Jung At Heart Archive June 2009

Where to go?

I read an interesting piece in the NY Times last week -- Where Can the Doctor Who’s Guided All the Others Go for Help?. Interesting because of the conclusions about where psychiatrists can go for help themselves. 

I often encounter the assumption among people I know that all therapists have been in therapy. Very few of them know that it is not a requirement in most training programs -- analytic training being the exception -- and in some, it is actually discreetly frowned upon. So for starters it is not reasonable to assume that a given therapist has ever been in therapy himself. And of course there is the question of what constitutes therapy anyway? Is what Paul did with Gina in Season 1 of In Treatment therapy? Is his short time with her in season 2? Is a brief course of solution focused therapy enough for someone who will be dealing day in and day out with the issues and lives of others? All good questions.

One psychiatrist quoted in the column --

“In my situation, it would be difficult to find someone,” Dr. Dan Buie, a beloved senior analyst in Boston, told me. It is not that psychiatrists aren’t waiting in wing chairs all over the city. It is that so many of them are former students and former patients. One generation of psychiatrists grows the next through teaching and treatment.

Surrendering that professional identity to become a patient reverses a kind of natural order. “You can’t be a simple patient,” Dr. Buie said. “Anyone I’d go to, I’ve known.” To avoid it, some travel to other cities for therapy (probably passing colleagues in trains heading in the other direction).

There is also the factor of experience. It is one thing if my internist is younger than I; she is closer to the bones of medicine, and with any luck we can get to know each other for years before serious illness requires more intimate contact. It is another thing if my therapist is younger than I.

“It would be a big mistake not to turn to someone,” Dr. Buie went on, “but I might have some trouble going to younger colleagues. It’s hard to understand the issues that come up in the course of a life cycle unless you’ve lived it yourself.”

Interesting to see the assumption that a psychiatrist could only see another psychiatrist. Not someone who is known as an excellent therapist, but a psychiatrist. Though it seems to me an obvious choice to look to someone outside of one's own professional circle in order to bypass this particular obstacle. Yet it is not mentioned in the article as a possibility.

Or an analyst trained in psychoanalysis might choose to see a Jungian. Or a Jungian to see a Freudian or even an Adlerian. Why must the therapist chosen be of the same theoretical persuasion?

Excellence as a therapist is not a function of the degree the therapist practices under. It is a function of talent, devotion, ongoing study and supervision, personal work, personality and a host of other qualities. There is nothing in the training of a psychologist or psychiatrist or any other variety of therapist which leads to one being better than another. That training is the ticket to entry into the field and it is only after entering that the real work of becoming a therapist, in the best and deepest sense of the word, begins. 


Jun 29, 2009 11:09 AM

Therapy and Baking Bread

The woman we get bread from is taking the week off so I have been considering baking some bread today. When I first started making bread, I had to follow the recipe very carefully. Each time I made it, I learned something about the qualities of bread and what was essential to making good bread because each time, no matter how hard I tried, some error would creep in -- a mis-measurement, the wrong temperature, too much humidity, something. From the errors I learned what was essential and what was not and how to work with less than perfect conditions. And by repeating the process many times, I learned what makes the difference between  a leaden mass of hard dough and a beautifully browned and fragrant loaf of bread. Now that I have made bread many many times, I can be less rigorous about following the recipe. I can add ingredient, change them, make substitutions so long as I stay with the essential elements and requirements of turning flour and liquid and yeast into bread. 

Doing therapy is not unlike baking bread. The therapist first needs to learn the recipe and follow it carefully -- that is what new therapists do. And they must do this until they have a solid understanding of what the essential ingredients and conditions are. Therapists need to learn about the frame and why it is essential to the process. And learn what kinds of deviations, alterations to the recipe, work and which will likely lead to something less than desirable.

Thoughts on a rainy summer day.

Jun 23, 2009 10:20 AM

Feeling Function

Google News Alerts tossed up a link to an interesting book review this morning -- interesting enough that I pre-ordered it from Amazon. The book, Doctoring the Mind by Richard Bentall tackles some of the same issues I ruminate about here. 

