Adam Blatner, M.D.

 May 17, 2012
  Supplement to a lecture given at the Senior University Georgetown's Summer Program, June 4, 2012)

The following are various comments that occurred to me to supplement what I said in the talk. The field of psychotherapy has evolved a lot, and I wanted to catch you up on some of the trends. Second, I want to fill you in on some of the issues that have come up, because they are exciting to me, at the forefront of culture. Why are people getting stressed out? And what are they seeking in therapy?

First, I’m sorry to report that a goodly percentage don’t care much about the why—or want to find a simple object to blame—not their own faulty thinking and valuing—and basically they just want relief—symptom relief—which does nothing to address the underlying condition in many cases. Occasionally that’s all that’s needed.  But most often, people need to realize that they’d be crazy if they weren’t feeling crazy. That is to say, they’d be foolish to deny that anyone with the stresses they have piled up would not be feeling confused in their minds. Even if the stresses were obvious—and often they’re not—the confusion comes from the mistaken belief that they should be able to cope, everyone else does.

First of all, everyone else is not coping. Most folks are just quiet about it and able to continue some social facade of normality. Lots are on medications. Others are suffering and that may be contained within family dynamics, but spouses and other relatives may know and are suffering, too. There are all kinds of ways this is playing out.

So psychotherapy for lots of clients involves a very iffy mixture of saying you want to change but not really, an ongoing negotiation. Lots of clients just want to complain about what seems like a host of various stresses, hurts, disappointments, accusations of others’ having unrealistic expectations—indeed, I’m reminded of Hamlet’s soliloquy, the one that starts, “To be, or not to be.” It’s a meditation on suicide, and why not. He says:
    For who would bear the whips and scorns of time,
    The proud man’s contumely,
    The pangs of despis’d love,
    The Law’s delay, the insolence of office,
    The spurns that patient merit take of the unworthy;
    When he himself might his quietus make with a bare bodkin?
  – that last line means, when he could just ease himself out with a knife to the heart.
All I’m saying here is that life is tough and there are lots of reasons to feel down, anxious, depressed.

And psychotherapy can’t guarantee that it can be made all nice. What it can do is offer an opportunity to make choices a bit more consciously. I note that good choice making involves three components: First, you don’t rush into it or avoid the decision-making. Second, you make a real effort to weigh the pros and cons. You can never do this perfectly, but you can make a reasonable effort. Third, you get impartial consultation. If it doesn’t work out, you did better than most in trying to decide—truth is you can’t know all the variables perfectly.

Adjunctive Therapy

Adjunctive means in addition, and some times the in addition is the main thing. If a soldier gets his leg blown off by a land mine, then surgery is the main treatment, and maybe blood transfusions. But in fact it’s the physical therapy, and then prosthesis, the artificial leg, and then the occupational therapy, and the psychology needs to be going on throughout, maybe in no way like psychoanalysis, but still looking at what needs to happen to support the patient’s spirit, morale, family relations, and the like. Even if the therapy is mainly performed by the physical therapist and the social worker who works with the soldier’s family, too, it’s important—and in the long run, might well be the most important element.

Now I’ve come around in my thinking to look at major mental illness as being as catastrophic, as life-changing, as scarey, as grief-filled, as a stroke or having your leg blown off, or both legs! And of course therapy is needed to address the psychological elements here. In the past there was a naive assumption that healthy people could cope with such changes, but if you look up close, what was going on under the surface for our parents was simple containment, not healthy working through. They put a lid on it when they could, which was mostly. Often it took a bit of numbing alcohol to help. Their families suffered, but the bottled-up (in both meanings of that term) guy wouldn’t admit openly that he was up-tight and sitting on turbulent emotions— wouldn’t admit it to himself, either. Our parents generation had a lot of subtle what we today recognize as PTSD. 

So psychotherapy helps in supporting recovery, even if it isn’t the main treatment.

Mild Neurosis

The problem psychiatrically is that there are three levels.

