Jung At Heart

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!

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?

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.

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?

Yesterday I ran across an interesting blog post about the possibility of therapist and patient blogging together about the therapy -- you can read it here.  After reflecting on how blogging is of use for her in her therapy, she goes on to consider co-blogging and suggests:

"Idea # 2: Start a new Co-blog

This idea was inspired by an Irvin Yalom story about how, after each therapy session, he and a patient wrote a brief synopsis about each of their experiences, learnings, understandings etc. in that session. They then shared what they wrote at the beginning of the next session. It was intriguing how each picked different components of the session as meaningful. It seemed like a really interesting way for a patient to learn to fully understand their behaviours and experiences from a third part perspective.

I thought maybe Dr. X. and I could set-up a private blog; with the two of us as co-bloggers. Maybe we could shorten our sessions to 30 minutes and then each of us would be responsible for utilizing 20 minutes sometime during the week for each of us to blog about the experience. At the beginning of each session we would debrief what was blogged by each of us."

And this sets me to thinking again about therapeutic space, the therapeutic frame.

I read Yalom's book, Every Day Gets a Little Closer: A Twice-Told Therapy some years ago when I was deep in the throes of my own analysis. At the time it seemed such a bold and good idea, that the patient and the therapist would each write about the therapy. I was insatiably curious about what my analyst thought and what he might say and I already wrote voluminously after each session in my journal. I never followed through on asking about it though and I suppose never really seriously considered it as an option.

I did once in my analysis give my journal to my analyst to read. I had the notion that this would reveal to him what I found far more difficult to put into words in the sessions. He read it and there were no amazing revelations or changes that happened as a result. He told me then, and I came to understand that what was important was that I reach the place where I could and would put into words and speak what I until then would only dare write. Writing was safer. I could edit as I went along. I could stop and start. I could strip down my experiences, my self, to just the words that I wrote without the tone of my voice, or difficulty saying it or flush on my cheeks or any of the other embodied expressions that were part of sitting face to face and speaking the words. I was, without realizing, privileging the words over the embodied experience and expression of them, believing that the Word mattered most.

All of this reaches into the concept of Therapeutic Frame. In an excellent article on the frame, Robert Maxwell Young writes:

"the analytic frame is not confined to the room where the therapy is done. It is ideally tacitly in the minds of both therapist and patient all the time. It is there when you open the door or speak on the phone. It is carried with the patient (or not) between sessions: it is internalised. It is conveyed by the therapist’s demeanour, tone of voice, pauses, silences, grunts, the wording of any note or letter which it is appropriate to send to the patient. It is evident in pauses. It is all aspects of analytic space. To maintain the frame is to maintain the analytic relationship. Its essence is containment." (emphasis mine)

So the frame is more than just the physical setting. It is the larger notion of the therapeutic space, that space in which both therapist and patient relate to each other in support of the therapy. It includes sessions on the telephone, or in writing, or in other ways that the two engage in their work together. 

Young says:

Acting out is a substitute for verbal expression. It is expressive, symbolic communication, but it is not relfective. The patient is acting rather than reflecting. Where acting out is, thought cannot be.

One feature of acting out is that the therapist is usually put under pressure to do something he would not otherwise do — to go after the patient in some way, e.g., to write to the patient or phone, to reveal something, to move, to change a session, to press the patient, to relent about a decision or take a firm line, even to lose his temper."

There are purists who hold to a highly structured and idealized sense of the frame. Robert Langs is one and there are others as well. Frame becomes elevated to an almost absurd level so that ordinary human interaction becomes almost impossible -- like offering a tissue to a patient who is crying. But within the therapeutic community there are variations in how the frame is constructed and maintained. For the purists, a letter from a patient between sessions is an instance of acting out and they would not read it but rather place it on the table and wait for the patient to talk about it. And it is acting out, because it is an extra-therapeutic contact, a kind of effort to gain more time and attention from the therapist outside of the boundaries of their time together, and it is writing rather than putting the feelings into words and speaking them in the session. But that it is acting out does not mean it is useless, meaningless or bad; what it does is signal the presence of unresolved feelings or or need. 

The actual words of the letter may indeed impart thoughts or ideas not expressed in session but it is what drives the desire to write them rather than say them that is probably of greater importance. And dealing with the fear/resistance to expressing those feelings and thoughts directly is a big part of what depth psychotherapy is about.