Bentall's thesis is that, for all the apparent advances in understanding psychiatric disorders, psychiatric treatment has done little to improve human welfare, because the scientific research which has led to the favouring of mind-altering drugs is, as he puts it, "fatally flawed". He cites some startling evidence from the World Health Organisation that suggests patients suffering psychotic episodes in developing countries recover "better" than those from the industrialised world and the aim of the book is broadly to suggest why this might be so.

The reviewer tells us:

The first answer, he suggests, is a greater regard for the role of adverse circumstances in provoking mental illness. If bad things happen to people, this is registered in their bodies' chemistry ("a troubled brain cannot be considered in isolation from the social universe"). The second answer is a concomitant respect for the power of interpersonal relationships to ameliorate these effects. One of the concluding chapters, entitled "The Virtue of Kindness" (the subject of the psychoanalyst Adam Phillips' latest book), asks if psychotherapy can help. The short answer is yes, because a person, unlike a drug, can learn to listen to another's story.

 I have struggled with what it means that we are so willing to accept as gospel theories about mental illness that keep coming up as unsupported by research. The latest example:

New research dismisses the widely held notion that a "depression gene" makes a person facing stressful life events more likely to develop depression.  

In 2003, mental health researchers announced that a genetic variation that affected the body's serotonin levels increased a person's risk for major depression if they endured several emotional events. Yet efforts to repeat and confirm that study's findings have been inconsistent, according to the National Institute of Mental Health.  

Now, scientists reporting in The Journal of the American Medical Association say that genetic variation of the serotonin transporter gene, or 5-HTTLPR, may have no effect on depression risk.  

How is it that we, especially here in the US, are so willing to accept anything that sounds scientific even when it is not supported? Why is it that sounding technical and scientific is enough to override any and all other possibilities? 

Also this morning, following a comment on the IAJS* email group, I read a piece by Marie Louise von Franz -- "C. G. Jung's Rehabilitation of the Feeling Function in Our Civilization".** Those of you who are familiar with the MBTI know that "feeling" in the typological sense does not equate to emotional but is instead about values and is, along with "thinking" a rational function. In her lecture, she said,

"The contemporary Zeitgeist belittles feeling...

I don’t think that we can achieve much if we remain on the level of “reasonable” materialistic thinking—it it not altogether wrong; it is wrong only if we infer “that is it...

Jung says in a letter that we have become too lopsidedly intellectual and rational and have forgotten that there are factors that cannot be influenced by a one-track intellect. We then see emotionality flaring up as a compensation (letter to Albert Oppenheimer, 10 October 1933. 1973a, 128–129). We need to be more than just reasonable and level-headed, an attitude which only infuriates the young people. We must offer them a creative spiritual, non-materialistic view of reality as a whole—namely a real connection with the unconscious as a supramaterial, extrasensory reality to which we must relate, not only with our minds but also with feeling and emotion." 

I want to reflect on this further, but my intuition tells me this is part of what is at the root of the current sorry state of affairs in mental health. Technical thinking, the dominant thinking mode of modernity, devalues thinking through the feeling function, the kind of thinking that values, for example, what Bentall refers to when he points to the currently undervalued place of listening, via depth psychotherapy, in treating the problems now considered to be "mental illnesses".


* IAJS -- International Association for Jungian Studies

** Jung Journal: Culture and Psyche, Spring 2008, Vol. 2, No. 2, Pages 9–20 , DOI 10.1525/jung.2008.2.2.9


Jun 21, 2009 11:53 AM

Mental Illness

A week or so ago my son and I had a vigorous debate about the DSM. And as I listened to him, I realized he believed that those categories carried meaning in a very different way from the way I see them. I remember when I was in graduate school and learning the rudiments of being a therapist how eager I was to find recipes and prescriptions of treatments, because somewhere inside I knew I didn't really know anything. Structure, in the form of techniques, diagnostic frameworks, anything that brought order for me I grabbed onto for dear life so that I could figure out how to actually *be* a therapist. And I'm pretty sure, even if he might not admit it, that's where he is too. For him, determining a diagnosis is critical. So to him, that new diagnoses will be added in the DSM V is a good thing.

