It is encouraging that more and more people – psychiatrists, patients, and researchers – are opposing drug treatments for depression, anxiety, and ADHD. But this is only half the battle. To oppose the level that psychiatry, my field, has sunk to comes with the obligation to right the ship. It is essential, and of paramount importance, to restore psychiatry to its proper place, where patients are well treated. In the history of psychiatry, the quest used to be to devote all of one’s thought and study about the real sources of human suffering, and submit it, with humility, in the service of the patient’s authority, rather than ask patients to submit themselves to psychiatric authority – as taught by psychiatrists such as D.W. Winnicott, and the ‘Object Relations’ school of Ronald Fairbairn, and finally the illuminating teachings of Harry Stack Sullivan on Schizophrenia as practiced at Chestnut Lodge. Unfortunately, this has all too often gotten lost, due to ego, money, and power.
It doesn’t have to be this way. But where do we turn? Obviously we need to recover from practices that violate the fundamental principle of “Do No Harm.” But over and above that, we have to constructively treat and heal the ‘pains’ of our patients.
The sad thing is that we already have everything we need: the lost art and science of psychotherapy. Don’t get me wrong, there certainly has been a lot of bad therapy over the years – all kinds of schools, theories, fads etc. My own roots were in psychoanalytic psychotherapy. But it was beset by considerable problems. Its practice suffered from dogmatic theories and miscast beliefs, which worked to the detriment of the responsiveness of our patients. I moved on to develop the Psychotherapy of Character.
As opposed to the fraudulent ‘chemical imbalance’ theory of ‘biological’ psychiatry, psychotherapy not only effectively treats us but it is consonant with the way psychiatric symptoms actually develop in the first place. The wisdom, the art, the science, the neuroscience of psychotherapy respects the complexities of the human condition. It addresses the workings of the brain, and in precisely the way our consciousness forms in the first place. Patients mourn the traumas of life in the human context of safe boundaries and genuine emotional holding and relationship with the therapist. Our consciousness is organized as a play in the theater of the brain – with a cast of characters, relatedness between them, scenarios, plots, landscapes, and set designs.
We write our plays throughout our development, as the actualities of others’ responsiveness, deprivation, and abuse impacts the unique constellation of our temperaments. (See – “A Unified Field Theory of Consciousness – A New Paradigm”) Once established we play out our scenarios over and over again. We are prisoners of a drama we can’t even see. Psychotherapy is a kind of living theater that gives form – and access – to our invisible internal play. Therapy serves to deactivate a problematic and damaged play, and allows us to write and inhabit a new one that heals symptomatic suffering and fosters authenticity and the capacity to love.
To become a psychotherapist takes many years of disciplined work. One learns, fundamentally, by paying attention to our patients. There needs to be years of apprentice-like learning that requires careful supervision. One needs to know oneself, so that our own plays don’t interfere with our patients’. This requires therapy for ourselves. Psychotherapy is not a ‘we-they’ enterprise. A therapist cannot consider himself superior or better than his patient. We are all fellow-travelers in the human condition. Only mutual respect can foster the mourning of our problematic plays and recovery from suffering.
Why would someone come into my office to be a patient in psychotherapy? Why would he decide to subject himself to the inconvenience, the considerable expense, the uncertainties, and the discomfort of confiding in a stranger, while contending with stigma and shame?
A patient comes to a psychiatrist for relief from his suffering. The word ‘patient’ itself comes from patiens — “enduring pain and suffering.” Human suffering takes many forms. People may feel unhappy, lonely, angry, or sad. They may have symptoms: obsession, compulsion, anxiety, so-called depression, panics, phobias, paranoia, delusions. People have characterological behaviors that get them into trouble—drinking, drugs, gambling, eating (anorexia, bulimia, overeating, bingeing), sexual perversions, impulsivity, rages, emotional isolation, narcissism, echoism, sadism, masochism, low self-esteem, and psychotic and manic states. They may have crises in their lives: divorce, death, loss, illness, rejections, failures, disappointments, traumas of all kinds, and post-traumas.
Suffering does not exist in a vacuum. It flows from our damaged plays of consciousness. Since there are built-in fault lines to every problematic play, the way we break down follows along those fault lines. The way a person breaks down reflects the way he is constructed. Suffering is the manifestation of something having gone wrong in his characterological play.
To attend to a patient’s suffering, we must explore his inner play. This exploration is the journey of psychotherapy. It proceeds through a responsive conversation between therapist and patient. What transpires is far more than the cognitive content of the words. It is the exploration of a patient’s invisible, unique inner drama. However, the transformative process in therapy, ultimately, does not turn on this exploration, per se. It follows from the responsive engagement between us. Emotional holding allows one to digest and mourn the internal play. And finally, it is responsiveness and holding with the patient’s Authentic Being that fosters the writing of a new play, grounded in authenticity and love. A therapist does not heal his patient. He does not have such a power. He facilitates the processes that do it all on their own. When a patient writes his own new play, which flows from his authenticity, it is his own. It may be very different from his therapist’s political, religious, or scientific beliefs. This is as it should be.
We all have the regular human struggles in our lives. Nobody—neither patient nor therapist—is spared his fair share of tragedy and suffering in life. Having sufficiently dealt with his own characterological world in no way means the therapist is better than his patients or a kind of superior being. It allows him, however, to have enough internal and external resources to deal with his own ongoing life issues, so they don’t interfere with his clarity and genuine availability to his patients. Even if he does get temporarily reactive and lost in his own play, he can quickly recover.
Being a therapist goes against the natural human inclination to avoid discomfort. It means a therapist has to allow himself to sit with the full range of human darkness, as well as human virtue, in himself. Consequently, I know in myself the worst and the best of the whole range of human impulses. This is not always easy. People tend to want to see themselves as good and to see badness as located outside themselves. A therapist is willing to resonate with the full range of his patient’s characterological dramas, while possessing the facility to retain his grounding in his own authentic self.
All humans are capable of the full range of human possibility. Our persona imagination encompasses the full scope and is resonant with even the greatest extremes. The range of personae runs the gamut from Gandhi to Jeffrey Dahmer. We all carve out our unique character plays from the collision of our temperament with our developmental experience. In this sense, we all come to our characterological positions honestly. If I felt a resonance with Jeffrey Dahmer, this does not mean I would cannibalize someone. But it is in my image-ination potential and in yours. No character personae are outside the great human drama. Being human encompasses them all. With a sufficient anchor in his authentic self, the therapist accepts that all potential persona identities and motives are in us but not of us.
Patients always know, no matter what, that something is amiss in them. Otherwise they wouldn’t be there. Keep in mind that psychotherapy is an exploration of the patient’s characterological world and the forces that brought it about. Even a depraved characterological identity does not encompass the Authentic-Being of the patient. The point of the therapy is recovery from a problematic character identification. The problematic character identification is in the patient, but it is not reflective of the patient’s Authentic-Being or potentially recovered self.
Respect for the patient means respecting his boundaries. Exploitation means violating the boundaries. There should never be any exploitation in therapy. The list of exploitations isn’t long: sexual, sadistic, power, financial, ego aggrandizement for the therapist, or having the patient serve the therapist’s emotional needs. Both parties are sitting in their seats and do not engage in any action — impulsive, or premeditated. All exploration is properly on the screen of the living theater in the office. Violation of boundaries always leads to sadistic aggression and violence. The therapist’s provision is much like that of a good parent — with boundaries and good-enough loving. I reiterate “good enough” because – as in child raising – there is no such thing as perfect responsiveness in therapy.
And finally, confidentiality is of the highest order. Confidentiality is the boundary that keeps a safe circle around the therapy. This means it is safe for the patient to say anything without reference to any consequences in the outside world. The only usage and value of what is talked about is in the service of the therapy itself. Confidentiality ensures that the content of the therapy will not be used for any advantage or disadvantage for either the patient or the therapist outside the therapy.
Therapy from the beginning to the end is a responsive engagement between my patient and me. A new patient comes to my office because he is suffering. I need to hear the nature of his suffering. I need to know something about his circumstances. And I need to get a preliminary sense of his characterological world and how it got to be the way it is. The first few sessions will be focused on this discovery. This is the evaluation. I am evaluating the nature of his situation in order to be in a position to address what would be involved in dealing with it. New patients often think when I use this word that I am evaluating them in relation to a judgment about their worth and value, or evaluating whether I would accept them into therapy or reject them. This is not the case. I am, in a preliminary way, getting to know them. Likewise, they are evaluating me based their impression of me. They are, in a preliminary way, getting to know me. We are on equal footing, and all the processes that will ensue are purely human.
There are no formulas at the beginning of therapy or at any point during the therapy. As I open the door for the first time, I am open to the various impacts this new person makes on me: his appearance, his style of dress, the manner of his greeting, his response as I usher him to his chair. I do not study these things. I simply notice their impact on me. As I ask what brings him to my office, he tells me the specifics of his suffering. I listen to the content, and I feel the emotional impacts of his presence. I am responsive to whatever presents itself. I may continue the discussion of his “problem,” or I may shift my response to the state of feeling that is present or the state of feeling that is conspicuously absent. If the person is reticent, I may be active in my engagement and actively responsive to what is presented. If the person floods the discussion, I may interrupt. If the person is tangential, I may refocus. If the person tells me his story, I may quietly listen. From the beginning, therapy is a responsive engagement.
The culmination of the evaluation usually results in the first connection between patient and therapist. Just to have someone hear the pain of the suffering without ridicule or diminishment is a form of emotional holding. This is amplified when there is shame involved. The initial symptom is always a veil for a deeper pain. When this is touched upon and addressed in the evaluation sessions, the patient is reached in his real pain. He feels understood and listened to.
Even when some temporary relief takes place during the evaluation, as is often the case, this is not the treatment, and it is short-lived. This is the just the prelude. The evaluation isn’t much different from the false intimacy of two people sitting next to each other on a long train ride. One may confide very private stuff to this stranger. The conversation feels very intimate, but it is an anonymous false intimacy, predicated on never seeing this person again.
The beginning of therapy is but an introduction to a stranger, making a first and an essential emotional contact. But we will see each other again. We will deepen our exploration. We will move toward a trusting closeness, which is not anonymous. Real trust always has to be earned. And as always happens, the patient’s internal dramas and cast of characters will make their presence felt. In order to find our way, we always have to slog through the characterological dramas. They always come alive in the office. This is the hard part. In order to reach the patient’s Authentic Being, we have to grapple with this odyssey. It is only as this takes place that real trust can emerge.
Of course one does not at all need to be a doctor to be a therapist. There are some advantages, mostly learning how taking responsibility in life and death situations changes a person. Knowledge of the body, consciousness, and physical ailments can be very useful during the therapy. The downside of doctors is that many are sadly not geared to be responsive, with respectful relationships. We need to offer real psychotherapy on a very broad scale. The need is enormous. We need therapists of all persuasions – psychologists, social workers, and others to develop into really great therapists. We need everybody who is dedicated to a revival of this lost art, in every discipline that seeks to practice it. The secret truth is that recovery from symptoms is not that hard. It is incredibly satisfying to help people recover from their suffering, and fulfill their best selves.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.