Jung At Heart

Old news is good news

Thu, 24 Jul 2008 14:44:30 -0400

I subscribe to Google News to keep up with what's happening in psychiatry and psychotherapy. And the other day it served up an interesting item on Jungian books. But the item dates from January, 2004! I wonder what made Google cough it up yesterday?

Anyway, the list is from Deirdre Bair, who wrote a long and excellent biography of Jung, which I recommend highly. Here are her picks, courtesy of the Guardian:

1. Memories, Dreams, Reflections by CG Jung

2. Modern Man in Search of a Soul by CG Jung

3. Man and His Symbols by CG Jung (ed)

4. Jung and the Post-Jungians by Andrew Samuels

5. The Jungians by Thomas B Kirsch

6. On Jung by Anthony Stevens

7. Jung by Anthony Storr

8. The Vision Thing by Thomas Singer (ed)

9. CG Jung Speaking: Interviews and Encounters by William McGuire and RFC Hull (eds)

10. The Discovery of the Unconscious by Henri Ellenberger

What do you think? I have read all of them. And I have no real quarrel with her choices. I might not us Stevens or Storr , including instead Jung's Answer to Job and Susan Rowland's Jung as a Writer.

Midlife ➞ Becomes Later Life

Sun, 20 Jul 2008 12:49:05 -0400

It's not that there hasn't been the usual run of mental health news to fret about this week; there has. But I have been deep in thought about later life and what it means for us and how we respond to it. Midlife has gotten lots of press. Midlife crisis is so widely known it is all but a cliche. As with many life issues, as the Baby Boomers turned 40, we began to write about midlife. And as we Boomer women reached menopause, we began to write about it. And now, we , those of us like me on the leading edge of our generation, have moved firmly into what is the last quarter of life. And apart from a lot of articles about how to live to be really old and pieces about retirement, there doesn't seem to be much yet about entering the last chapters.

Some of us may live longer, but this period, from 60-85, seems to be the place of late life issues.

Let's look again at this quote from Jung that I included in my last post:

In the secret hour of life's midday the parabola is reversed, death is born. The second half of life does not signify ascent, unfolding, increase, exuberance, but death, since the end is its goal. The negation of life's fulfillment is synonymous with the refusal to accept its ending. Both mean not wanting to live, and not wanting to live is identical with not wanting to die. Waxing and Waning make one curve.

The goal of all life, the end point, death is what lies in front of us all. And in this last quarter, it looms larger than it has before and is much more a part of consciousness. To be fully alive is to know that death lies ahead.

Between here and death, there is a lot of territory. Work to be done to deal with things left undone, to reconcile ourselves to our past, to seriously consider the story we have been living with an eye especially toward any changes we want to make in the remaining years.

A friend of mine, a woman in her mid-70's, mentioned last week that she wishes she could read about this life period as she could about midlife. The issues of midlife are not hers. She wrestles with the conflict between the desire to do and the body that no longer wants to. With the bubbling up of creative possibilities that she does not know she can bring to fruition. She is a bit further down the road than I am, but she raises issues I am already aware of -- of having to prioritize in a new way, to come to terms with the certain knowledge that if there is something I want to do, want to create, I have to get down to work now because time is passing swiftly.

And how to wrestle with these issues without succumbing to despair or melancholy and regret is a major concern. What does it mean to become old? How to come to terms with a body, a face that is not the face or body I carry in my mind's eye of myself? Finding a new rhythm. Finding people willing to wrestle with me. These are the issues is see right off. Issues I plan to explore for myself and for my work in the weeks and months ahead.

Where are we going?

Sat, 12 Jul 2008 11:36:09 -0400

When I was in college, each year at the beginning of the year was a campus-wide symposium centered on a book or books that everyone read over the summer. I think it was my sophomore year that the topic was summarized as "Who am I? Where am I going?" -- absolutely spot on for 19 year olds struggling to figure out who we were.

But these questions are the questions for a lifetime, not just for the emerging adult to wrestle with. There is an emerging notion that the goal of life is happiness, that anything short of happiness in life is indicative of some disorder, some brain dysfunction. There is a Brave New World quality to that, a denial of the value and meaning in our unhappy times, in our valleys.

Jung notes:

In the second half of life, that long span from 40 to 90, where we spend most of our adult lives, we come face to face with disappointment and defeat. Marriages fail, parents die, friends die, careers wane or fail. But this is as much a part of the natural curve of life as are the acquisitions of the first half of life.

The turns of the second half of life when seen as depression, as a problem to be solved, made to go away may yield short term satisfaction. If instead we take them as a call to deepening, to enrichment and meaning, then what was a crisis becomes an opportunity.

There is meaning in this

Tue, 08 Jul 2008 12:29:57 -0400

A flurry of articles has set me to pondering again the meaning of how we think about depression. Let me share them with you.

First, take a look at "How Prozac sent the science of depression in the wrong direction" in the Boston Globe. Now no one seems to have told the drug companies about this, or at least not their marketing divisions because the commercials for Cymbalta and the like are still running telling us that "depression hurts" and pushing the chemical imbalance theory of depression, though it is discredited now. Interesting that there have been researchers saying for years that there was no evidence to support that theory but only now is there reluctant yielding to that reality.

Now the sharp-eyed reader of that article will notice that Lehrer puts forward another theory for depression and mirabile dictu, now it is brain cells --

"In recent years, scientists have developed a novel theory of what falters in the depressed brain. Instead of seeing the disease as the result of a chemical imbalance, these researchers argue that the brain’s cells are shrinking and dying. This theory has gained momentum in the past few months, with the publication of several high profile scientific papers. The effectiveness of Prozac, these scientists say, has little to do with the amount of serotonin in the brain. Rather, the drug works because it helps heal our neurons, allowing them to grow and thrive again."

Which might make you think that the only treatment for depression, for these dying brain cells is medication. But what about the studies that show that other treatments are as effective if not more so -- like regular exercise or psychotherapy? Could it be that they also revise neurons? Is anybody looking to see?

But what about this, from Furious Seasons:

"Anti-Depressants Don't Work In 40 Percent Of People Due To Four Genes

File this under "well now they tell us": Mayo Clinic psychiatrists announced last week at a conference in Britain that 40 percent of people who take an anti-depressant cannot respond to the medication owing to a genetic "abnormality."

Uh-oh.

As John Grohol points out, this is part of a narrative that has seized the media and, from where I sit, psychiatry as well. The trumpet of mental disorders as medical in nature and best treated medically continues to play despite the accumulating evidence against it. The chemical imbalance theory fails? Okay, try this dying neuron theory.

"This would be true if mental disorders were pure medical diseases. But they are not and have never been. They are human constructs of aberrant behavior or emotions. They are by no means universal (although some of the big ones, like depression, can be found in most human societies)."

Lehrer reports: "Castren says that patients must still work to cement these connections in place, perhaps with therapy. He compares antidepressants with anabolic steroids, which increase muscle mass only when subjects also go to the gym."

To which Grohol replies:

"You need some encouragement for a drug to take effect? This is nonsense. Drugs either work or do not, they do not need to be “cemented” to the brain through therapy."

So as I was in the shower this morning, I got to thinking about how persistent this effort is to make depression, and there are other instances as well of course, a medical illness. Because it seems to have taken over and become the dominant paradigm at least in the US. Even in the face of reports of potentially serious side effects like GI bleeding

And I wonder if it has something to do with a kind of puritanical underpinning to our culture, one which sees problems which are not medical as so much whining. So a person who is depressed and isn't considered medically ill -- you know, that fuzzy term "clinically depressed" which only means that a clinician says the problem seems to be depression, because there is no way to definitively establish such a diagnosis -- might be expected by those around him to "pull up his socks and get over it" or just get n with things. Whereas someone who is ill and needs medication, well, it's not his fault; it's his brain chemicals or dying neurons or something. Is it maybe underneath it all about blame? Blame and an all but irresistible American attraction to the promised quick fix.

Certainly money plays a part. And turf guarding. But there is more.

A look at mid-life

Sat, 05 Jul 2008 11:02:45 -0400

Carl Jung was the first to see the psychological and spiritual significance of midlife transition. He observed that for normal development, in the first half of life we create a life and an understanding of who we are based on what parents, other significant adults, our peers, partners and society in general expect of us. In the process we learn, from the reactions of these significant others, that parts of us are not acceptable; these parts get repressed in our unconscious as shadow. For normal development in the second half of life, we need to create a life based on who we truly are. To do this we need to complete two main developmental tasks for midlife transition: First, we need to go within and reclaim those parts of ourselves repressed when young and other parts of our self we have never known. And second, we need to reshape our lives based on this increased understanding of who we truly are.