Now that I have been doing this work for a long time, the diagnosis, a la the DSM, doesn't seem very important to me. My task is to respond to the person sitting opposite me and as I listen to him or her, try to hear what is being said, where the sore places are, what this person's story is. I am listening to stories of lives. 

Is the person who comes to see me after having had several relationship failures mentally ill? Really? Because in the mainstream mental health system, if insurance is to pay, he or she must be diagnosed with a mental illness to warrant treatment. But is that kind of unhappiness in life indicative of illness? Or the man who has lost his job and feel useless and afraid? That doesn't seem like mental illness to me. Or the woman wanting to make sense of her fears and to understand her dreams? Or the couple who seem to have forgotten how and why they fell love with each other? Or the woman who is lonely and isn't sure how to make friends? I have seen people like this again and again over the last 35 years. None of them were mentally ill. All of them were experiencing problems in finding the life they wanted.

When I was in college, I took a couple of courses from a brilliant and somewhat eccentric psychologist, Irwin Kremen, I remember his saying that from the moment of conception we are subject to a wide variety of noxious influences. Some of them leave long lasting effects, some do not. But no one is without blemish. 

Someone is likely to come along and comment that I don't understand how terrible schizophrenia or major depression is. But I do. And it seems to me there is something different about what we call major mental illness from what I see day to day in my practice. As much as anything, this may be because I am a psychologist and not a psychiatrist. But the people who come to see me, with but a few exceptions over these many years, have been people who are able to work and have functioning lives. They suffer, often terribly from unhappiness and problems in their lives, but they are not incapacitated. 

Maybe one of the reasons for depressed morale among psychiatrists, as noted in Ars Psychiatrica, is the whole muddle of what is mental illness. As therapists also struggle with changes in the climate for mental health treatment and the strictures of third party payments, maybe we all need to be willing to step back and see what we are about really. Maybe only some of what we do belongs under the umbrella of the medical model while much of what we see and do in psychotherapy, regardless of the training of the therapist, belongs someplace else. Consider that the word psychotherapy is from the  Greek words psychē, meaning breath, spirit, or soul and therapeia or therapeuein, to nurse or cure. Does the care of the soul really belong in the medical model?


Jun 15, 2009 2:21 PM

In Treatment - Season 2

  • In TreatMent 2 --  Week 7
  • In Treatment 2 -- Week 6
  • In Treatment 2-- Week 5
  • In Treatment 2 -- week 4
  • In Treatment 2 -- week 3
Jun 15, 2009 11:44 AM

Is bitterness a mental illness?

There have been stories here and there about the upcoming DSM V for several months now. The most recent, in the LA Times, takes a somewhat optimistic view --

"Over the next 18 months, psychiatrists will hammer out a draft of the fifth edition of the American Psychiatric Assn.'s Diagnostic and Statistical Manual of Mental Disorders, more commonly called DSM-V. Nowhere have the discussions been more heated, the ramifications most vividly foretold, than here at the organization's annual meeting. 

Some psychiatrists warn that the tome runs the risk of medicalizing the normal range of human behaviors; others vehemently argue that it must be broad enough to guide treatment of those who need it. 

But all agree that the so-called bible of psychiatry is expected to be considerably more nuanced and science-based than the last edition, DSM-IV, published in 1994. 

Brain imaging and other technologies, plus new knowledge on biological and genetic causes of many disorders, have almost guaranteed significant alterations in how many mental afflictions are described."

