genetic analysis provides diagnosis and therapy for disease and aging.
These assumptions underlie the human genome project, the multi-billion dollar national project to sequence, clone, and map the 100,000 genes in the 23 pairs of human chromosomes. But fundamental rules governing population genetics stand in at least partial opposition to the uniqueness equation and to the assumptions. Essentially, the unique relationship between genes and phenotypes is flawed because most complex phenotypes (including diseases) have a unique genetic basis. Rather the relationship between genome and phenome is characterized by great complexity involving interaction between many genes, gene products and environmental signaling. This interaction may involve 10, 100, 1,000 or more genes for any common disease like cancer or the heart diseases [4]
In addition, the interaction will be function of personal natural history and present environmental setting, so that even in simplified cases, where genetic connections may be traced, the genes will have different effects in different environments. Population genetics shows that a precipitating environment is required to produce disease manifestation across the entire range of genetic variation [4,5]. For cardiovascular disease, most cancers, non-insulin-dependent diabetes, and most mental diseases, there is no evidence for single-gene causality -- and certainly none that would support the uniqueness equation. Disease natural history conflicts with genetic determinism. Diseases determined at fertilization, as Thomas McKeown [5] has made clear, are based in genetic abnormalities of one kind or another. Examples are sickle cell anemia, cystic fibrosis, and Duchenne muscular dystrophy.
There are literally thousands of these diseases, but they occur within the human population at extremely low frequency and account for less than 2 per cent of our total disease load. So, only 2 per cent of the time does the 'bad gene causes disease' mechanism operate, while 98 per cent of the time humans are born with genetic constitutions capable of supporting a life span of over 100 years, an average life expectancy of about 85 years, and an old age relatively free of morbidity [5] The human genome needs to find itself in an environment for which it has adequate representation - proper nutrition, housing, and sanitation, to name the obvious requirements - but the deterministic/mechanistic model of sabotage from within is not adequate to explain most human diseases.
Evolutionary Biology Conflicts with Genetic Determinism
Most people, scientists included, are not aware of problems within evolutionary biology having to do with genetic mechanisms. These problems do not provide any weakening of the foundations supporting evolution; they do provide concern that we may have oversimplified the idea that evolution is to be explained by genetic mechanisms alone. Again, this is a complex area but we can state the following. In the area of evolution, genetic change is seen as one end point of evolution, and change in genes (mutations) is seen as one element providing a basis for phenotypic variance that may be acted upon by natural selection. But gene changes alone will not and cannot explain evolution. The mechanistic genetic model does not explain how individual organisms generate their phenotypes in the presence (or absence) of gene changes in a variety of environmental settings [6]. Individual development is one missing link in our current theory of evolution, a link that is recognized, and one that the biological community is now struggling to mend and incorporate into a more complete picture of natural selection. As an illustration, there is the absence of relationship between genetic and morphological complexity of species.
Some closely related species cannot be seen by expert examination to be different (have different morphology), yet they show great variation in complexity at both genetic and protein sequence levels. Somehow organisms are able to take vastly different genomes and construct nearly identical phenomes. This cannot be explained by a simple linear genetic paradigm. Equally puzzling, humans and chimps have a very different morphology, yet humans do not differ genetically from chimps by more than one to two per cent Somehow we are able to construct very different organisms from very similar genomes; this IS currently not explained by genetic theory.
Developmental Cell and Molecular Biology Conflict with Genetic Determinism
First, genetic determinism for complex traits has assumed the notion of 'gene programs' to help explain the causal linkage between genes and phenotype. But this assumption has been found to be without experimental verification. There are no genetic programs [7]. There are only genes that encode for proteins. Some of these genes, and their protein products, are extremely important. When they are mutated or missing, the effects on a complex trait are profound. We have assumed that these genes control this or that trait, but now we see that these genes only supply an important protein used by the cell or organism in constructing a complex trait. Genes, for example, do not control developmental traits; they only contain information necessary for the synthesis of proteins used in development -- in the assembly of the organism. The control for this assembly is not found in the DNA; it is elsewhere within the cell and it depends on a vast array of information coming from many sectors of the organism.