Today I’m going to talk about the current history of psychotherapy, especially the changes in the last century, and more so in the last fifty or so years. I’ll acknowledge some pioneers but give more time to recent trends.

Psychotherapy is mainly talk therapy, or what I did, which was to add some measure of role playing, action, a touch of drama. There are also approaches that use art or music or other media. But psychotherapy is not using medicines, nor other physical modalities, nor using a hospital as a place of retreat, or restraint—those are not psychotherapy. Psychotherapy seeks to change mood, thinking or behavior through talking, mainly. It can happen one-to-one, one client, one therapist; or with couples; or with families; or with groups! And the point I’ll make today is that what goes on in therapy is way different from the cartoons of the guy on the couch!

Things have changed a lot, certain trends having diminished, other trends having expanded. Also,  all this has been happening in a culture that is likewise changing. Indeed, the field of psychotherapy as it has evolved mirrors in interesting ways the other facets of culture change.

So the purposes of this talk are several:
  - to catch you up on what’s been happening and break you out of old and outmoded stereotypes
  - to sensitize you to the meanings of the trends more recently—their significance
  - to warm you up to some of the issues involved.

The Process of Dialectic

That fancy word refers to a process described by the philosopher Hegel almost 200 years ago, a process of thesis, antithesis, and synthesis: which means somebody gets a bright idea and someone else criticizes or even fights against it; and eventually some other person —and rarely the same person—struggles with the struggle and comes up with a resolution whereby both sides get to be at least partly right—the synthesis.

I find this process throughout history in almost every field—as did Hegel—and it helps to think of how things evolve. It’s not just one doggone thing after another. One king fighting another king and now the peasants work the land under one regime and later they work under another regime—maybe a little better, maybe a little worse. That indeed typified large chunks of history for large numbers of people. The idea of progress is relatively new in human history— a few hundred years old and accelerating in rate of change, in part because the that rate of deep change has become far more rapid and discernable within one’s own lifetime.

In a few decades I’ll tell my great grandchildren, When I was your age we psychiatrists used to talk with patients. They’ll say, No way or whatever is current slang. I’ll say, yes! We even used to listen!

Psychotherapy has changed. And I’m a dying breed: Psychiatrists who were especially interested in psychotherapy, talk therapy, not so much medicines. Oh, I appreciate how much good medicines can  do when used wisely—which they aren’t always—but how can you help patients come forth into the world?

And even though I’m mainstream enough to get into a higher category of academic and professional acceptance, I’m also maverick enough to have straddled the arena between psychoanalysis and biological or pharmacological psychiatry.

Iatros   psych-iatros, refers to physicians. I’m an MD who then specialized in working with people with mental illness. Psychologists and counselors had different backgrounds. Psychiatrists had about 8 years post-graduate work, most counselors have about 2 and psychologists have about 4. But psychiatry as a field has retreated from the practice of psychotherapy—for many reasons, mainly that insurance companies won’t reimburse them with near as much money as they could make from seeing patients for consultations for being on medicine. I won’t go into the rant about what this has led to.

I got interested in a particular type of psychotherapy called psychodrama or using role playing in psychotherapy—and to understand it better, I became an amateur student of comparative psychotherapy of all sorts—there are hundreds of different approaches—and secondary to that, became interested in the whole endeavor. How does talk alone or mixed with art, drama, poetry, physical exercises, and such help?

Now that I’m retired , why am I still interested? Because whatever works has transcended the boundaries of treatment of sick people in a sick social role in a medical model. Even those models are outdated and there are new ones, such as the recovery model. There is also personal coaching and ways to help healthy people become even healthier, more resilient.

Indeed, what we’ve learned is that what used to be called psychotherapy has always worked better on people who were relatively healthy, and it never worked very well for people who were much more severely mentally ill. And for those in-between, it worked some.

