Adam Blatner, M.D.

May 13, 2008

The field of dynamic psychology needs to broaden its horizons beyond the theories developed before the 1980s, taking into consideration the growing awareness of a number of other phenomena that hadn’t been adequately woven into those earlier theories.

As an amateur student of the history of psychotherapy, I have been thinking about the recent history and also future of psychotherapy. First, we should think of therapy as a sub-category of practical applications within a wider field of psychology (and psycho-pathology–that is, what makes people sick and what are the dynamics of illness), in the same way that medical practice should be rationally founded on growing insights into the actual way the body works, gets sick, and heals.  (I discussed this more in a chapter on meta-theory in a recent anthology about the theoretical advances in psychodrama.)

Being a physician and psychiatrist, I think of psychiatric theory as being in many ways analogous to what theory in medicine is about. And staying with that analogy, many breakthroughs in the history of medicine come from developments at the edges or even beyond the formal boundaries of what is accepted as mainstream medical theory or practice.

The motivation for this piece arose from my having become aware of a new trend in psychoanalysis, begun in the 1980s, called “relational psychoanalysis.” Pioneered by the late Stephen Mitchell and others, it views the separation of modern psychoanalysis into competing schools as foolish and advocates an intelligent integration of such approaches as Kohut’s self psychology, the object relations school of psychology, the interpersonal approach of Harry Stack Sullivan, ego psychology, drive psychology, inter-subjective analysis, and other sub-types of psychoanalytic thought. I concur and go further, advocating a continuing expansion of a depth-psychology approach that also can include other dimensions, such as further dynamics of interpersonal relations, small and larger group dynamics, work in communications theory, and research in social psychology. All these have profound dynamics and should be recognized as being part of a true “depth” psychology. For example, I’ve realized that the dynamics of rapport—why we prefer and choose some people over others, and how we cope with our own choices and those of others—also known as the sub-field of “sociometry,” (invented by Dr. J. L. Moreno, who also invented psychodrama) inform any more comprehensive depth psychology as much as the ideas of Freud about instincts or Jung about archetypes.

Considering psycho-somatic interactions, we need to include also the depth psychology dimensions of what Wilhelm Reich called “body armoring” (in his early 1930s book, Character Analysis). These ideas were developed further into other “body” therapies since then. At the psycho-cultural level, psychoanalysts such as Erich Fromm noted some of the built-in biases of Western (Capitalist) culture—and also the pitfalls of Marxist culture—deserve to be recognized as having not only roots in individual psychodynamics, but also consequences.

Issues taken on by existential psychotherapists that deal with the sense of meaning and fears of death should be incorporated into this growing synthesis, and I would strongly suggest that the frontiers of dynamic psychology must include the best insights of many, many others, such as Carl Jung, Alfred Adler, and so forth.

Part of the rationale for this proposal is the analogy to medicine: That is, dynamic psychology and the art of psychotherapy should be open to considering factors that may have been largely unknown years ago. In medicine, theory and practice advanced when the awareness of the microscopic world became more apparent in the mid-19th century.

Just when the theory of infection was becoming quite fashionable, though, it turned out that infection was not the cause of another group of mysterious illnesses! Around the 1890s some of these illnesses were found to be due to nutritional deficiencies (e.g., “Beri beri, due to thamine—vitamin B1—deficiency; or, later, pellagra being found to be due to Vitamin B2 (Pellagra). The point here is that sometimes mainline theories must be stretched, or added to, broken open, dissolved and re-formulated in a more expanded way. How could disease caused by radiation be recognized until the technology for causing radiation sickness more reliably was first invented (e.g., distilling radium, the x-ray machine, etc.)? Are there perhaps equivalents to these developments in the psycho-social realm?

Problematic Conditions

Certain conditions to be mentioned stretch the boundaries of conventional theories of psycho-pathology. For one thing, they bring in the cultural definition of illness and the way society defines and treats these people. Sometimes they add a tone of moral condemnation, suggest a type of irremediable impurity, or in other ways alienate the implied “patient.” Sometimes they go in the other direction, perhaps over-medicalizing these people, undercutting the need for people who are thus cast into the sick role (i.e., they can’t “help” it) to participate actively in their own rehabilitation. The boundaries of responsibility and accountability become mixed.