"The experience of Self brings a feeling of standing on solid ground inside oneself, on a patch of eternity which even physical death cannot touch." Marie-Louise von Franz

Middle age is a time in which adults feel a need to reassess where they are and make changes while they feel they still have time. A person experiencing midlife symptoms may ask: Is this all there is? Am I a failure? Symptoms and behaviors during midlife crisis can range from mild to severe and may include:

• Boredom and exhaustion, or frantic energy

• Self-questioning

• Daydreaming

• Irritability, unexpected anger

• Acting out with alcohol, drug, food or other compulsions

• Greatly decreased or increased sexual desire

• Sexual affairs, especially with someone much younger

• Greatly decreased or increased ambition

"The disintegration of personality sounds much less ominous if it is understood as an opportunity for new life rather than the end of the line. Such an attitude is more than mere consolation for the person going through the experience; it can mean the difference between life and death, for it offers the possibility of meaning in what would otherwise be pointless suffering. This is especially true in the middle years of life, when many are brought to their knees either by circumstances or by ignorance of their own psychology, and often by both" Daryl Sharp

We go on a heroic journey at midlife as we struggle against ‘levelling down to collective standards'. This struggle is vital for us individually as it leads us to creating a personally meaningful second half of life.

“Individuation is a natural necessity…its prevention by a leveling down to collective standards is injurious to the vital activity of the individual…any serious check to individuality is an artificial stunting.” Jung

Letting GO

Mon, 30 Jun 2008 11:52:51 -0400

This weekend quite by accident I happened to see a photo of a woman I saw in therapy many years ago. I recognized the name -- the face, like mine has aged and I probably would not have recognized her had I seen her on the street.

And that set a kaleidoscope of remembered patients now long gone from my life in motion in my mind's eye; of patients I saw years ago, kids from the therapeutic nursery program I oversaw over 30 years ago. What ever happened to those kids? The child who was electively mute? The one with feet scalded by an angry mother? The man who struggled with a serious physical illness? The women who were my Handless Maidens? Among many others.

Because that's the thing about being a therapist. Patients pass through our lives. And unlike friends, who, even when contact is lost, we can locate again and find out how they are doing, patients, when they leave, may or may not ever contact us again. That's part of the deal, one of the things we have to accept from the beginning. These people who become an intimate part of our lives, sometimes for years, may very well, when they leave, leave us behind except in memory. And when the desire to know how they are arises in us, we have to be satisfied with not knowing.

When my daughter was born, we chose for the announcement a phrase I had read somewhere -- A child is someone who passes through our lives on the way to becoming an adult. And maybe a variant of that is apropos for therapy and therapists -- a patient is someone who passes through our lives on the way to becoming.

What is change?

Sat, 28 Jun 2008 08:51:32 -0400

As we move into the presidential campaign, one word seems to be everywhere -- CHANGE. No candidate wants to be the one standing for the status quo. And then this week I read Stephen Diamond's blog entry on change or acceptance in therapy. Which set me to thinking about what we mean by change in either of these contexts.

Someone last night was telling me that she had changed herself from an introvert into an extravert, by way of explaining her enthusiasm for door to door campaigning. But did she really change her basic self or did she learn to adopt what we Jungian would call an extraverted persona? C. G. Jung applied the words extravert and introvert in a different manner than they are most often used in today’s world. As they are popularly used, the term extraverted is understood to mean sociable or outgoing, while the term introverted is understood to mean shy or withdrawn. Jung, however, originally intended the words to have an entirely different meaning. He used the words to describe the preferred focus of one’s energy on either the outer or the inner world. Extraverts orient their energy to the outer world, while Introverts orient their energy to the inner world. My best guess is that the direction of her energy remains toward her inner world but she has learned how to present herself in an extraverted manner when the occasion demands it.

In a similar fashion, people who only know me from my teaching or workshop presentations would swear that I am extraverted. I am at ease speaking in front of groups, animated, energetic. But what they do not realize is that is a costume of sorts that I wear for those settings, that I wear because I have a role to play. The "real" Cheryl is the introverted one.

So, in order to be effective as a teacher or speaker, I did not change who I am; rather I became adept at donning the costume of a more extraverted version of myself. In part in order to do that I need to be more accepting of who I am, of my basic nature in order to take on a persona that works for me.

Therapy for many people, maybe most who seek it is about change -- changing how they feel, changing relationships, changing the direction of their lives. And many times they don't have a clear idea of what that means, just that they are unhappy as things are. I often ask patients what is the life that they want? What would it look like? How would it be different? And what stands between them and having that life? Then comes the hard work of dealing with those obstacles, often self-created. It is important to deal with the past, to work through those issues and finally come to acceptance that it is what it is. And get on to the business of playing the cards that we have been dealt. Because we can't change the circumstances of our birth, the parents we have, the childhood we lived, the forces that shaped us. We can change how we see those things but they themselves will not change. In fact it is acceptance that paves the way for change.

One of the goals of the personal myth exploration is to reveal the story being lived, because until it is revealed, it cannot be changed. Change as a goal sounds very appealing. But the work to make it is another task altogether.

Jung on torture

Thu, 26 Jun 2008 08:51:12 -0400

"The healthy man does not torture others - generally it is the tortured who turn into torturers." --Carl Jung

I offer a Jung Study Group here in Maine. I started it 2 years ago partly in response to interest from classes I taught at the local Senior College, but even more as spur to myself to read Jung. I admit to being a bit lazy and that has led to a tendency to read more modern writers, Post-Jungians, on Jung than Jung himself. So the study group makes me fill in that gap because we are slowly working our way through the Collected Works, though we are not reading every single volume. Right now we are just beginning Answer to Job.

As it happens I have not gotten to Vol. 10, Civilization in Transition, from which that quote comes. Take a look at The Existentialist Cowboy for a nice use of Jung's ideas to critique our present situation.

I promised more about personal myth and I will deliver later today or tomorrow.

In Treatment fans..,

Sat, 21 Jun 2008 12:22:52 -0400

Good news! According to TVoholic, HBO has given the go for a second season of In Treatment, which will return sometime in 2009. I am looking forward to it as you are and will, of course, blog each episode as I did this year. Most of the patients wil not be returning, though Paul and Gina will be back. What kinds of patients/issues would you like to see Paul deal with?

How Others See US

Mon, 16 Jun 2008 10:58:42 -0400

Knowing how peeved I get by drug ads on television, my husband sent me the link to this terrific article the other day. It is written by a BBC correspondent here in the US. I enjoyed all of it, but especially what he says about drug ads.

"The biggest single market is in drugs that deal with erectile dysfunction. My favourite features a group of men who gather together to play in a band.

I think it is meant to show them looking relaxed and happy, but they are such good musicians you cannot help noting that impotence has left them with plenty of time on their hands to practise their instruments.

The best part of the adverts tends to come towards the end when the law requires the pharmaceutical company to list the possible side effects of the various products.

Sometimes these are spelled out in a warm tone implying this is all a bit of a formality imposed by our fuss-budget of a government.

On other occasions they are rattled out at speeds normally only reached by horse racing commentators in the closing stages of a big race.

The symptoms include coughs and sneezes, runny noses and rashes but there is a more alarming end of the spectrum too where you are solemnly warned of the possibility - presumably small - of suffering a stroke, a heart attack or even death - the last and greatest side-effect of them all."

And he concludes --

"Those adverts with their sure sense of how to play on our doubts and insecurities are a symptom of the restless energy of American capitalism and of the belief that it can apply to issues of health and happiness just as readily as it can apply to polish or pet food.

The downside of the system for me? Well, I have rampant, raging hypochondria these days to add to my chronic, jerky-induced indigestion.

And the upside? Well, there is bound to be something I can take for it.

If I can just manage to plant myself in front of the television until an advert for the tablets I am waiting for eventually pops up."

I will be writing more about personal myth tomorrow.

Colliding worlds

Fri, 13 Jun 2008 13:30:08 -0400

This is one of those posts in which my two worlds -- knitting and my work -- collide briefly.