But this feels exceedingly rosy to me. Especially when there is consideration of adding bitterness, sub-clinical bipolar disorder and other variations of what many, including me, consider to be within the range of normal experience and behavior. And I cannot believe that there is real research evidence to establish these or many of the existing diagnostic categories as anything other than descriptions of clusters of behavior. Because all of the diagnostic categories rely on observer report, not tests or other diagnostic tools, because they simply do not exist. What we have now are lists of symptoms or behaviors -- display 6 out of 10, for example, and you fit the category; 5 and you don't. But that makes no sense. What is the difference between the two such that having slightly more symptoms means you are mentally ill -- and that term is an argument for another day -- and thus appropriate for treatment? Are habits -- like gambling or excessive time online -- really indicative of pathology? And why is making them mental illnesses in the best interests of patients, especially when there is no evidence of etiology for either one?

Steve Diamond and Christopher Lane have been writing on either side of the issue of whether or not bitterness is appropriate for inclusion in the DSM V. Diamond argues

"Bitterness, which I define as a chronic and pervasive state of smoldering resentment, is one of the most destructive and toxic of human emotions. Bitterness is a kind of morbid characterological hostility toward someone, something or toward life itself, resulting from the consistent repression of anger, rage or resentment regarding how one really has or perceives to have been treated. Bitterness is a prolonged, resentful feeling of disempowered and devalued victimization. Embitterment, like resentment and hostility, results from the long-term mismanagement of annoyance, irritation, frustration, anger or rage. Philosopher Friedrich Nietzsche noted that "nothing consumes a man more quickly than the emotion of resentment."

Most mental disorders stem either directly from--or secondarily generate--anger, rage, resentment, hostility or bitterness. This is why I personally applaud the American Psychiatric Association's long overdue recognition of the debilitating and deleterious aspects of Post-Traumatic Embitterment Disorder (see my previous post on "The Trauma of Evil"). There is no question that, if left to fester unconsciously, anger, rage and resentment about having been traumatized become bitterness and hostility, which in turn give rise to self-defeating, sometimes passive-aggressive, destructive, vengeful or even violent behavior. Pathological embitterment is a dangerous state of mind that can and does motivate evil deeds. This attempt to include what I would categorize as another "anger disorder".

 He has written several times now about his view of rage and anger and where they become pathological. And in some ways I see his point, especially vis a vis violent behavior, which he has  discussed earlier. One example can be found here. But the tool of the DSM diagnosis is a very crude one and one which really does not discriminate by degree. And we have seen more disorders become spectrum disorders so that where normal behavior ends and pathological begins becomes more and more difficult to discern. Thus the concerns raised by Lane and others, including me.

Lane asks:

In its discussion of post-traumatic embitterment disorder, the APA may have correctly gauged the mood of the country, but as usual it has ignored or shunted aside most of the explanatory context, to pathologize the individual in all of her or his frustrated grievance.

"They feel the world has treated them unfairly," says Dr. Michael Linden, a German psychiatrist who labeled the behavior. "It's one step more complex than anger. They're angry plus helpless."

Linden estimates that between 1% and 2% of the population is embittered, though he didn't specify whether that percentage increased during or immediately after the Bush years. Perhaps he should. Others reviewing his work note that PTED includes "a high degree of comorbidity [and] diagnostic uncertainty . . . : 66% adjustment disorder, 40% dysthymia, 34% generalized anxiety disorder, 18% social phobia, 18% agoraphobia, and 16% personality disorder."

But adjustment disorder, a highly elastic concept, is itself a capacious term to describe predictable, largely routine responses to stress. Why, then, is the APA discussing the inclusion of a new term that not only overlaps so strongly with existing "disorders," but also has so many obvious, identifiable causes in the world?

My alarm bells go off when understandable behavior -- like bitterness about things like the reversals of fortune many have suffered in the current economic downturn or political bitterness so common in the Bush years -- is made pathological. Because once something can be tagged as mental illness, it no longer has to be taken seriously. Questions like what does it mean that a significant segment of the population feels embittered about the future, already too seldom asked, become even less likely to occur, because it's about an illness, a disease. Whose interests are served by this?

And, as is mentioned in the LA Times piece, we also have the additional problem of conflicts of interest among those serving on the panel writing the DSM.



Jun 4, 2009 11:41 AM

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