BROADENING THE HORIZONS OF PSYCHOLOGY
May 13, 2008
Adam Blatner, M.D.
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
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?
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
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
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
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
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.
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.
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.
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.)
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