In two knitting communities that I am a sometime member of, there are discussion threads on knitting as therapy, meaning more less in place of actual therapy. Von Franz wrote of knitting:

Everybody who has knitted or done weaving or embroidery knows what an agreeable effect this can have, for you can be quiet and lazy and also spin your own thoughts while working. You can relax and follow your fantasy and then get up and say you have done something! Also the work exercises patience...Only those who have done such work know of all the catastrophes which can happen -- such as losing a row of stitches just when you are decreasing! It is a very self-educative activity and brings out feminine nature. It is immensely important for women to do such work and not give it up in the modern rush. (The Feminine in Fairy Tales, Spring Publications, 1972, p. 40)

recognizing the value of handcrafts like knitting. And this makes a great deal of sense. Indeed, I read a post today by Dr. Smak about the meditative value of knitting which is the value that I see. And similarly with painting or writing or working in clay. They are all means for allowing us to surrender the monkey mind a bit, to allow to filter in some deeper part of ourselves which works on whatever it is that we are occupied with. But as therapeutic as these things can be, they are not in themselves therapy. Therapy puts into words the feelings and experiences and perceptions that can keep us from the life we want. Art, music, knitting, writing gives us means of expressing some of those same things, some ways of working with them transformatively or meditatively.

Which is not to say that therapy is what any painter or knitter or writer needs. Only that each can nourish the other in the process of expanding consciousness and developing our lives. My analysis is knit into every piece I have worked on during it. Dreams, interpretations, thoughts all became part of the fabric of what I made. Each enriching the other.

Personal Myth, 3

Wed, 11 Jun 2008 13:21:08 -0400

Here is an exercise you can use to learn more about your personal myth --

Begin by recalling a character from a myth or fairytale that feels particularly important to you. Now, sitting quietly where and when you will not be interrupted, become the character. See yourself as the character, feel as your would imagine the character to feel.

Now, take some time and complete the following statements. Write as much as you want about each one:

1.“I am ..."

2. “My purpose as this character is … "

3. "I feel ..."

4. "What I like about being this character is …"

5. "What I don't like about being this character is ... "

6. "As this character I desire … "

Read back over what you have written. Do you see ways that this character’s feelings resemble your own in a situation in your life? Can you see the story you are living?

My colleague and I will be offering a workshop on exploring personal myth in the fall. I will announce details at the end of the summer.

Tincture of Time

Mon, 09 Jun 2008 10:28:59 -0400

Scientific American, in one of their "60 second science" features, reports on a study recently published which appears to replicate the findings of a study from at least a decade ago in the UK -- namely that grief counseling after traumatic events may be more harm than help. Again this finding seems obvious if we consider that grief and other uncomfortable emotions are normal following such events. It is only when, by community consensus, such emotions and reactions persist and interfere with normal life that treatment may be called for.

As an example, when I first met my ex-husband's mother 40 years ago, I asked her if she had any siblings. She teared up and said she had had a brother but he died. Judging from her reaction, I thought this must have been recent. But I discovered that actually her brother had died more than 50 years previous when he was a toddler and she was a young child. We could certainly say that such a reaction is unusual, but she managed quite handily to deal with the ups and downs of normal life -- a marriage, two children, family, outside interests. And she could certainly have benefitted from therapy to deal with the issues in her family that left her with a terrible burden of guilt. But, by all reasonable criteria, she was a healthy functioning adult and not in need of treatment.

Taking something like this on a larger scale, like the aftermath of 9/11, we can see that it is expectable that those who lost loved ones that day or had their own narrow escapes or lived or worked in Manhattan, might well have lingering effects of that experience. But the vast majority of those people have gone on with their lives, even though they may still have difficulty thinking about or talking about those events. It is that small portion of people whose grief and reactions have paralyzed them, frozen them in that time, who would most benefit from treatment. But we cannot know who those people will be until time has passed, until time has had opportunity to heal wounds, as it most often does.

The intentions behind grief and crisis counseling are good but research has again suggested they are not helpful.

Sickening

Sun, 08 Jun 2008 07:55:44 -0400

There is something odd about the trend to turn any behavioral quirk or any departure from happiness as illness needing treatment, preferably of the pharmaceutical variety, something we might call the Sickening of America. Or a push to make us all the same -- bland and conforming. Perhaps this rush to medicate is the realization of Brave New World. Take a look at the instances of "problems" being sought for treatments, as detailed in The Independent --

The following were all mentioned as targets for treatment with psychopharmacology:

Shyness

Bereavement

Internet Use

Temper

Pornography "Addiction"

Gambling

Compulsive Buying

Fear of Public Speaking

Low Sex Drive

Stealing

Poor Social Skills

Domestic Violence

If all of these are treatable "illnesses", then obviously the range of acceptable normal behavior is narrowed considerably and any thoughts about autonomy and ability to change one's own behavior or to find value in exploring its meaning go out the window.

"For drug companies, this market is potentially huge. It's claimed, for example, that almost half of women have a sexual problem. Nearly 8 per cent of adults, it seems, have intermittent explosive disorder, while another 8 per cent are compulsive shoppers. Thirteen to 15 per cent – around 10 million of us in Britain – are said to be social phobics, and up to 10 per cent have a fear of public speaking. On top of that are the gamblers, the phobics and the depressed – all suitable cases for treatment.

But critics argue that some of these treatments amount to medicalisation of individual differences and traits. Unlike physiological diseases such as cancer, behaviour disorders are a grey area, with no clear boundary between normality and illness. While there is no doubt that people at the extreme end do need treatment, others who may have symptoms may not."

Even those at the extreme ends could just as easily benefit from therapy, from gaining some insight and understanding about the problems experienced and some alternative ways of dealing with them.

That drug companies are eager to expand their markets in this way is understandable from their point of view. But why are the people for whom the drugs are prescribed so eager to see themselves as disordered and thus willing to be medicated? Especially given the side effects that accompany these medications? What does it mean that so many are willing to opt to be seen as "sick"?

Working at home

Fri, 06 Jun 2008 10:49:53 -0400

Therapeutic space is an important issue not much written about but which reflects certain basic attitudes about therapy. I wrote about some of that here and here. The question arises now because I am planning some changes to my space and a friend asked me about my choices.

As I said in my earlier post, I choose to have my office in my home. This is a philosophical choice based on my understandings about therapy. Both of the analysts I have worked with have had their offices in their homes, so it is something I am used to. And to the extent that most of us model our way of practicing on those therapists we admire, they are a part of my choice. But more than that, I see this choice reflecting the fact that I do not see therapy as a medical treatment. I see therapy as a part of life and needing to be grounded in the ordinary stuff of daily life lest it become too rarified and too removed from day to day existence. My office space is not just another room in my house -- there are no photos of my children and no deeply revealing personal items. Access to my personal living space is closed off. But it is clear that it is located in the place where I live. Occasionally there are noises from life going on elsewhere in the house. Or the smells of food cooking. I take care to make it that my husband, the only person who shares the house with me, is not able to hear what is said in my office -- for the most part, I see patients at times when he is out doing his own work.

For you In Treatment fans, my space is personal like Paul's is -- in my home, yet not part of every day family gathering. Furniture reminiscent of what might be in a living room, yet not part of family living space. Comfortable, personal, yet observably not family space. Now my furniture is a more motley collection, but falls along the same dimensions a Paul's. And the presence of my desk marks it subtly as an office.

There have been times when the fact that my office is in my home raised issues for my patients, especially when my children were younger and could from time to time be heard on the stairs or elsewhere in the house I lived in then. Sometimes patents would begin to feel envious of them, or want to be one of my children Or imagine living in my house. But that became part of the material we worked with, part of the fabric of the therapy.

I have thoughts of writing a piece about how therapist's shape their spaces someday and have collected some data toward that. One finding that emerged is that of the two dozen therapists who completed my questionnaire, those who identified themselves as cognitive-behavioral in orientation saw ease of parking or proximity to mass transit as key elements in their choices, whereas depth oriented therapists focused on the atmosphere created by furnishings and art in the space itself -- outer vs inner space considerations. I like that.

Imagine this ...

Thu, 05 Jun 2008 09:13:09 -0400

A university dedicated to the study of and preparation for psychotherapy!

Google News turned up this interesting little piece from the International Herald Tribune--

Seven decades after Sigmund Freud fled from the Nazis, Vienna has turned one of his dreams into reality: a university dedicated to psychotherapy.

Admissions to the university, named after the Austrian pioneer of psychoanalysis, have soared since it opened in late 2005.

"We're the first university worldwide to offer a complete psychotherapy degree, which Freud wrote about in 1928 as his great dream," said Alfred Pritz, founder and rector of the Sigmund Freud University. "We're realizing that now."

After an initial intake of some 40 students, the private college now has more than 500.

In the US, this kind of enterprise is all but impossible to imagine. The closest we come is Pacifica Graduate Institute, which is Jungian, but does not include an undergraduate component. Otherwise in most colleges and universities, psychotherapy is available as a field of study on the graduate level in clinical psychology and in clinical social work, but nearly always from the frame of cognitive behavioral therapy. Indeed, if one were to accept the current mainstream thinking in this country about psychotherapy, it is that CBT is the only valid approach. And Freud and Jung have been banished to history of psychology courses and to departments of religion and other disciplines which use Freudian and/or Jungian theory a a lens through which to view literature and the like.