This control corresponds to epigenetic regulation. Far from being controlled by simple, linear genetic causality, development is seen to rely on a complex, nonlinear determinism closer perhaps to chaos theory than it is to genetic theory. It is, of course, an amalgam of both. Creativity is evident, a creativity at the cellular level that uses genetic and other information to construct the organism. This creativity is hidden in the epigenetic regulatory processes of living cells; a creativity that may be illuminated by a new biological paradigm capable of going beyond and encompassing the genetic paradigm. Second, informational redundancy in organisms, and especially within cells, confounds the uniqueness equation because more than one gene can bring about the same. The uniqueness equation completely fails, as there is informational redundancy not only at the gene level, but at the epigenetic level as well. There are many examples in the current literature of experimental biology testifying to the ability of the organism to get along without what were thought to be crucial genes [1]. The organism, when a gene is missing, finds other genes or finds new ways (epigenetic controls) to use vast numbers of remaining genes to produce the same or highly similar phenotypes [1].
Conclusion
The new biology is discovering important areas of conflict with the prevailing paradigm of genetic determinism. These discoveries lead us into new realms of complexity, and we see that obvious characteristics of life such as purpose, and creative (as distinct from vital) forces need to be accommodated. An epigenetic paradigm holds possibilities for recapturing these characteristics within a scientific framework. Through epigenetic controls or vast networks of genes, gene products, and environmental signals found in living cells there is an opportunity for a new understanding. This understanding may augment the idea of body wisdom. Rather than the need to orient ourselves to a technology devoted to engineering genes so we can fit imperfectly into a persistently degraded world, we may come to understand how to re-engineer the world to reflect the ancient and highly adapted genome that we humans bring with us as our evolved informational capacity The genome is well, changes only slowly and with difficulty; the environment is not well and can be changed to reflect human needs inseparable from the diverse needs of the planet itself. An epigenetic paradigm, then, is a goal worthy of our highest priority and one toward which we have taken the first steps.
References 1. STROHMAN, R.C. Ancient Genes, Wise Bodies, Unhealthy People: Limits of Genetic Thinking in Biology and Medicine'. (1993). Perspectives in Biology and Medicine, 37 (I), pp.112-144. 2. WOLF, S. & BRUHN, J. G. (1992) The Power of Clan. New Jersey: Transactional Publishers. 3. ELSASSER, W. (1987) Reflections on the Theory of Organisms. Quebec: Orbis Publishing. 4. Wahlsten, D. (1990) 'Insensitivity of the analysis of variance to heredity-environment interaction'. Behav. and Brain Sci.13 109-161. 5. McKEOWN, I. (1988). The Origins of Human Disease. New York: Basil Blackwell, Inc. 6. Gottlieb, G. (1992). Individual Development and Evolution: The Genesis of Novel Behaviour. Oxford: Oxford University Press. 7. NIJHOUT H. F (1990) 'Metaphors and the Role of Genes in Development'. BioEssays 12 441 446. 8. NEEL, J.V. (1961) a Geneticist looks at Modern Medicine. Harvey Lecture Series. pp. 127-150. New York: Academic Press. This article originally appeared in Network and is republished here with permission. Reference Strohman, Richard C. (1996). Toward an epigenetic biology & medicine. [Online]. Network. [1996, May 15]. Perspectives
Leadership for Innovation in Health Care
June 2000 Cambridge, MA
Sponsors: Innovations in American Government Program, The Ford Foundation
John F. Kennedy School of Government
Bureau of Primary Health Care, US Department of Health and Human Services
The Access Project, Robert Wood Johnson
Foundation Speaker: Ron David, MD
Senior Fellow for the Center for Policy Alternatives Washington, D.C.
To illustrate the interconnectedness of leadership, innovation, and health care, Dr. Ron David chose the path of the storyteller in order to appeal more effectively to participants’ hearts. “I want to touch you emotionally…to touch soft hearts, to inform hard heads,” he said.
“People are rarely persuaded rationally until they are first persuaded emotionally. And once we are persuaded emotionally, we are hard to dissuade with the most cogent, rational evidence.” Dr. David told stories illuminating the dangers of investing in the medical model of care, challenged longstanding assumptions about health care, and offered prescriptions for change. Referring to a story in the Boston Globe, in which columnist Ellen Goodman praised the human genome project as “the book of life,” Dr. David warned against buying into such scientific reductionism. “The genetic code is not the book of life, but is instead a footnote or an index, perhaps a chapter.”
Noting that human beings are a complex formula of physiological, psychological, and spiritual elements, he challenged conference participants to turn away from the pervasive reliance on the medical model of health care and to look for ways that truly lead to health and healing. Recalling his own and others’ journeys through the practice of health care (in clinical, administrative, and policy positions), Dr. David concluded that the answer to what ails the human community lies not in the riches of medical technology, but in the most human of emotions – caring.
In order to construct a new broader model, Dr. David offered definitions of leadership, innovation, health, and care. He defined leadership not as “getting people to follow,” but as “influencing people to face tough tasks…One tough challenge is facing the fact that medical technology and care are not the paths to health and healing. There’s a tougher choice to make.” He defined innovation as “an act, an idea, a thing that’s new, not a variation on something old.” And he defined health as “the propensity, the will, and the intention to adapt, and to adapt for the particular purpose of evolving in the direction of complex, creative organisms.” It is that increasing complexity – differentiation and integration – which generates further creative evolution, in human beings and in communities. Health care can be conceived and expressed in terms of several models:
The clinical model, which operates on a continuum from the absence to the presence of symptoms of disease; the role performance model, in which one’s health reflects the roles that are assumed and interaction with others in relationships and in the performance of tasks; the adaptive model, which combines role performance with adaptation to the physical environment (involving, for example, extreme temperatures or the presence of toxic substances); the spiritual model. At the healthy end of the spiritual continuum is a sense of exuberance, “the feeling of meaning and purpose in the world, a sense of vitality and energy. At the other end is the experience of enervation, listlessness, apathy.”
“It is that larger spiritual experience – that is not embedded in the genetic code – that determines the direction we move in and our capacity to survive,” Dr. David said. “It is that spiritual experience that has to be kept alive in our communities if we are not just to survive, but to thrive.” Attending to the human spirit, Dr. David contended, is the work of leadership for innovation in health care. In a validation of this viewpoint, he cited Proverbs, “…the spirit of man will sustain his infirmity, but a wounded spirit, who can bear…?” Finally, Dr. David defined care as “serving another with compassion and selflessness.” Serving, not providing services. “People don’t need service. Refrigerators need service. Cars need service. People need relationships and care. They need to be served.”
Elaborating on the limits of the medical model of care, Dr. David referred to the work of Ivan Illich (Medical Nemesis) and his discussion of iatrogenisis – a neurosis or physical disorder caused by the diagnosis or treatment by a physician. Three types of iatrogenisis are described by Illich: clinical (in which a condition is invented or generated that requires medical supervision – for example, the excessive prescription of antibiotics); social (repression by hierarchies of dominance -- racism, sexism, heterosexism, nationalism, anti-Semitism, social class ostracism); and cultural (resulting from a lack of understanding that sickness is a signal that an individual or a society needs to be transformed).
The latter two, especially, can result in despair and listlessness, which then can manifest physiologically. “If we don’t address those issues, what happens is what has happened: medicine begins to be an institution of social control,” Dr. David said. Doctors must educate legislators and policy makers about the social and cultural causes of illness, and advocate a more reasoned approach to dealing with those problems. Dr. David offered prescriptions to overcome the limits of the medical model of care:
1. Medical care does make a difference, but “we have to fight tooth and nail to be sure that caring is injected back into medical care.”
2. Health care providers must become revolutionary. Referring to the work of feminist bell hooks, Dr. David prescribed moving patients from “communities of recovery” to “communities of resistance.” Health care providers not only must nurture people to a path of healing or recovery in clinical terms, but also help them work with others to build resistance to the underlying causes of their illnesses, such as toxic environments or the sicknesses of the social order.
3. Health care providers must imagine putting themselves out of business. They must stop expanding their role into domains of human welfare where they don’t belong, and must “stop professionalizing health care to earn a profit.” Providers should encourage patients to envision a larger model of health, to move out of a clinical model into a broader, spiritual model.
4. Dr. David recommended a book by Ken Wilber, Grace and Grit: Spirituality and Healing in the Life and Death of Treya Killiam-Wilber, a story about a woman dying of cancer, her husband, Ken Wilber, their encounter with the health care system, their diagnosis of its problems and recommendations for change.