One of the most controversial of these conditions is the idea of addiction. The ethical problem lies in the degree to which such a condition should mitigate punishment for criminal misbehavior while “under the influence,” or for behaviors aimed at getting the money to feed the habit. What does it mean, then, to call something a “disease”?

What about those problems that have become recognized as partaking of many of the dynamics of ordinary physical addictions, yet also not sharing certain other features. There may be no physical withdrawal associated with such para-addictions, but so many of the other elements share in this compulsive pattern. Thus, shopping, news-watching, internet or email addiction, sex, food, going into debt, gambling, and other behaviors might be viewed as “addiction”?

Is there another kind of addiction or associated condition known as “co-dependency,” or the problem of “enabling” those who are addicted? What is the treatment then?

A key point to be made is that one can become addicted without having an overwhelming or even moderate predisposition due to early child-rearing problems. The addictive process can be intrinsically rewarding enough, seductive enough, so that one can become caught in its web.

Another point addresses the boundaries: When is religion addictive? When it is part of a “cult”? What is and is not a cult? Might some people participate in a group as if they were in a cult even if the leader and the relationship with many if not most of the other followers clearly are not in a classical cult dynamics?  Could there be cult-like, borderline issues that some folks get caught up in? And might there be leaders who become a bit cult-leader-like even in otherwise non-cult-ish denominations?

Similarly, can there be other pseud-totalitarian contexts, communities, business environments, industries, that to a less dramatic degree nevertheless partake of cult-like dynamics even though such groups are not formally at all “religious”?

The psycho-social issues are rampant, then, and my own bias is that psychology and psychotherapy must include culture, sub-culture, social network dynamics, as much as personal psycho-dynamics.


This term refers to the way a person can have both diabetes and a broken leg. An indvidual might suffer from several co-morbidities. Perhaps the aforementioned, plus an infestation of fleas, alcoholism, vitamin deficiency, athlete’s foot, and other conditions—we would see these people at the city general hospital and admit them not only with the primary diagnosis, but also with the informal diagnosis of “fubar” or fouled-up-beyond-all-recognition. (Sorry, but that’s the way interns developed their “Mash”-like warrior humor.)

Addictions, for example, are sometimes a matter of social network—everyone drinks in some sub-cultures, and one threatens the sense of belonging by trying to opt out of the tavern. Sometimes drinking is self-medication for a post-traumatic stress disorder—this, alas, is becoming increasingly prevalent in the wake of a war. The problem with co-morbidity is that often the different response patterns or factors reinforce each other and make it far more difficult to break out of the pathological thought-feeling-behavioral syndrome.

Speaking in terms of therapy, a general rule of thumb is that for every co-morbid factor, then, the amount of therapy or rehabilitation effort doubles, if not more. If it takes 40 hours of therapy to clear up a minor phobia that results from a trauma, it might take 80 hours if that trauma is complicated by having been imposed by a significant other. Then it’s not just the trauma that’s the problem, but the sense of trust in close relationships.


Before the 1970s, it was thought that many people with “war neurosis” were really suffering from residuals of early childhood disorders. The idea that normal people could get disordered without this predisposition didn’t fit the prevailing psychoanalytic theories. This all changed in the years after the Vietnam War, and not just because of what happened to soldiers. More evidence emerged that victims of crime could also be traumatized.

The Feminist revolution also raised consciousness about the problem of rape. The callous ideas that “she asked for it” and “maybe she really enjoyed it” were vigorously countered, and along with that there emerged a host of people who claimed to have been sexually abused, but felt that they wouldn’t be believed. Sensitivity to this theme was heightened, and Freud’s early acknowledgment of the prevalence of sexual abuse—and his mid-career recanting of this view in favor of viewing the memories as the patient’s fantasy—became a minor scandal in the field of psychoanalysis.

Trauma, like addiction, has its own psychopathology, and it transcends more traditional models of psychology and psychopathology. We need to more vigorously develop multi-dimensional theories of these conditions, and multi-modal treatments based on more holistic formulations.


A related condition that needs to be recognized is the condition in which victims of abuse cling to, forgive, depend upon, and sometimes even join with their abusers. (The “Stockholm Syndrome” refers to this last pattern of the victims of kidnaping defending their perpetrators.) The degrees of denial, minimization, and engaging in behaviors that perpetuate the cycle of domination and violence require a more interpersonal understanding of dynamics. These, in turn, also need to be placed into a recognition that we presently have a remarkably alienated culture—one in which the victims perceive that they have no wider social network where they can take refuge (a perception that is often fairly realistic!). Social programs (or the lack thereof) for shelter and alternative living situations are being developed, but they are often viewed as laced with danger: “Your kids will be taken away from you if you go there!” is a not infrequent threat by the abuser to keep the abused in line.