Challenges of Psychotherapy

Tue, 03 Jun 2008 11:09:00 -0400

A week or so ago, PsychCentral had an interesting post about the challenges of psychotherapy. I agree with the message but I had a few additional thoughts of my own, which I will post over the next few days.

Grohol writes:

"6. “Side effects” of psychotherapy are unpredictable.

At least with psychiatric medications, you have a laundry list going into your prescription knowing what to expect. In psychotherapy, you never know what to expect. You could go into a session feeling perfectly comfortable, end up discussing a traumatic childhood experience, and come out feeling completely exposed and re-traumatized.

Unfortunately, many therapists won’t discuss or acknowledge such “side effects,” but they occur all the time. And the worst part for an individual is that you never know what might be in store in any given week. Being aware that psychotherapy is often a very emotionally trying experience helps, but it can still catch you off guard."

I understand the point being made here, but I wouldn't call it side effects, but rather effects. I tell my patients up front that it is not at all unusual to have periods of feeling worse before feeling better. Because as we go along, feelings and experiences that they have been defending against and resisting feeling will surface and in the process bring some discomfort. But what we do then is find our way through those feelings and experiences to come to a new place of understanding them and being able to face them and deal with them rather than defend against them. A side-effect, in common parlance, is a usually unwanted effect from a treatment But at least when working in depth, the occurrence of these experiences is part of the process, even if not a particularly enjoyable one, for most of the time, the only way out is through the experience.

Breggin on Bipolar kids

Wed, 28 May 2008 09:59:05 -0400

Following up further on last week's Newsweek cover story on bipolar children, Peter Breggin writes in Huffington Post

"First, all of these preadolescent children are being wrongly diagnosed by conventional psychiatric standards. We have no evidence at all that temper tantrums and other unruly behavior, however extreme, is a precursor to being diagnosed with bipolar disorder as an adult.

Second, since there is no known connection between children diagnosed bipolar growing into adults diagnosed bipolar, the data about a 10% risk of suicide is misleading and irrelevant.

Third, there's no evidence whatsoever that individuals diagnosed "bipolar" have a "miswired brain." There's not even any such evidence for a biological flaw in adults who suffer from full-blown manic-like episodes, let alone children whose parents and teachers cannot control them.

The concept that children have bipolar disorder and should be treated with highly toxic adult psychiatric drugs is strictly a drug-company marketing ploy. If it's true that 800,000 children have been diagnosed, it has become an enormously successful marketing strategy with tragic results for children and their families.

There's an even more sinister aspect to all this. There has been a real increase in teenagers and young adults who display episodes of manic-like symptoms such as insomnia, excessive energy, racing thoughts, grandiose ideas about themselves, irrational and outrageous behaviors, extreme irritability, paranoia, and psychosis. However, in my three and one-half years of intensive psychiatric training in the 1960s, I saw only one case of a young person suffering from these symptoms. In the following years through approximately 1990, I saw few other cases. Yet nowadays I evaluate many teens and young adults with manic-like symptoms in my medical and forensic practice. The reason for the change? As I document in detail in Brain-Disabling Treatments in Psychiatry (2008), antidepressant drugs, so freely given to children and youth, cause a high rate of manic-like behaviors."

Now it is true that Breggin is a controversial figure in psychiatry, but to my mind no more so than those pushing the bipolar agenda. Breggin is generally opposed to overmedicating, which seems to me to be a worthy position. In these times, howvere, to take this stance is quite heretical, at least in the mainstream psychiatric world.

Like Breggin, when I was first in practice in the 70's, w saw *very* few children presenting with symptoms of major mental illness. And it was almost unheard of for young children to be on psychiatric drugs of any kind. Already though there were movements toward diagnosing ADHD in younger and younger children and putting them on Ritalin -- it just had not yet become widespread practice.

We face the law of unintended consequences as more of these kids who have been medicated nearly all of their lives with psychiatric drugs with as yet unknown long term effects. Ad I don't think what we will see will be pretty.

Dreaming more fully into existence

Tue, 27 May 2008 09:50:35 -0400

There are a number of writers in psychoanalysis that I enjoy reading. Thomas Ogden is one of them. Last week I read this description by him of the analytic process, a description which I find to be quite lovely:

"A person consults a psychoanalyst because he is in emotional pain, which unbeknownst to him, he is either unable to dream (i.e. unable to do unconscious psychological work) or is so disturbed by what he is dreaming that his dreaming is disrupted. To the extent that he is unable to dream his emotional experience, the individual is unable to change, or to grow, or to be become anything other than who he has been.The patient and analyst engage in an experiment within the terms of the psychoanalytic situation that is designed to generate conditions in which the analysand (with the analyst's participation) may become better able to dream his undreamt and interrupted dreams. The dreams dreamt by the patient and analyst are at the same time their own dreams (and reveries) and those of a third subject who is both and neither patient and analyst.

In the course of participating in dreaming the patient's undreamt and interrupted dreams, the analyst gets to know the patient in a way and at a depth that may allow him to say something to the patient that is true to the conscious and unconscious emotional experience that is occurring in the analytical relationship at a given moment. What the analyst says must be utilizable by the patient for purposes of conscious and unconscious psychological work, i.e., for dreaming his own experience, thereby dreaming himself more fully into existence. "

From This Art of Psychoanalysis:Dreaming Undreamt Dreams and Interrupted Cries

Conventional wisdom

Wed, 21 May 2008 08:52:53 -0400

Synchronicity struck in my world again this week. Just as a discussion about why more Jungian therapists and analysts do not treat schizophrenics began on the IAJS discussion list, Furious Seasons posted a link to an article which challenged my assumptions.

For as long as I have been in practice, it has been the custom to treat schizophrenics and others with psychosis with medication and hospitalization and rarely if ever with therapy. I think in 35 years I have seen only one person carrying a diagnosis of schizophrenia and he did not stay in therapy long. Lacking experience working with people with this kind of problem, I admit I doubt my own ability to do so effectively, but I had really not questioned the conventional wisdom, surprising really given my general bias for therapy. Then I read of this study, reported in the Journal of Nervous & Mental Disease a year ago.

"This prospective longitudinal 15-year multifollow-up research studied whether unmedicated patients with schizophrenia can function as well as schizophrenia patients on antipsychotic medications. If so, can differences in premorbid characteristics and personality factors account for this? One hundred and forty-five patients, including 64 with schizophrenia, were evaluated on premorbid variables, assessed prospectively at index hospitalization, and then followed up 5 times over 15 years. At each follow-up, patients were compared on symptoms and global outcome. A larger percent of schizophrenia patients not on antipsychotics showed periods of recovery and better global functioning (p < .001). The longitudinal data identify a subgroup of schizophrenia patients who do not immediately relapse while off antipsychotics and experience intervals of recovery. Their more favorable outcome is associated with internal characteristics of the patients, including better premorbid developmental achievements, favorable personality and attitudinal approaches, less vulnerability, greater resilience, and favorable prognostic factors. The current longitudinal data suggest not all schizophrenia patients need to use antipsychotic medications continuously throughout their lives."

If I stop and think about it, the results make sense. Why should it be any more necessary for someone with schizophrenia to necessarily require medication forever than it is for someone with depression? Why have we assumed, with very little, if any, question, that those with major mental illness must always be medicated? What does it mean that we are in the process of "promoting" depression, ADHD and probably others into the category of major mental illness by expanding the definition of bipolar disorder?

It seems to me that for the most part the debate about the majors -- schizophrenia, bipolar, and other disorders involving psychosis, pretty much ended in a conclusion that they are primarily biological some years ago. At least I have not heard or read of anyone arguing otherwise for a long time. And somehow that came to equal chronic and requiring medication much the way diabetics require insulin.

But if there is a group of people with these disorders in whom they are relapsing and remitting in nature, then it would seem worthwhile to reconsider these assumptions. And why not therapy as part of treatment? If a patient is not floridly psychotic, why wouldn't therapy be both helpful and possible?

I am thinking that the person who raised the question in the IAJS discussion had a point.