For those who were more severely disturbed, for a while there just wasn’t much that could be done—about 65 years ago. There was electroshock or electro-convulsive treatment—that really worked well for some patients but not others—really, though, those and others that give me the shudders were just ways to calm people down. We didn’t know what was going on. We still don’t know that much, but there are a number of medicines that work better than anything before—actually, several generations of improvement—for many conditions, but not all. And even so there is much that remains mysterious. But all that is not psychotherapy, which involves non-physical means, psycho- referring to the mind, what we can do to modify the way people think.  That last part interests me.

It applies to education and healthy child-rearing, how we run our businesses and how we run our culture. Now there are therapies that work in couples, families, and groups—it’s not all one-to-one any more.

The other point I want to make is that there is a creeping rise in people’s expectation. In our own lifetime the expectation has shifted so that there are more refined ways to raise kids other than hitting or intimidating them. Bosses who just scare and yell at their subordinates are no longer imagined to be forceful—they’re considered jerks. And so forth—lots of general social standards have shifted—they’ve raised the bar on what is truly civilized. So I see the general process of what I call “psychological-ization”—becoming more psychologically-minded—more empathic, more sensitive—happening in marriages, in people’s expectations of themselves, in many churches—and so forth.

I don’t see much psychology happening on the public scene yet, on the political scene. Primitive rhetoric is not that different from fifty years ago. Being out-front bigoted is less respectable, but many people still feel quite entitled to maintain certain prejudices. Ironically, one of the greatest pockets of resistance to liberalizing laws about homosexuality come from churches that are mainly part of the African-American subculture.

Anyway, the point here is that psychotherapy has been changing as much as many other fields, from computers to medicine. Yet there’s a major lag in public perception—major! This is partly the fault of cartoonists! The psychoanalytic couch has been an ol’ standby and about as unrealistic as the tiny desert island theme. And much of what can be shown on television—the few shows that have featured psychotherapy, tend to be more psychoanalytic, with the therapist being silent and letting patients thrash around in their own mind-swill.  I never liked psychoanalysis especially for this phony passivity.

Now many people who do therapy use a more active approach, partaking of cognitive therapy, which really prods patients to think a bit more logically. I generally approve of this, but I deny that this one type of therapy does the job for all patients, or does enough of a job.

There are many facets to bringing people forth. First, that’s the way I think of it—not just fixing them, or relieving symptoms, but raising consciousness, helping them to be more mentally flexible and able to cope with our changing times.

This is not easy—the second point has an associated lightbulb joke—remember those, around since the 1970s?—How many psychiatrists does it take to change a light bulb. Answer, only one,  but—big but—the light bulb has to ask to be changed. Ha ha.

Actually, probably a quarter of all the people who have been exposed to treatment have been forced into it grudgingly, often remaining in denial—there’s nothing wrong with me! People in substance abuse programs who have been sent there or go to jail; teenage delinquents in youth centers. People supposedly in recovery who never really accepted that they were sick to begin with. Others, maybe another half, want symptom relief, not to feel so depressed or rage-filled or anxious, but if one held off on the prescription pad and inquired about their life, they’d be crazy not to be so crazy! What I mean is that any outsider looking at their life is likely to say, “Whoa! If all that was happening to me, I’d be just as up-tight or more so!”

An eminent psychotherapist observed about 40 years ago, lots of people don’t really want to get well so much as just to get by better with the ways they are sick. Their attitudes and goals and the systems they are trying to work within are often full of stress. So we’re talking patch jobs, crutches, what can keep them going. Sort of like in the military in the 2nd world war, lots of soldiers or pilots used amphetamines to keep alert on extended-fatigue missions.

Social Madness

Let me say right now that part of the problem is that we live in a culture that has come to a rough balance with its own madness, its own gross inequities. We feel that we have earned fully our way to whatever the haves got, and the have-nots have simply failed to try hard enough. That this belief, this complacency, is full of holes, is something that the mainstream—who tend to be more articulate than those who are pushed to the margins, the marginalized—believe. It’s a sort of “I’m alright, Jack” attitude—a phrase used by some English unionists when their own financial and economic security had been established even if that puts others out.

Programs that overwork workers, under-pay workers, and so forth are part of this system, and overwork and other social pressures are not yet recognized as major stresses. