Jung At Heart Archive March 2010

Please don't go there!

This past week both Daniel Carlat and John Grohol posted about prescribing privileges for psychologists. And I think this debate is a lot about the turf war that has gone on between psychiatrists and psychologists for at least a couple of decades now.

Carlat favors psychologists gaining prescribing privileges but as a part of what he would propose as a rather sweeping change to the training of both psychiatrists and psychologists.nHe would have them train together with psychiatry leaving behind those aspects of medical education that he sees as not relevant to psychiatry -

I suggest that the process begin with a work group created jointly by the American Psychiatric Association and the American Psychological Association. Yes, let’s get psychiatrists and psychologists in the same room, and reverse engineer an ideal curriculum for integrative psychiatric practitioners. Let’s face it, going to 5 to 7 years of psychology graduate school, then capping is with 2 years of psychopharmacology is not an efficient use of training resources. It’s almost as ridiculous as going to four years of medical school, one year of medical internship, then three years of psych residency.

There must be a middle path—perhaps a five year program that would interweave coursework in physiology, pharmacology, and psychology from day one. The specifics would require much thought and discussion, and would best be done by reverse engineering. Start with the ideal psychiatric practitioner, list the core competencies such a person requires, and then figure out the very best way to teach those competencies.

And certainly that is an intriguing possibility. But how would not the market forces continue to work in this new blended profession in the same way that it has in psychiatry? I recall a study in which it was shown that a psychiatrist doing a medication only practice, seeing 3 or 4 patients per hour could easily earn 57% more than one who spends a significant amount of hours seeing therapy patients. Why believe that members of this blended profession would be immune to this kind of economic incentive? And, given that third party payers are already biased away from therapy to medication, why would they change their position?

I think what we see here is the confluence of a couple of issues underlying the old turf battle. For psychologists to gain prescribing privileges, they become more like "real" doctors, which as everyone knows can and do prescribe medicines. So it addresses an old inferiority contained within the profession. 

Psychiatrists have pretty much abandoned psychotherapy -- many residency programs provide very weak training in therapy these days -- in favor of a model rooted more firmly in the medical model. As non-medical professionals gained the right to practice psychotherapy, doing so began to carry less prestige for physicians already in a specialty often derided by their more "medical" colleagues. Abandoning psychotherapy for psychopharmacology and a brain illness model has allowed psychiatrists to be "real" doctors.

But now the psychopharmacological enterprise has fallen under a cloud with the problems of compromised researchers and the emergence of data suggesting that the medications perform much more poorly than thought. Which begins to make psychotherapy more attractive again. 

But the siren song of money will trump any of this. And so long as volume of patients yields the most income, psychotherapy will be honored more in the breach than in practice.


Mar 27, 2010 10:52 AM

Whose goals?

Don't make assumptions about overweight clients, such as about whether they have an eating disorder or are working toward acceptance of their weight.

Understand that an overweight person's problems are not always a result of their weight and that therapy does not bring thinness. Be aware that resolving life issues also does not necessarily result in weight loss.

These are certainly two of the most important points from the guidelines against size bias that I cited last week. And, I think probably the most difficult for many therapists to follow. Change comes slowly but in my professional lifetime, we have moved from seeing therapy as a corrective to homosexuality* so that in a recent article in the Journal of Analytical Psychology**, we find the following:

Analytical psychology pursues the purpose or goal of the psyche and its products. Consequently what is reflected upon are the variety of phenomena the psyche produces that may or may not form into a defined category of homosexuality or other non-normative sexualities. The analytic challenge may then be to view these erotic products of the psyche as meaningful in the context of an individual life, with implications that only become significant through that individual’s proclivities. p.115

Clearly the individuation promoted in analysis is not to change the homosexual to a heterosexual, and not to make the promiscuous man monogamous. If change is not the goal, then what might be expected?  For the man ... being in relationship to the phallus and its symbolic power would demand a development in his relationship to himself. p.121

And if we change the focus of this piece from homosexuality to fat, then consider ho the same material might be read:

Analytical psychology pursues the purpose or goal of the psyche and its products. Consequently what is reflected upon are the variety of phenomena the psyche produces that may or may not form into a defined category of weight or other non-normative bodies. The analytic challenge may then be to view these products of the psyche as meaningful in the context of an individual life, with implications that only become significant through that individual’s proclivities.

Clearly the individuation promoted in analysis is not to change the fat person to a thin person. If change is not the goal, then what might be expected?  For the person ... being in relationship to the body and its symbolic power would demand a development in her relationship to herself.


I come back again and again to Bion and his dictum that we approach sessions without memory or desire. I have to remember when I work with someone that it is not my life we are considering, nor are my choices or the choices I think I would make necessarily the best ones for the patient. This is a tough position to hold, to be as neutral about what the patient chooses as humanly possible in order that the choice be his or hers. 

It is a challenge, particularly for so-called normal sized therapists to look at a fat patient and not see something that should be changed, that can be changed if only...

In Yalom's essay, "Fat Lady", he talks about the process of therapy, of Betty's depression, and her weight loss, which by the time treatment ends amounts to 100 pounds. And of course the consensus is that because she lost so much weight, this therapy was spectacularly successful.  

At the end of the essay, he writes:  

“It’s the same with me, Betty. I’ll miss our meetings. But I’m changed as a result of knowing you .”  

She had been crying, her eyes downcast, but at my words she stopped sobbing and looked toward me, expectantly.  

"And, even though we won’t meet again, I’ll still retain that change.”  

“What change?”  

“Well, as I mentioned to you, I hadn’t had much professional experience with the problem of obesity.” I noted Betty’s eyes drop with disappointment and silently berated myself for being so impersonal.  

“Well, what I mean is that I hadn’t worked before with heavy patients, and I’ve gotten a new appreciation for the problems of.. “ I could see from her expression that she was sinking even deeper into disappointment. “What I mean is that my attitude about obesity has changed a lot. When we started I personally didn’t feel comfortable with obese people.” In unusually feisty terms, Betty interrupted me. “Ho! ho! ho! Didn’t feel comfortable. that’s putting it mildly. Do you know that for the first six months you hardly ever looked at me? And in a whole year and a half you’ve never, not once, touched me? Not even for a handshake!”  

My heart sank. My God, she’s right! I have never touched her. I simply hadn’t realized it. And I guess I didn’t look at her very often either. I hadn’t expected her to notice!”  ***

 Many times a patient will say to me, "I know you think I should do X", because that is what they want for me to think and want. And often they are initially unhappy when I remind them that what they decide will not change my life, but it may change theirs so it is what they want, what they choose that matters. 

When I enter a session with a patient I endeavor to do so without memory or desire -- which is to say that any day as I meet with my  patient, I put away thoughts about this blog, about my husband's latest project, about other patients, and about our last session with each other  and I prepare to meet her in the moment and without an agenda. I wait for her to begin and allow her to set the agenda for our time together. I follow the thread of her concerns and as I do so, bits and pieces of the other times we have met come to mind. I hear more of her themes and as we go along I am relating them to themes I have heard from others and what I know about such themes. I am aware of issues in her life that have led to her personality being structured as it is -- this is a clinical piece where I touch into my database of experience with people who have similar histories and who have had the constellation of issues in their lives that she has has and what I know from more theoretical material as well.  I challenge a bit here, ask a question there, offer a suggestion, share a personal experience. I watch as we do our dance of of speaking and listening and I see when an interpretive arrow hits the mark and when it misses.

Bion wrote:

Desires for results, 'cure' or even understanding must not be allowed to proliferate.****

How difficult this is in an age of treatment plans and goals, of war on obesity, to say nothing of our own biases, blind spots, unconscious desires, and personal experiences! And yet, it is imperative if we are to honor the patient's goals, and the purpose of her psyche. 

There are gray areas, there is no doubt about that. Times when the patient's life is at stake, as we saw last season of In Treatment seem to demand that we take action and assert our own goals. Even in that instance, it is not clear that Paul had to act as he did, that there was no other way to get April the medical treatment she did need. And his action did ultimately destroy the therapy. 

But the gray areas are uncommon. Far more common are instances such as confronted Yalom when he worked with Betty. When his very negative attitudes toward her weight and her body met and colluded with hers own internalized loathing of it leaving no room for understanding of the meaning of her weight and her feelings about it to develop. Because that meaning was subsumed by her, and it seems by Yalom as well, to the goal of changing her, of making her more normal. 

Being without desire to change our patients, to make them more "normal" is not easy.

“We cannot change anything until we accept it. Condemnation does not liberate, it oppresses.”  C.G. Jung


* I do not regard efforts to change sexual orientation as valid psychotherapeutic enterprise.

**"Expressions of Homosexuality and the perspective of analytical psychology", JAP, 2010, 55, 112-124

*** Yalom: Love's Executioner & Other Tales Of Psychotherapy. New York Basic Books, 1989. p. 123

**** Bion: "Notes on Memory and Desire"


Mar 22, 2010 9:58 AM

Diagnosis?

I have written here about my reservations about the diagnostic system we use in mental health. I have problems with the lack of theory to support it, with the proliferation of categories, with the way it is used by third party payers to control who can and cannot receive treatment. And I have doubts about the applicability of the medical model for most of the people most of us who practice outpatient psychotherapy see. Problems in living just do not equate to illness for most of our patient population.

So I have been thinking about a post made by Stephen Diamond last week on what is a mental disorder. He and I are in radical agreement on the difficulty in finding the line between normal and abnormal. But we find less common ground here:

"...as Freud famously observed, we are all at least a little neurotic. And existential frustration, anger, sadness, despair and anxiety are feelings every person experiences at some point. Just because someone doesn't meet the criteria for a diagnosable mental disorder only makes him or her "normal" insofar as mental suffering will always be an inescapable part of the human condition. Psychopathology is always relative. Receiving a psychiatric diagnosis does not necessarily mean the cause or etiology of the disorder is known or agreed upon. It doesn't necessarily mean one has some "brain disease" or "biochemical imbalance." Nor does it typically necessitate pursuing one particular type of treatment or therapy over another. However, refusal to diagnose by clinicians can be a kind of naive denial, resulting in not taking someone's suffering sufficiently seriously to intervene--sometimes with catastrophic consequences. When that mental suffering--whatever its source may be--manifests in debilitating, intolerable psychological and/or physical symptoms or destructive behaviors, a psychiatric diagnosis formally recognizes the need for additional support and possible professional treatment. Which of these two options is truly more humane?"

Borders and boundaries are devices we use to order the world. We make lines on a map and then find comfort in knowing that this is where our country ends and theirs begins. But boundaries are less lines than they are areas. Is there a clear line where the land ends and the sea begins? No, instead, we have wetlands that are neither wholly land nor sea, an area in-between. We might want to consider then, that there is an area of personality, present in all of us, which is between what we call sanity and madness, a borderline area.

It would be nice to imagine that there were some scientific way to determine diagnosis, but there is none. Absent biological or chemical tests to establish diagnoses, we fall back on consensus reality and struggle with the unevenness of such a standard. We look to mental health professionals to be in touch with society’s understanding of people and relationships between them, of relations between emotions and the self, and on local custom and ways of perceiving experiences. One outgrowth of this approach is the DSM IV. It is an attempt to develop, by consensus, descriptions of all disorders thought to be reflective of mental illness of one kind or another. Categories have been expanded and elaborated in the years since the first edition was published; yet, all but the rarest of categories still depends on the subjective judgment of the examiner. That a mental health patient might be diagnosed as bi-polar in one setting and schizophrenic  while presenting the same symptoms suggests how primitive our ability to make distinctions really is. Local custom, training of the examiner, examiner biases, insurance coverage, perceived stigma carried by various diagnoses, and funding sources can all influence the diagnosis made as much as the behavior and history of the patient.

That such factors as funding sources and examiner bias influence diagnosis goes against the image of the medical model as scientific. However, subjective and external factors often matter more than the symptoms displayed. In private practice, the fact that medical and insurance records cannot be guaranteed to be private, the tendency is to choose the least stigmatizing diagnosis possible.  A facility has beds for patients with one kind of diagnosis but not another, so the effort is made to fit the patient where the space is. Or health insurance severely limits coverage for treatment for minor disorders but is more generous for ones that are more serious, resulting in the push to gain coverage, not strive for accuracy in diagnosis. All of these disturbances, in what we might like to believe are an orderly and scientifically based process, reflect variations in the consensus reality and its deviance from the ideal.

We imagine ourselves to be far more advanced than the ancient Greeks who relied upon consensus reality and collective roles to determine what was and was not normal. But is it really the case that we are as autonomous and individual as we want to believe? 

It is generally assumed in medical circles that the examination of a patient should lead to the diagnosis of his illness, so far as this is possible at all, and that with the establishment of the diagnosis an important decision has been arrived at as regards prognosis and therapy. Psychotherapy forms a startling exception to this rule: the diagnosis is a highly irrelevant affair since, apart from affixing a more or less lucky label to a neurotic condition, nothing is gained by it, least of all as regards prognosis and therapy. C.G. Jung


Mar 16, 2010 11:11 AM

Psyche Goes to the Movies -- An Angel at My Table

Today's film is An Angel at My Table. Originally produced as a three-part miniseries for New Zealand television, this extraordinary film is based on the life of Janet Frame, an introverted, sensitive girl who was later misdiagnosed as schizophrenic and spent eight years in a psychiatric hospital. She would later become one of New Zealand's most celebrated poets and novelists, publishing her first books while she was still confined to a mental ward. Part one traces her childhood and adolescence. Part two covers the terrible years when Ms. Frame was endured lengthy public hospitalizations for mental illness, receiving countless ECT treatments, until the publication of her short stories and first novel, and a prize for the latter, altered the manner in which she was regarded by psychiatrists and led to her emancipation from the hospital, barely avoiding a lobotomy. Directed by Jane Campion. Click here for Roger Ebert's review.


Mar 14, 2010 10:23 AM

Checking Bias

Around a year ago, I wrote about my reaction to Irvin Yalom's essay, "Fat Lady".  At that time, I wrote:

How is a fat person, who, no matter the reasons for being fat, certainly has a whole host of emotional issues about her size and her body -- how is such a person to find the courage to talk about those feelings in the presence of someone who finds her as disgusting as she herself often does? How can she roar her anger at the prejudice she encounters? How is she to arrive at being able to care about her body and for herself lovingly rather than with contempt and hatred? And supposing she doesn't want to devote herself to losing all that weight? Supposing she wants to get off the diet merry-go-round and concentrate on being healthy and fat (and yes, that is possible)?  

The operative assumption is that in a room with a normal weight therapist and a fat patient, that only the patient has a problem is, it seems to me, a very weak one.

I have remained interested in this issue, both personally and professionally and will be writing a series of posts about fatism, fat bias, fat acceptance and related issues -- not to the exclusion of all else, but in addition to my thoughts about therapy. 

In a long review article in Nature,  Rebecca Puhl and Chelsea Heur of Rudd Center for Food Policy & Obesity at Yale. Their research showed:

Obese individuals are highly stigmatized and face multiple forms of prejudice and discrimination because of their weight (1,2). The prevalence of weight discrimination in the United States has increased by 66% over the past decade (3), and is comparable to rates of racial discrimination, especially among women (4). Weight bias translates into inequities in employment settings, health-care facilities, and educational institutions, often due to widespread negative stereotypes that overweight and obese persons are lazy, unmotivated, lacking in self-discipline, less competent, noncompliant, and sloppy (2,5,6,7). These stereotypes are prevalent and are rarely challenged in Western society, leaving overweight and obese persons vulnerable to social injustice, unfair treatment, and impaired quality of life as a result of substantial disadvantages and stigma.

However, the realities of the effects of this bias and how it poses barriers to all kinds of care are little discussed as we focus on the "War on Obesity".

As I have been doing my own research and reading, I was surprised to find that the APA Monitor actually published a brief set of guidelines for therapists interested in being "size friendly" -- it's a short piece and seems to have been little noticed, though it was published in January 2004. Here are the guidelines:

Don't make assumptions about overweight clients, such as about whether they have an eating disorder or are working toward acceptance of their weight.

Display size-friendly artwork or magazines--such as BBW Magazine--in your office or lounge.

Have seating in your office that can accommodate larger people. An example is armless chairs.

Raise your colleagues' and students' awareness by addressing these issues in formal and informal ways, such as during clinical supervision or in workshops. 

               Ask larger clients about eating behaviors in the same way you would ask a thin or average-sized person.

Through self-questioning and introspection, become aware of your own level of prejudice toward overweight people.

Educate yourself on issues that affect overweight people, such as the genetic influences of size and the effects of dieting on physical and mental health.

Understand that an overweight person's problems are not always a result of their weight and that therapy does not bring thinness. Be aware that resolving life issues also does not necessarily result in weight loss.


How do you or therapists you know measure up against these guidelines?

Mar 13, 2010 12:56 PM

More on Social Media

A couple of people emailed me to ask me to say more about why I wouldn't Google a patient. I don't think that doing so would be an ethical violation, but I do think it could have an undesirable impact on the therapy. I think this because it would interfere with the emergence of information and material from the patient. And quite possibly, even probably my view of the patient and his life could be altered by what I might discover through this kind of covert information seeking. Then again there is the problem of disclosure, because certainly at some point the therapist would have to disclose that this had happened, or the therapist becomes guilty of holding a secret. All in all, whatever small benefit that might be found in Googling a patient, for me is cancelled by the significant potential problems.


Mar 8, 2010 3:23 PM

Dealing with Social Media

Social Media sites seem to have spread like mushrooms in a damp summer. Facebook, Twitter. Even knitters have Ravelry. WE could argue about how useful these sites actually are and what "friending" really means, but that is for another day. My concern lately has been possible conflicts for therapists and patients. Last week I worked on a social media policy for my practice and posted it here. In the interests of discussion, I thought I would post it here as well and ask you, my readers, your thoughts on this issue.

Social Media Policy

° Friending

I do not accept friend requests from current or former patients. This holds true on Facebook, LinkedIn, and all other social networking sites.  I feel that adding clients as friends on these websites blurs the boundaries of our therapeutic relationship. If you have questions about this, please feel free to bring them up when we meet and I’m happy to talk more about it.

° Twitter

I do not follow current or former clients on blogs or Twitter. If there are things you wish to share with me from your online life, I strongly encourage you to bring them into our sessions where we can process them together, during the therapy hour.

° Interacting via social media sites

Please do not use messaging on websites such as Twitter, Facebook, and LinkedIn to contact me. If you need to contact me between sessions, the best way to do so is by phone or direct email.

° Use of Search Engines

It is NOT a regular part of my practice to search for clients on Google or other search engines. 

° Email

If you choose to communicate with me by email, please be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. 

Thanks to Dr. Keely Kolmes for her permission to modify her form.

Mar 1, 2010 9:33 AM

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