Bipolar children, again

Tue, 20 May 2008 12:34:26 -0400

After reading the Newsweek article on bipolar disorder in children that both Furious Seasons and CP&P write about this week -- and please read them as they critique the article far better than can I -- I recall a child I was called to consult on years ago. This little guy was 4 and the nurse in his school was certain he had childhood schizophrenia. He had echolalic speech (Echolalia is the repetition of vocalizations made by another person) and made bizarre hand motions when he spoke, both of which are among the indicators for autism and childhood schizophrenia. I made a home visit and I saw a child who did indeed exhibit these odd behaviors But something about him didn't seem to fit those rather dire diagnoses. There was something in the way he looked at me and made eye contact with me that didn't fit. So on as a wild shot, I ordered a hearing exam by an audiologist. And lo and behold, it turned up a 75% loss in both ears. His speech and hand motions were also common in deaf children.

So I was thinking of him as I read about Max in the Newsweek article, Max who now at age 10 has been on 38 different psychiatric medications which have had who knows what effect on his brain development. And I wonder what would have happened to that little boy I saw years ago if he turned up today presenting the same symptoms. Would anyone think to look for horses instead of zebras? Or would he, like Max, be submitted to the none-too-tender mercies of medications not even certified for use in children?

Those years ago, there were very few psych meds in use and even fewer with children. Without the hammer of medication, every symptom was not a nail.

I wonder what was wrong with Max in the first place, back before he was "treated"?

Negative Mother Complex Writ Large?

Sat, 17 May 2008 16:14:17 -0400

I have been thinking a lot about sexism, gender slurs and misogyny as the political campaign has unfolded. This morning I posted some thoughts here, spurred by references to a couple of articles. It seems clear to me that there is something operating in the cultural unconscious that allows the things that Marie Cocco reports in the Washington Post the following, among others,:

"I will not miss seeing advertisements for T-shirts that bear the slogan "Bros before Hos." The shirts depict Barack Obama (the Bro) and Hillary Clinton (the Ho) and are widely sold on the Internet.

I will not miss walking past airport concessions selling the Hillary Nutcracker, a device in which a pantsuit-clad Clinton doll opens her legs to reveal stainless-steel thighs that, well, bust nuts. I won't miss television and newspaper stories that make light of the novelty item."

Grouped together, as they are in her piece, the ugliness leaps out and makes one feel a little ill.

Judith Keller, in a piece in the Chicago Tribune, reminds us that this is

" a familiar image in books, films, songs, comic books, TV series, video games and, now, politics: The woman as monster. The over-large, over-ambitious, overbearing creature who irritates everybody, the death-defying witch who just won't go away—and who therefore must be destroyed.

She's a vampire, a zombie, an alien, a werewolf, a psychopath, a serial killer. She's Alex, the Glenn Close character in "Fatal Attraction" (1987), who ... keeps ... on ... coming. She's the looming, clutching, stifling mother or wife or girlfriend in a Philip Roth novel. (Which novel? Take your pick.) She's the eerie, outlandish creature in the Sylvia Plath poem "Lady Lazarus" (1965), who proclaims, "Out of the ash / I rise with my red hair / And I eat men like air." She's the vengeful giantess in the 1958 film "Attack of the 50 Foot Woman."

The relative absence of outrage and acceptance by commentators, pundits and ordinary men and women suggests that we may be in the grip of a cultural complex, an example of the negative mother complex on a large scale.

Today I ran across a short article by Clarissa Pinkola Estes, known to many as author of Women Who Run With The Wolves in which she to speculates that what we are seeing is the negative mother complex writ large --

The negative mother complex is as above, but also is understood as a sudden negative reaction to a woman in particular– that reminds a person in some way, consciously but more often unconsciously, of negative experiences with one’s earliest mother figure. A person caught in a negative mother complex projects that the stranger or known woman before them now, is somehow like ‘the old mother’… and lashes out in the present as they might have wished to long ago when they were smaller and powerless against, say, an unfair or self-centered mother, or an ineffectual, helpless mother.

In a woman, her tone of voice especially, but also a certain kind of unassailability, or a form of confidence or sureness about oneself, certain physical features, certain fragrances, certain words, a certain look in the eyes, a certain slant to the mouth… can act as triggers, setting off the negative mother complex in a person.

The complex does not allow the person to perceive or react to the woman before them as human, just as they did not see the early mother figure as human, but rather as spiteful, selfish, imperious, or impervious to them… among others reactions.

Cultures can carry and react with negative complexes also, sometimes carrying

unconscious desire to punish anyone reminding them of an earlier time when ‘the people’ had not ‘enough’ respect or notice or nourishment from a governmental source they depended on…

Now, large groups in the culture jump at innocent leaders just because they carry some words or tones or features that somehow remind of the time the people were badly mistreated or mal-nurtured by the previous regime… and more so, reminding the people of the worst: their own powerlessness to change that dark time or intervene in it.

None of this is to suggest that opposing Clinton is indicative of pathology, only that she has become a lightning rod for a negative mother complex that afflicts the culture as a whole, demonizing in particular powerful women. When this happens, the criticism becomes not of her behavior or policies, but become tinged with often violent imagery out of proportion to the actual behavior criticized.

That it is a complex and largely unconscious can be seen in its acceptance as just the way things are, with hardly a murmur raised to confront it. Indeed, to raise the issue is to run the risk of being attacked for "playing the gender card" as if gender were not a significant issue.

Cocco concludes:

There are many reasons Clinton is losing the nomination contest, some having to do with her strategic mistakes, others with the groundswell for "change." But for all Clinton's political blemishes, the darker stain that has been exposed is the hatred of women that is accepted as a part of our culture.

Mother

Fri, 16 May 2008 18:57:58 -0400

My mother died 15 years ago today. She was a difficult woman, and as is the case for many, dealing with her influence in my life occupied a great deal of my analysis.

The mother complex is a potentially active component of everyone's psyche, informed first of all by experience of the personal mother, then by significant contact with other women and by collective assumptions. The constellation of a mother complex has differing effects according to whether it appears in a son or a daughter.(The Jung Lexicon)

It isn't possible to escape the influence of mother in the development of any and all of us.

Jung tells us of several forms the mother complex can take in a woman --

The exaggeration of the feminine side means an intensification of all female instincts, above all the maternal instinct. The negative aspect is seen in the woman whose only goal is childbirth. To her the husband is . . . first and foremost the instrument of procreation, and she regards him merely as an object to be looked after, along with children, poor relations, cats, dogs, and household furniture.(Jung, CW 9i., par. 167.)

and

In another version, what Jung calls the feminine instinct is inhibited or wiped out --

As a substitute, an overdeveloped Eros results, and this almost invariably leads to an unconscious incestuous relationship with the father. The intensified Eros places an abnormal emphasis on the personality of others. Jealousy of the mother and the desire to outdo her become the leitmotifs of subsequent undertakings.(Jung,CW9i par. 168.)

This inhibition can also be expressed in another way, in which the woman identifies with the mother.

As a sort of superwoman (admired involuntarily by the daughter), the mother lives out for her beforehand all that the girl might have lived for herself. She is content to cling to her mother in selfless devotion, while at the same time unconsciously striving, almost against her will, to tyrannize over her, naturally under the mask of complete loyalty and devotion. The daughter leads a shadow-existence, often visibly sucked dry by her mother, and she prolongs her mother's life by a sort of continuous blood transfusion.(Jung, CW9i, par. 169.]

And then there is the negative mother complex, the stuff of novels and films, where there is tremendous resistance to mother and all that she stands for.

It is the supreme example of the negative mother-complex. The motto of this type is: Anything, so long as it is not like Mother! . . . All instinctive processes meet with unexpected difficulties; either sexuality does not function properly, or the children are unwanted, or maternal duties seem unbearable, or the demands of marital life are responded to with impatience and irritation.(Jung,CW9i., par. 170.]

This kind of daughter knows what she does not want but is usually completely at seaas to what she would choose as her own fate. All her instincts are concentrated on the mother in the negative form of resistance and are therefore of no use to her in building her own life.

"As we know, a complex can be really overcome only if it is lived out to the full. In other words, if we are to develop further we have to draw to us and drink down to the very dregs what, because of our complexes, we have held at a distance.

This type [the woman with a negative mother complex] started out in the world with an averted face, like Lot's wife looking back on Sodom and Gomorrah. And all the while the world and life pass by her like a dream -- an annoying source of illusions, disappointments, and irritations, all of which are due solely to the fact that she cannot bring herself to look straight ahead for once. Because of her unconscious reactive attitude toward reality, her life actually becomes dominated by that which she fought hardest against...But if she should turn her face, she will see the world for the first time, so to speak, in the light of maturity, and see it embellished with all the colors and enchanting wonders of youth, and sometimes even of childhood. It is a vision that brings knowledge and discovery of truth, the indispensable prerequisite for consciousness. A part of life was lost, but the meaning of life has been salvaged for her."(Jung, CW9i)

How it works

Thu, 15 May 2008 13:06:52 -0400

Someone asked me -- and I am so grateful that people keep asking me these things because they give me topics for posts -- someone asked me how therapy works, if it isn't about telling people what to do.