Can a society be neurotic? What if this was the real diagnosis during the 1950s and 1960s when increasing numbers of housewives were medicated with first Miltown (meprobamate) and then Librium and Valium (benzodiazepine medications)? The anxiety they felt—or that’s how it was diagnosed—was clearly a sign of their maladjustment. The idea that it was normal and sane to be adjusted to the often stiflingly boring and emotionally draining role of the nuclear housewife might itself be better recognized as a sociosis, a “common sense” value that on closer inspection is misleading and often anti-therapeutic.

(I’m reminded also of the advertisements of men looking like reputable physicians recommending the health benefits of smoking!)

My impression, after over 35 years of clinical work, is that at least 40% of the overall weight of distorted thought in most of my patients was due to continued belief in “common sense,”—those generalities about values and norms in culture that were insufficiently differentiated and globally applicable.

Sexual Boundaries

Here is a poignant problem: In the 1960s, homosexuality was a type of sickness. By the later 1980s, it was no longer so considered by most psychiatrists—although a few still held out! If not a sickness, then, what was it? In many states it was still illegal to engage in homosexual acts even in the privacy of one’s home until this was only fairly recently changed in court decisions.

Another problem that is still controversial is the proper treatment of gender dysphoria, or transgendered-ness? At what age might his syndrome be addressed? Other dimensions of sexuality are still operating at the margins of legality and society. What’s at stake here is the coerced use of treatment (with, let us recognize with cold eyes, the requirements of payments of hefty fees.

I suspect that there may be other categories of behavior or experience that may have previously been considered a form of illness, something that should be treated, yet on further consideration, this may not be so. On the other hand, there may be some behaviors that had been considered if not normal than at least nothing to be diagnosed as an "illness." (Alcoholism or tobacco dependence used to be in this category.) Perhaps shifting that thinking might be more useful. (Philosophically, then, I don't consider any of these entities, categories, names, to reflect ultimately valid phenomena; rather, they are social constructs, and my own bias is towards the pragmatic---what is more or less useful to think of in a certain way.)


Psychotherapy was expensive decades ago, and fees have risen so that it becomes prohibitively expensive today. Just as nurses salaries have quadrupled, so also have the fees of non-medical psychotherapists—it’s part of a mixture of entitlement, rising expectations, reduction of the gradient of hierarchies, and cultural norm-shifts that blur boundaries between “service providers.”

When I was in training, the unspoken sense was that recommending a course of psychotherapy was fairly benign—it didn’t have the morbidity of major surgery, for example. This was an era in which one didn’t question the costs of treatment. Alas, medicine costs and treatment fees have risen far more than the overall income of the population. We also are living at a point of transition from a culture in which the idea that “we can’t afford it” was not a respectable response to a culture (emerging now!) in which questions of relative costs and affordability are most relevant considerations.

Those who are attuned to longer term therapy may be in denial of the financial stress—even (dare I say) trauma—imposed on patients when the full costs of a program of treatment are noted. (I wonder if such issues are even discussed in the training of counselors and psychotherapists today.)


Another category that was marginalized—treated as if it were beneath serious consideration—by the dominant majority of a-religious psychological and psychiatric professionals was that of religion. This mid-century attitude was that religion was a collective neurosis, a hold over of superstitious thinking, clung to neurotically by those who used magical thinking to cope with the realities of life. In the last few decades, though, mainstream psychology has increasingly recognized the vital role of spirituality as a component of rooted-ness, meaning, groundedness, and mental health. Sure, some religion can be used foolishly and manipulatively, and religion can be a source of neurosis; but then again so can other situations that happen without appeal to supernatural values. Political demagoguery can also be a powerful neurotogenic force.

We need to expand our psychology to recognize the power of aspects of the mind that are as yet still fairly mysterious. For example, certain kinds of spiritual experiences that include visions are not pathological when other ego functions are fully operating.

On the other hand, equally taboo for many therapists was a direct confrontation with religion, in that some people were suffering from what might only be called “spiritual abuse.” My hunch is that threats of damnation, vivid descriptions of hell, and the idea of the near-inevitability of cosmic punishment has been far more toxic for many people than has been recognized. Some kids may have been more sensitive, have taken these images literally, and have been more bothered than anyone wanted to admit. There are more nurturing and also scarier types of religion.

In some settings, religious youth groups and other community activities might be functioning as the healthiest parts of a general community. In other settings, some sub-groups of religion might be more cult-like. The culture continues to have a conversation as to wich practices should be rightfully considered wicked, depraved, sinful, non-human nature, hurtful, unfair, racist, sexist, overly orthodox and which are considered to be too worldly, lax, wishy-washy, making-it-up-as-you-go-along (as if that were a bad thing), etc.

Fear of Death

Ernest Becker, Irvin Yalom, and others have rightly pointed out that the fear of death is not an inconsiderable source of distress and underlying psychopathology in many people. What is the actual pathology? Is it inevitable. Becker, I think, over-diagnosis the problem: It’s one of those kinds of things that one can infer to be at the root of all kinds of things, but that kind of logic allows one to place all kinds of things “at the root of” all kinds of things. Yalom, though, notes these issues as coming to the surface in certain specific cases. My hunch is that if one asks about it, it may be brought out as an issue, but that over-focus on the part of the therapist may lead to an over-focus on the part of the patient.

Body Therapy

Psychosomatic illness is well-recognized as being real, but it is unclear how much and in which way this problem operates. There was the problem of over-diagnosis and excessive hypothesis-building in the 1960s, at the zenith of psychoanalytic influence, and many of these formulations simply haven’t panned out. The opposite, though—that there are no psychosomatic interactions—may be even more untrue. My hunch is that it’s a mixture, and more, that psychoanalysis as a method may be inadequate to bring out and clarify the dynamics.

Wilhelm Reich, as mentioned above, noted in the early 1930s in a classic text, Character Analysis, that people carried their neurotic patterns not only in their minds, but also in their bodies. People who were anxious about something held their bodies in a defensive posture, with various muscle groups being kept tense. Angry people might chronically clench their jaws, building up that John McCain-like hypertrophy of their jaw muscles. Reich and a number of others who came later recognized that to really work with a neurosis, it was important to help clients become aware of these patterns of body-tension. The phrase, “body-mind” medicine was not just a bit of jargon! Work on releasing these tensions was equally important for holistic treatment. Staying only on the mental level wouldn’t suffice because the physical patterns reinforced the deeper attitudes.

Action Therapy

Related to body therapy has been the emergence of a variety of action therapies, drawing on drama, dance-movement, and other sources. Psychodrama, Pesso-Boyden Psychomotor therapy, and related approaches get people more physically involved. Through re-enactments, they are able to also re-experience a positive or healing alternative to their fixed negative memories. Some experts in treating trauma, for example, suggest that experiential approaches must supplement if not replace “talk” types of therapy.  

This isn’t simply a matter of discussing the type of therapy, but of broadening our view of the nature of psychological functioning, of recognizing the need for physical action, or spirituality, of other dimensions. It’s like physicians recognizing that no medicines can replace a wholesome diet in the treatment of certain complexes of disease. All modalities must be used, based on a wider perspective as to how the body-mind works and what it takes to help it heal.

Positive Psychology

A broader view of psychology recognizes that, like the body, the mind has its own complexity and own resources for healing. One approach to healing is to diagnose what’s wrong and try to correct or counter the pathological elements. Another approach—and both approaches can and should be utilized!—is fostering the mind-body’s natural capacity for healing and resilience. Thus, it’s not just a matter of diagnosing what’s wrong and addressing that. Equally important is the challenge of strengthening the person’s ability to get in touch with liveliness, creativity, spontaneity, positive thoughts, more constructive interpretations, nurturing social networks, and so forth. There has been a movement in psychology in the last fifteen years called “positive psychology” that in some ways refines and carries forward the insights of humanistic psychology.

Humanistic psychology was popular in some circles in the 1960s and 1970s because it emphasized those qualities that only humans could do—using imagination, creativity, empathy, meaning-making, spirituality, more complex skills, and the like. It emphasized what Freud might have called the power of “sublimation”—though they might not have phrased it thus. (Humanistic psychology was a reaction to, on one hand, the reductionistic “rat psychology” of the behaviorist tradition in academic psychology in the 1920s through the 1940s, and on the other hand the reductionistic—in another way—psychoanalytic approach that viewed the problem as the human need to civilize primitive and essentially antisocial drives.)