5. Dr. David’s final prescription was “to approach patients as partners, stop thinking of the word ‘compliance’ and move to the experience of ‘cooperation,’ and engage them in a political movement, to help create a community of resistance.”
-from How Therapists Diagnose: Professional Secrets You Deserve to Know and How They Affect You and your Family
by Dr. Bruce Hamstra
St. Martins Press, NY, 1994
Therapists are faced
with a formidable task with each new patient they see. Without some guidelines
based on a body of knowledge, experience and social agreement, the assessment
process would be haphazard and nearly impossible. To find their way through
the murky puzzle of emotional pain, most therapists rely on the Diagnostic
and Statistical Manual of Mental Disorders published by the American
Psychiatric Association. This manual is commonly referred to as the DSM.
The DSM lists the usual diagnostic categories found in the United
States and describes the symptoms and behavior patters typically found
under each category. Each category is given an identifying number.
To diagnose patients, therapists obtain as much information as they can
about the patients' symptoms, behaviors and personal history. Referring
to the DSM, therapists then attempt to match this information with
the criteria listed for a certain diagnostic category. Quite often, however,
patients receive more than one diagnosis.
While this might be seen by some as a superficial pigeonhole, the psychiatric diagnosis can be extremely helpful and valuable. If a patient's behavior and symptoms are similar to those of other individuals with a known disorder, then therapists can now accurately predict the course of the patient's symptoms as well as the method of treatment. Although the symptoms often overlap and seldom exactly match the categories in the DSM, these categories at least give the therapist a starting point from which to begin hypothesizing some ideas about treatment.
On the negative side,
insurance and managed care copanies have also learned the value of diagnostics
for their own purposes. Increasingly, therapists must report a patient's
diagnosis after two or three sessions and request approval for further
treatment. Whether the insurance company approves of long or short term
therapy is tied in wththe diagnosis and severeity of symptoms. Yes, this
is a setup for therapists to overdiagnose in order to continue treatment.
IN the worst case, like that of epole who were kidnapped, improperly diagnosed
and held by a well-known psychiatric hospital chain in Texas, you end
up with a diagnosis you don't desire that leads away from relevant treatment
for your actual complaint, including involuntary hospitalization.
But
Whose Light Is It? Some Major Drawbacks
Aside from the hint
of impropriety given above, there are other conflicting issues about the
subject of psychiatric diagnosis and the DSM. These exist on the
political, social and clincial levels. Bear i mind that most psychiatrists
are aware of these issues and, at least for the past fifteen years or
so, have been giving them much more consideration. Nevertheless, the problems
remain.
Politics,
Power and Social Judgment
First,
let's consider some of the larger political and social issues. The APA
is a professional trade organization for psychiatrists. Like most trade
organizations, the APA has political agendas that serve the needs of the
profession and, in the APA's view, the needs of the general public as
well. Large trade organizations such as the APA and American Psychological
Association and the National Association for Social Workers have enormous
lobbying power and ultimately have the capacity to influence legislation
and social policy. This process is an inevitable part of a democratic
society.
If you obtain a copy
of any edition of the DSM, you will see that the copyright is held by
the APA. In essence, the APA owns the framework for the diagnostic categories,
their symptom clusters and the multiaxial system. The APA, a closed
professional organization with political power, defines what a particular
mental is and essentially owns the right to that definition. Can you imagine
this happening witha clearly defined physical illness such as pneumonia?
It seems that the mental health industry has a unique set of rules.
By law, facts cannot be copyrighted, although the manner and form
in which the facts are expressed can be copyrighted. The APA
does not claim that the DSM is factual. Wisely, it states that
the categories and criteria are simply guidelines. And yet, despite
this disclaimer, the DSM is widely accepted as the law of the land in
regard to diagnostics. All mental ealth professionals in the United
States for legal purposes and insurance reimbursement use the DSM, whether
they agree with it or not. It has evolved into an extremely
powerful social tool that determines the boudnaries of
mental illness as well as the activities of mental health professionals.
Who or What Is Abnormal?