So here is how therapy works, in my opinion. And I am not talking here about cognitive-behavioral therapy here -- which is short term and not so much about relationship.

In therapy, no matter how much you may believe you are controlling your responses and behavior, over time your habitual ways of thinking and acting about yourself and your world show up. These are the stories you tell yourself about yourself. As the therapist questions your habitual responses and views and challenges your ideas about yourself and the world, ever so gradually, you start to change -- daring to be more open, to question what you have believed, to try new ways of behaving. It is slow and subtle. The therapist has to be both patient, caring and willing to challenge the patient. And able to not take personally the feelings the patient has toward her or him.

Gradually the story the patient tells herself about herself changes. The things that used to be self-defining recede a bit to allow other self-perceptions and beliefs to come to the fore. The more deeply ingrained the patterns, the longer it takes to change them.

It's not magic. It isn't quick. It is work. It does work.

To what end?

Tue, 13 May 2008 11:38:21 -0400

I received an email the other day from a reader asking me what I thought the diagnosis for Sophie of In Treatment would be. The reader speculated either Oppositional Defiant Disorder or Bi-Polar Disorder, because of the suicide attempt. So I thought I would write about that today.

Back in the dark ages when I was first in grad school in clinical psychology, it was *very* unusual for a teenager to be given a major psychiatric diagnosis. Our understanding then was that teenagers are in the normal course of things pretty volatile and that distinguishing normal adolescent mood swings and behavior from pathology is very difficult. Having now had 35 years of clinical experience plus the opportunity to be up close and personal with my own children and their friends, I see no reason to change that notion.

The excuse given for burdening children and teens with these major diagnoses is that it gets them treatment earlier. But when that treatment all too often consists only of psychotropic meds with very little if any literature about their long term effects on development, one has to wonder if treatment is of net benefit to them. To say nothing of what it means to an adolescent to have a psychiatric label become a significant part of her identity. And we know that identity formation is one of the major developmental tasks of adolescence.

Sophie appears to be doing fine in school and she is a talented gymnast. There do not seem to be any behavioral concerns about her from either of those quarters of her life. She does have a great deal of conflict with her mother, but that is not of a magnitude or seriousness to warrant a diagnosis of any kind. To me, it appears that her symptoms are primarily in response to issues in her environment -- her father's neglect and acting out, the poor boundaries of her coach. I can't see any of her symptoms as other than at the outside of what teenagers sometimes do.

Sophie also responds very well to therapy. She forms a solid therapeutic relationship with Paul and makes significant progress. This argues against major mental illness.

So my inclination would be to avoid any major diagnosis -- if pressed I would likely use adolescent adjustment disorder. Given the research showing the over-diagnosis of bi-polar disorder and the questions many, including me, have about the appropriateness of making a BPD diagnosis in a minor, that diagnosis seems unwarranted altogether.

The basic message I would want to convey to Sophie and her parents is not that she is "sick" or "mentally ill", but that she is under considerable stress and that with help she can learn better means of handling stress so that her life works better for her. I would want to concentrate on empowering her in developing good decision making skills and other tools necessary for successful life as an adult.

Why Magritte?

Fri, 09 May 2008 12:54:37 -0400

A little over a year ago, I wrote a post about memory and used three of several paintings by Magritte. The images are very provocative and I continue to reflect on them. What intrigues me beyond the images themselves is that for some reason people keep coming to this blog via a Google search on Magritte and La Memoire. I have noticed in my blog stats for some time that there have been a few hits every week on this search string, but lately it has been several a day from all over the world. And I have no idea why. So, if anyone reading this post got here via a search for that image, would you leave a comment or drop me an email -- the contact form is on the right if you scroll down a bit -- and tell me about your interest. Because it is driving me nuts!

Overdiagnosed? No, Really?

Tue, 06 May 2008 12:57:34 -0400

Thanks to Furious Seasons for pointing me to this study suggesting what many have known a long time, namely that bi-polar disorder is overdiagnosed, though I would submit that it is but one of several instances of overdiagnosis.

"Lead author Mark Zimmerman, M.D., director of outpatient psychiatry at Rhode Island Hospital and associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, notes, "Clinicians are inclined to diagnose disorders that they feel more comfortable treating. We hypothesize that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication responsive." He continues, "This bias is reinforced by the marketing message of pharmaceutical companies to physicians, which has emphasized the literature on the delayed and underrecognition of bipolar disorder, and may be sensitizing clinicians to avoid missing the diagnosis of bipolar disorder."

That a patient might be diagnosed as bi-polar, in one setting and borderline in another 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. Occasionally a psychiatrist or therapist might apply a more serious diagnosis to someone they find irritating, in an unconscious attempt at retaliation. Or 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.

Another factor is the mostly unconscious desire of the prescriber to be perceived by the patient as helpful. Peter Giovacchini wrote some years ago that he thought the reason there were so many antidepressants on the market was that the depressed often do not respond rapidly to therapy and thus can be less than gratifying to treat but when the psychiatrist could prescribe a medication, the patient was often very grateful. Of course he was writing in the day when most psychiatrists did therapy as well as prescribe medications.

More than sixty years ago, Jung was expressing doubts about the value of establishing a diagnosis:

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. (Jung, Collected Works, vol. 16, p86)

Of course we're introverted!

Mon, 05 May 2008 09:06:21 -0400

An online friend of mine from Sweden -- and isn't it grand that this medium allows us to form relationships with people in far flung places that we might never otherwise meet? -- and I have been talking about the relative typology of his country and my part of the country and joking that Sweden and New England have in common an introverted preference. I was just guessing, based on my experience of living here most of my life, but as it turns out, it seems I am right, at least according to Richard Florida's column in yesterday's Boston Globe --

"But what accounts for such psychogeographical clustering? One potential explanation is that people migrate to places where their psychological needs are easily met: Open people choose to live in places with hustle and bustle to satisfy that craving for new experiences, while conscientious people settle in places where the atmosphere is ordered to meet their need for predictability.

Or perhaps, personality is influenced by our surroundings. More emotionally stable people who live in places where neurotic types form the majority may become irritable and stressed because the people around them are getting to them...

Our research suggests another possibility as well: the link between personality and the willingness to move. Conscientious and agreeable types in particular are less likely to move. Once they find a place, they tend to spread out gradually over time. Extroverts, on the other hand, are much more likely to move over greater distances. Open-to-experience types are drawn to thrills and risk, and moving, after all, is one of life's biggest new experiences.

This fuels a process of selective migration whereby agreeable and conscientious regions are drained of the most driven, most creative, and most mobile - only reinforcing their psychogeographic profiles, while magnifying the innovative edge in places where open-to-experience types concentrate."

So my observation to my friend that New England feels quite introverted fits this research. With all the caveats about typing a region or a country in mind, it seems to me that New England is generally a place of "if you don't bother me, I wont bother you" attitudes, the more so the further north you go. People here are cordial and welcoming to tourists and newcomers, provided they do not think they will be taken in as the equivalent to long lost family.

When I first moved to Maine more than 35 years ago, I met a woman who had lived in my small town for more than 70 years. Naively I said, "So you must be a native then."

"Oh no ,dear," she gently corrected me, "I'm from away. I was born in New Hampshire."

Not for us the expansiveness of the South or the West. We mark our land and our lives with our stone walls and live happily together savoring our tradition and lack of excitement. Our humor is dry -- listen to any of these samples to see what I mean.

"Psychologists have shown that human personalities can be classified along five key dimensions: agreeableness, conscientiousness, extroversion, neuroticism, and openness to experience. And each of these dimensions has been found to affect key life outcomes from life expectancy and divorce to political ideology, job choices and performance, and innovation and creativity."

Wikipedia tells us of these 5 dimensions, derived from The IPIP-NEO (International Personality Item Pool Representation of the NEO PI-R™):

"The Big Five factors and their constituent traits can be summarized as follows:

Openness - appreciation for art, emotion, adventure, unusual ideas, imagination, curiosity, and variety of experience.

Conscientiousness - a tendency to show self-discipline, act dutifully, and aim for achievement; planned rather than spontaneous behaviour.

Extraversion - energy, positive emotions, surgency, and the tendency to seek stimulation and the company of others.

Agreeableness - a tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others.

Neuroticism - a tendency to experience unpleasant emotions easily, such as anger, anxiety, depression, or vulnerability; sometimes called emotional instability."

A short form of the test is available here.

Psychologists really can't resist typological measures. Something in us seems to want to look again and again at clusters of trait and attitudes that will allow us to characterize large groups of people. Wikipedia offers an overview of some of them here.

You can view the maps of our psychogeography here.

Is this what we need?

Wed, 30 Apr 2008 15:16:26 -0400

The Last Psychiatrist has a great post this week on one of the proposed changes for the DSM as outlined in a report from Diagnostic Guidelines Task Force of the International Society for Bipolar Disorder. And in case you had any doubts, of course "They not only broadened the definitions of acute mania, bipolar depression, and bipolar II but also proposed definitions of bipolar spectrum and pediatric bipolar disorders." And they believe that the category, schizoaffective disorder, should be removed.

Should there be any surprise at the report? Does the fact that the leader of the task force has the following disclosure statement:

"Disclosure: S. Nassir Ghaemi, MD, MPH, has disclosed that he has received research grants from Janssen Pharmaceutica, Novartis, Abbott Labs, Eisai Inc, and GlaxoSmithKline, and has served on the speaker's bureau for Janssen Pharmaceutica, GlaxoSmithKline and Abbott Labs."

Does knowing that those companies vigorously promote and market their atypical antipsychotic drugs, the very drugs not trumpeted for treatment of bi-polar, offer some hints about forces underlying this report?

The following, from The Last Psychiatrist, really hits the nail on the head, not only for this issue but the whole mess f psychiatric diagnosis:

But the sleight of hand is saying that the schizoaffective is "really" a variation on a mood disorder (read: bipolar.) It is equally plausible that bipolar disorder is a variation of schizoaffective disorder since neither one exist except synthetically. I don't mean the symptomatology doesn't exist, I mean the classification is completely empty. We choose to call this thing schizoaffective, and now we choose not to. We chose to call it depression, now we choose to call it bipolar depression. It's not like you chose to call it a unicorn but later discover it's actually a rhinoceros. A more accurate analogy is that you chose to call this a unicorn, and now choose to call it a ki-ran. Wait-- what's a ki-ran, you say? Exactly.

Or, you find an elephant's leg, and say, this is an elephant. And next you find a horse's leg, so you say, this has much in common with an "elephant," same joint here, so this is an elephant also. Which would be okay, except then we start making treatment decisions based on that logic: ah ha! Antifungal cream is the mainstay of treatment for all elephant illnesses! And meanwhile the elephant dies of throat cancer. Does it make any sense that the best of our science suggests that the manipulation of four neurotransmitters is somehow involved in the treatment of every single psychiatric illness known, from anxiety to xenophobia? "

The entire enterprise of diagnosis seems more and more to me to be a production by the Wizard of Oz. It is thoroughly contaminated by economic interests, unsupported by substantial research which would pass the barest level for science, and it is all determined by committees.

Is this what we really need? Where are the questions about what the rush to medicate more and more people with inadequately tested drugs of limited value even for the problems they were originally designed to help?

This is all nuts!

Working Relationship

Mon, 28 Apr 2008 10:09:05 -0400

I was talking with someone a few days ago who said to me that she had left therapy because "the therapist wasn't helping her". And this set me to thinking because this is a common complaint.

Now if I go to the dentist because I have pain in my mouth and the dentist doesn't help leading me to seek help elsewhere, that seems reasonable. But I look to the dentist to *do* something to make me feel better. The dentist does not usually, at least in acute situations, require of me that I do more than be cooperative and hold my mouth open. But psychotherapy is a different thing altogether. Therapists do not perform procedures upon patients in order to relieve their suffering. We might sometimes wish we could ad certainly patients wish we would, but it just isn't that way.

In any depth psychotherapy, the therapist does not tell the patient how to solve problems. The focus of treatment is exploration of the patient's mind and habitual thought patterns. The goal of treatment is increased understanding of the sources of inner conflicts and emotional problems. This understanding is what we call insight. Now insight without action is pretty useless. But the therapist doesn't say to do this or that but instead might ask how this new understanding might be put into action in the patient's life.

In order to accomplish this work of therapy, the patient and therapist must have a good working relationship, or therapeutic alliance. The patient needs to feel that the therapist is on her side, so to speak, allied with her in her desire to have a better, happier life. And in turn, the therapist needs from the patient a willingness to do the work of therapy, to put feelings into words, to talk about what she is thinking and feeling. And that includes being willing to talk about feelings of anger, disappointment or frustration about the therapy or therapist.

Most often when I hear people saying that therapy isn't helping, I am also hearing an expectation that the therapist will tell the person what to do in order to feel better. And to a very limited degree, we can do some of that -- like take a walk or write in a journal or try painting or some other creative outlet when having difficulty between sessions. But on the big things -- like whether or not to stay in a marriage or change careers or leave home or any of many many other important life decisions, we cannot tell a patient what to do. We, as human beings ourselves, have enough trouble finding our way through the complexities of our own lives and not only cannot, but really should not presume to be in a position to make decisions for others in their lives. No matter how much the patient may want it. But talking about wanting that, being angry that therapist won't do it -- that is the stuff of therapy.

When therapy isn't going well or the patient feels dissatisfied in some way, the solution is to talk about it. Not every therapist/patient combination is a good fit. But it is difficult to arrive at knowing that without talking about it. One way to honor the process, even when it is not going well, is to give it the time required to talk about it. The therapeutic pair may arrive at a mutual decision to end the therapy or they may find through this often difficult kind of discussion that they move into a better and more solid working relationship.

To refer again to In Treatment, Paul had a good therapeutic alliance, achieved through some tough work, with Sophie. He could trust her to keep coming and she could trust him not to cross boundaries and to listen carefully to her. Alex didn't trust Paul and acted out his hostility instead of putting it into words. Their alliance was tenuous and would need a good deal of work to become solid. Without a good working relationship, one of mutual trust and understanding, it is very difficult to accomplish much in psychotherapy.

Looking at Psychotherapy

Sun, 27 Apr 2008 09:15:47 -0400

Sunday morning for me always includes watching CBS Sunday Morning -- the slow pace, longer stories and wonderful writing are an excellent accompaniment to my tea and Sunday paper. And this morning, they did a segment on psychotherapy. Of course I immediately knew I wanted to write a blog post on this and to my delight I discovered that the show has a text version of the story on their site.

On the surface, we seem to be in a time when traditional psychotherapy is falling out of the picture in favor of psychotropic drugs, brief behavioral approaches and self-help. Mental health centers around where I live have begun to change focus solely on medication and case management, forgoing altogether providing psychotherapy.

"What was once seen as a sign of illness or a character flaw is now widely accepted. By one measure, 91 percent of Americans would seek counseling or advise a friend or family member to do the same.

"What people are finding is that there's a tremendous value in bearing your soul to somebody who takes the time to listen, and to relate to you like no one else," said Dr. Gabbard. "

and

"So with all we have learned about the brain - how it really functions - is the whole notion of psychotherapy, the "talking cure," still valid?

More so than ever, says Dr. Gabbard.

"I think it's swinging from a kind of over-medicalization of psychiatry," he said. "I've seen so many patients who've had every drug in the book, and they come to me and say, 'You know, no one ever talked to me for more than ten minutes. Can I tell ya' about what's going on at home with my family?'" "

Of course, I basically agree with Gabbard but I a a bit less optimistic overall because of the fractured nature of the field, balkanized not only by theoretical orientation but by professional affiliation as well. And we do a terrible job of making the public aware of the benefits of therapy, of promoting what we do as not just about dealing with mental illness but also problems of ordinary life. Maybe what we need is a good PR firm to make certain that our voice is heard in the marketplace?

Personal Myth, 2

Thu, 24 Apr 2008 19:40:33 -0400

Human beings are narrative makers. We remember ourselves and our lives in stories -- stories we tell our friends, family, strangers, ourselves. When a new patient comes to me, I say "tell me about yourself" and await the story of this person's life and how it has brought her to me. And if we work together for some time, that story will change so that the story she tells at the end will be recognizable as hers but different in some ways from the tale told at the beginning.

"The universe is made of stories – not atoms" -- Muriel Rukeyser

So, we swim in a sea of stories -- our own and those of the ones around us. And we shape our lives around the story we tell ourself is ours, the story that we live. Think of a person you no doubt know whose life could be summed up in the song title, "I would do anything for love" -- can you begin to see the story he or she is living? And how might that person be able to change the course of the story, write a new chapter if only she knew it was what she is living?

"The story I am writing exists, written in absolutely perfect fashion, some place, in the air. All I must do is find it…." Jules Renard

Exploring personal myth is one way to discover the story.