Positive psychology, building on humanistic psychology and other developments, needs to be woven into a comprehensive view of psychology. We’re not talking merely about “integrating” different schools, but rather about developing a more comprehensive meta-model—interestingly, more like the way modern medicine is expanding to take in all sorts of new horizons.


Speaking of modern medicine and biology, advances in neuro-science must be included in this broadening of the scope of depth psychology. One set for consideration involves what John Ratey around 1995 called “Shadow syndromes" (in a book with that title). Might there be ten people with sub-clinical syndromes for every one with a clear-cut criteria-fulfilling syndrome? And might these subclinical syndromes nevertheless be  remarkably responsive to medical treatment? What if at least half of such people are in conventional psychotherapy and not responding well because of conservative attitudes that won't allow a trial of medication? (Examples of “shadow syndromes” mentioned by John Ratey in his book on this topic include subclinical bipolar, hypomania, ADHD, dysthymia, PTSD, obsessive-compulsive neurosis, schizophrenia, and so forth.)

Vocational Problems

I suspect the lack of vocational counseling processes as part of mainstream education reflects a widespread ignorance (among professionals) regarding the prevalence of ignorance about the issues regarding vocation: What are one’s natural strengths and weaknesses, authentic preferences versus what seems to be the prevalent fashion, and realistic awareness of what different vocations involve? I have no doubt that this influence distorts realistic thinking.

Competence tends to be thought of as an all-or-nothing matter, for example, whereas in reality a given job may require a goodly number of different types of competence. Often people may be competent at some of these, but this competence may mask a lack of competence in certain other role components, and marginal competence in yet others. In turn, struggles at work may be experienced as confusing, because the analysis of difficulties may be lacking. Many managers may have as much trouble as subordinates in clearly analyzing and tactfully coaching workers.

Can a worker arrange to delegate certain areas of weakness to a co-worker, and take on in trade certain other role elements? (This kind of trade-off is common in marriages.) I think that a good deal of stress arises from lack of awareness of one's own weaknesses as well as strengths, and from troubles at work due to these patterns. Yet unless such matters were carefully investigated, how would one even know?

Social and Psychological Ignorance

I further suspect that sheer ignorance of simple principles of psychology, lack skills in relating, and the lack of adequate modeling, might account for a not-insignificant part of psychopathology, just as a lack of knowledge about cleanliness and nutrition can lead to ill health. Those who would attempt to do a more analytic approach to therapy without balancing it with a psycho-educational component therefore cannot offer a holistic or perhaps even successful treatment. Part of the problem here is that many people with some psychological education are not differentiated from those without this knowledge. For example, a recently fashionable approach, Marsha Linehan's Dialectical Behavior Therapy (DBT), involves the building of skills as well as elements that are more like traditional therapy.

Asking Specifically About Issues

Unless the therapist or diagnostician asks specifically about various relevant issues, it is unlikely that the client will volunteer information. Most people take these life situations as implicit. Sometimes they think, “Doesn’t everyone do this?”

For example, taking a history that asks specifically about spiritual conflicts; feelings of meaninglessness; vocational confusion; sexual issues; and the like, may well not be brought up by the clients because of culturally-influenced shame. The non-directive approach only works for milder problems and for healthier, more psychologically-minded clients. For example, I know of cases of people in analysis who never talked about low-moderate grade sexual abuse in their marriage because they (a) assumed it wasn't all that abnormal; and (b) it would be disloyal to talk about such things. Ditto with problems with previous therapists. etc.


What else should be added to this list? Again, merely seeking ways to integrate the main schools of therapy may not be sufficient to address the wider problem: What other dimensions, issues, concerns, and dynamics need to be included in our advancing theory and practice. Sometimes these are brought up by recognition of a new type of client, sharpening a diagnosis, and sometimes a new type of treatment opens up a reconsideration of not only who might benefit, but what is there about this new treatment that might inform our understanding of the basic dynamics of those whom it benefits.

I hope readers of this paper will email me and suggest more comments and suggestions. If the ideas in this paper are true, it might suggest a more useful way to approach the frontiers of theory and practice in our field.