So back to the idea of co-blogging --

I have to wonder if, like writing a letter or sharing a journal, this isn't at base a way to sidestep the heart of the matter -- that it takes time and effort to work through our defenses and resistances and to do so in the presence of another human being. If the entire therapy were in writing, and I know that such work does occur, then writing this way could have a place. I know of at least one Jungian therapist who works with some people via email exclusively. It is not a big step to go from that to co-blogging in a private blog. But when the heart of the therapy is the face to face encounter, this does seem a bit off the point. Whether the reading and writing takes place within the hour or outside of it, it is still not in keeping with the basic rule -- saying whatever comes to mind. In fact I have some reservations about blogging one's therapy in the first place.

Even when one can be certain of anonymity -- and is that ever possible? -- blogging for others to read session by session what one is experiencing in therapy may have some educative value for others, but it is also in a way inviting others into the space of the therapy -- via comments and even in the awareness of an audience when writing posts. It took me a long time as a patient to understand the importance on my end for maintaining the container of the analysis, to not talk about it and my experiences so freely to others. It took me a long time to understand that what I was doing when I did that was avoiding dealing with all of it, all of my feelings within the analysis. In this way, a publically accessible blog is quite a different thing from a private journal -- the journal is not open for others to read or comment on. A patient may write therein about her therapy, her therapist, but in the sense that the therapist, as she carries him or her inside, is internalized, then it is within the frame of therapy. It is when others enter that space, others who are not included in the therapy per se, that it violates the container.

The boundary conditions of therapy are more complex than they seem at first glance.

What is success in therapy? How is that determined?

I read yesterday in Everyone Needs Therapy the following -- not being a resident of Illinois, I have no knowledge of the laws there regarding therapy and its practice --

"In the State of Illinois, after six months of treatment, if a patient isn't getting better under a social worker's care the social worker is legally mandated to punt to another therapist. I'm not sure how the other mental health professions handle this, but social workers can't let you malinger very long. "

Who decides that and how? A symptom checklist? What is "getting better"? What does this mean when applied to therapy modalities which assume a longer time frame for the work, like psychoanalysis or psychoanalytically oriented depth psychotherapy? Why would it be malingering for improvement to be slower in coming? What does this mean for and about patients who have benefited from rather long courses of therapy or analysis?

See -- more questions than answers. The law seems to operate on certain assumptions about therapy and about how much influence the therapist has over outcome. It also seems to assume that short-term or relatively short-term therapy is what defines therapy itself.

So how do we consider the therapy in the case of patients like Alex? This is a tough one. So much remained undealt with -- from the hostile attack Alex made against Paul to the fling with Laura to his relationship with his father to his return to flying that it is hard to assess. This is a therapy that was very much still beginning with the basic issues still emerging. And then Alex died. 

It is common to imagine that it is therapy that transforms people's lives, that there is something in the process that makes change happen, rather like a medical procedure. But therapy is only a small part of the process. It is but an hour or so a week and it lies with the patient to reflect on and use what is learned, seen, or gained in that hour in the rest of his life. Unless insights gained in therapy lead to action in the patient's life, nothing will happen. The therapist can help with providing some of the insight, the means for which to view one's life differently, but it lies with the patient to take in the interpretations, observations, suggestions and digest them and then apply them. Therapy is not magic.

So with Alex, we have someone who started out quite resistant to the process, who only reluctantly yielded to it and that only in spurts. Under the 6 week rule, Paul would have had to refer Alex on to someone else before therapy even started! Does this mean the work he was doing with Alex was a failure? Or is it that little bit by little bit Alex was coming to trust what was happening in his time with Paul and might he, had he lived, decided eventually to actually commit himself to the therapy and really get down to work? We'll never know, of course, but that certainly is a possibility.

Ultimately only the patient can decide if therapy was successful because it is the patient's life to live. Any therapist has the experience of patients leaving before he or she felt the patient was ready or had finished. And also patients who have stayed after the initial complaint is resolved. Some of what it means for therapy to be a success is determined by how one conceives of therapy in the first place -- as a way to solve problems or relieve symptoms or as a way to learn more about oneself and gain greater understanding of the meaning of issues and events in one's life. There is no one size fits all definition of success here.

When a third party pays the bill in whole or in part  for therapy, then it is reasonable to set some kind of standard for outcome. And insurance companies certainly lead the effort to do this. It is economics that set the agenda here though, make no mistake about it. But that is a topic for another day.