In the last 20 years or so, a plethora of books have been written on the subject of personal myth. Of the lot of them, 2 stand out for me as better than the rest:

James Pennebaker: Writing to Heal -- Pennebaker, a social psychologist, has done considerable work examining the healing potential of writing. You will find a paper describing his work here.

Sam Keen & Anne Valley Fox: Your Mythic Journey -- this book encourages the reader, through writing and reflection using question drawn from the work of Joseph Campbell, to uncover his story and explore its meaning.

I am never entirely happy with self-help books. In order to appeal to a large audience, in my view, they lose bite in favor of what is palatable and likely to engage masses of readers, rather the same way that the food from Taco Bell is suggestive of Mexican food but lacks the complexity and range of real Mexican food. So think of these books as a way to do personal myth, lite. Digging into one's life, looking at Shadow as well as Persona, takes time. Plus all of us are at best reluctant to look into the corners and under the rocks where our darker or less acceptable aspects lurk. That said, these books offer a palatable way to begin to look at personal myth and may whet appetite for looking deeper. But beware of a tendency to encourage inflation, to push to a perfect resolution.

Personal myth

Tue, 22 Apr 2008 13:38:30 -0400

Someone asked me recently if I really thought that longer term depth psychotherapy was really necessary. Necessary? I don't know that I can determine that for anyone other than myself, but I can say it is valuable for the person who wants to learn more about how she came to where she is in her life, what forces are operative in order to have a wider array of choices moving forward.

Jung said, "Generally speaking, all the life which the parents could have lived, but of which they thwarted themselves for artificial motives, is passed on to the children in substitute form. That is to say, the children are driven unconsciously in a direction that is intended to compensate for everything that was left unfulfilled in the lives of their parents. Hence it is that excessively moral-minded parents have what are called "unmoral" children, or an irresponsible wastrel of a father has a son with a positively morbid amount of ambition, and so on. "

In my own case, I remember all the time I was growing up the very clear sense that I was to go to college. Nothing was ever said about it, I just knew. My parents were both very bright people who had many of their own ambitions nipped in the bud when they married in their late teens and in the depths of the Depression. Neither of them attended college nor did either of them achieve the dreams of their youth nor did either of them do anything about that as they grew older and opportunity was greater. Their unmet desires to go to college, to be something were transmitted directly to me so that I never even questioned whether or not I wanted to go or that I would. Fortunately for me, this instance of parents' unfinished business is a benign one and one that served me well. But it is not always thus.

Consider some of our characters from In Treatment. Laura and Alex and Paul are all caught in webs of their parents' unfulfilled lives tangling up in their own dramas. These themes can continue over several generations if no one wakes up to them. Many years ago I interviewed a woman who came from a family where going back 3 generations, women had dropped out of school due to pregnancy. Throughout her teen years, she was given the message not to get pregnant and to graduate. When I asked how she had managed to escape the family curse, she told me it wasn't because she had heeded the conscious message she was given; it was because she was unable to conceive! The messages came on two levels -- the conscious admonition to do as they told her not as they did and the unconscious one that all a woman was good for was taking care of a man and her children. And it was the unconscious message she had tried to obey.

In depth psychotherapy there is the opportunity to explore these themes and begin to tease them apart. Laura might then be able to develop a relationship with a man who would notice her and care for her, be a real parter to her. Or Alex might be able to determine for himself what it means to be a strong man, what it means to be a father.

These are issues that often arise at midlife when life calls us to look again at who we are, what we have done, what we believe in. This is prime time for discovering what is the story we have been living; as Jung put it -- I asked myself, "What is the the myth you are living?" and found that I did not know. So...I took it upon myself to get to know "my" myth, an I regarded this as the task of tasks...I simply had to know what unconscious or preconscious myth was forming me."

More about personal myth in another post.

Scientific??

Fri, 18 Apr 2008 11:58:51 -0400

I tucked away this article by Stephen Dubner after learning of it on Furious Seasons. In it, Dubner, co-author of Freakonomics, asks a number of experts from the worlds of mental health and neuroscience "How Much Progress Have Psychology and Psychiatry Really Made?". I'll have more to write about some of the comments in the post on other days, but I wanted first to start with this:

John Medina, a developmental molecular biologist, author of Brain Rules, an affiliate professor of bioengineering at the University of Washington School of Medicine, and columnist for the Psychiatric Times.

“I certainly applaud the point of view of explaining psychological processes in biological terms … I am also the first to admit, however, that the view we get can be very disturbing.

How much progress has psychology really made in the last century? A lot, though the journey has been depressingly uneven.

Psychology is a truly original scientific product of the 20th century — the first real attempt to take the interior mental life of people seriously. Before that, we were drilling holes into the heads of mentally ill patients to drive out hallucinogenic spirits, or saying mental health was the interactive balance between a person’s bile and their phlegm.

My personal hero in the exodus away from mental superstition is a large bolus of ego named Emil Kraepelin (1856 to 1926). He had the audacity to assume everything that was psychological was simultaneously biological. Emil posited that by using the investigative tools of natural philosophy to study the brain, one could eventually ferret out the secrets of the mind. To show how truly radical this idea was, astronomers in his day were actively debating whether or not the dark places on the moon were caused by enormous swarms of migrating insects."

I am really hard pressed to see psychology as "a truly original scientific product of the 20th century", especially so clinical psychology. When I was first in graduate school, I had a long and contentious dispute with one of my teachers, Donald Mosher, about whether or not psychology was a science. Having spent half of my undergraduate career as a physics major, it seemed very clear to me that psychology was far more art than science. Discretion being the better part of valor, I dod not press the point too hard but we did argue it again and again over the years I was there.

Psychology, and let's assume throughout this that I am speaking specifically of clinical psychology here, wants to be scientific, wants it desperately. As does psychiatry. But if one looks closely and the theoretical foundations they rest on, regardless of one's orientation, there is precious little science there. Using statistical methods and diagnostic nomenclature does not a science make. There is certainly the stuff of an interesting article in exploring the meaning of this desperate desire to be a science, but that is for another day.

In light of the studies exposing the inflated success rates shown for al manner of psychotropic drugs, and the doubt that Wampole casts on the superiority of cognitive behavioral therapy, our most "scientific" therapy, it is very difficult to support the current state of mental health treatment, psychiatry and psychology as scientific, far less the entire enterprise of psychology.

This is not to ay that I believe we have not come very far in 100 years, because we certainly have. But to lay claim to what we do as science seems absurd to me.

Am I my depression?

Tue, 15 Apr 2008 09:18:27 -0400

Furious Seasons links today to an interesting piece by Richard Friedman in the NY Times . Both raise interesting and important points and should be read.

Friedman asks this, arising from one of his patients , now 31 who has been on SSRIs since she was 14--

"But now she was raising an equally fundamental question: how the drugs might have affected her psychological development and core identity."

Indeed, how might they? And why is this question only now being asked? And even more broadly, what does it mean to have depression as a primary element of one's identity, as if it were as immutable and permanent as height or eye color? Is her sadness or anger or ambition hers or is it her depression or her medication? And how could she ever tell? Who might she be had it not formed such a huge part of her life and development?

These are enormous questions and will or should be raised more often as we face the coming of age of countless numbers of children who have been medicated with one or another or several psychotropic drugs since childhood. I remain haunted by the girl in the Frontline episode who could not tell if her moodiness, something quite ordinary in adolescents, were indicative of a need to increase her medication *because* she has no sense of unmedicated moods. She has no idea what it is to feel happy or sad or angry or full of angst over being a teenager without medication, without holding in front of her in first place her "illness". In many ways, she, her unmedicated self, developed only to the point where the medication was begun and should she go off it, it seems she might well have to go through the process of learning to manage and understand her moods in the same way that all of us, the unmedicated, do as we grow up.

And these same questions come to mind as I read Friedman's article. One of the things I have heard again and again from people I know who have taken SSRIs is that their emotional range is blunted; they don't feel depressed but they don't feel much of anything, either up or down. And one of the things I remember vividly about being an adolescent was how intensely I could feel things -- enthusiasms, sadness, outrage, delight. How can someone who has been medicated so long even know what that feels like? And how likely is it that if and when they come off the medication, they interpret ordinary ups and downs, which they have not experienced, as indicative of their "illness" and thus necessitating medication again? How can I know what it is like to be an ordinary human being with the usual range of emotions and reactions if I have never experienced them? Might that be like having as a palette for experiencing life all the colors but none of them saturated?

Oh, and anywhere in this, was therapy even considered as an option?