All societies have some agreed upon guidelines for normal and abnormal or maladaptive behavior, whether formalized in a diagnostic manual or simply impolied and understood. Some extreme forms of disruptive, bizarre, impaired behaviors are considered abnormal in most all societies, while other, more subtle behaviors have been the subject of much disagreement. Whether of not these different behaviors constitute "mental disorders" becomes a value judgment.
Ultimately all diagnoses of mental disorders are social and vlaue judgments based on "scientific" data and socially agreed-upon criteria. This is unavoidable. But a problem inevitably occurs when a single group becomes powerful enough to identify and determine these boundaries. Although the APA has been increasingly more responsive to minority perspectives, female psychology and alternative viewpoints, the fact remains that their professional group holds some rather unique but pervasive social powers.
Some Clinical Problems with Diagnosis
The major drawback of any diagnosis is that it labels someone. Being labeled can distort other people's perceptions of you as well as your own self-image. People tend to see what they expect to see, therapists included. So onece you receive a diagnosis, there is an icreased possibility that other therapists will perceive you in a similar light. And once you learn of your diagnosis, the possiblity increases that you may start to define yourself in those terms. You might see yourself as very different from other people, even though it may be only one part of your thinking or feeling that differs significantly. The diagnosis can become a self-fulfilling prophecy or even a shared misperception between therapist and client. Although trained to look beyond biases, therapists can fall victim tot heir own expectations and categorical thinking. As discussed earlier, "mental disorder" diagnoses are not necessarily or firm categories...some are quite fluid and subject to frequent revision. Nevertheless, for practical purposes therapists often treat them as facts.
Fads
But there is another problem something therapists do not like to admit. Like everyone else, they are subject to fads. Strange as it may seem, a certain diagnostic category or "syndrome" suddenly becomes the object of ten zillion professional seminar and journal articles. Needless to say, the rate at which the disorder is diagnosed increases dramatically. And by the time it reaches Oprah or Dr. Phil, a large segment of the population suspects they have the disorder.
This is an unavoidable quirk of being human. Although science has come a long way, we should never forget that the Salem witch trials were based on the Malleus Maleficarium, a diagnostic handbook held to be the truth for over two hundred years.
Running Amok
Another problem with diagnosing "mental disorders" is that they can be culturally determined. Although many kinds of mental illness are recognized universally, others occur only in certain where they are not even regarded as mental illnesses. A psychiatrist from Thailand might have great difficulty diagnosing an abnormally thin American female who is preoccupied with food and determined to stay that way. The disorder, anorexia, is found most frequently in the United States and seems to be tied to certain American expectations about female physiques.
There are many other culturally bound syndromes. Amok is a behavior found primarily in Malaysia and involves a sudden homicidal killing sprees by a male following a personal humiliation. The frenzied attacker seems to follow a prescribed pattern. Asian males might suffer from koro, a fear that the penis will withdraw into the abdomen resulting in death, while certain Native American Indians experience windigo, the fear they will be turned into cannibals by an evil spirit. Spirit possession is quite common in certain African groups and includes hallucinations and clairvoyant experiences that might be seen as psychotic in the United States. In the group context, however, they reflect shared beliefs that are quite normal.
In many instances there indeed may be an underlying psychiatric disorder, but the manner in which it is expressed varies according to cultural expectations. In many areas of Africa, a variety of disorders, including major depression, generalized anxiety and even schizoprenia, are expressed through unusual physical symptoms rather than the symptom patterns typically seen in the United States. On the other hand, sometiems an illness or emtional problem is not simply the expression of a well known psychiatric disorder but is instead a unique interaction between culture and biology.
What's the Solution?
Some psychologists and psychiatrists as well argue that people should not be given an all encompassing diagnosis but should be assessed according their strengths and weaknesses in a variety of areas, including thinking abilities, coping skills and personality atterns. From this perspective, people are seen as constellations of factors adn ptoentials that don't necessarily add up to single definable entitites. Assessments would dscribe these constellations without giving them a larger label.
The important thing to keep in mind about psychiatric diagnoses is that they are very rough maps of an ever changing terrain. And they do not point to single causes of behavior. While some factors may be more important than others in certain cases, behavior (and disease) results from a complex interaction between biological, psychological and social factors. The relationship among these factors is much more complex that we ever imagined.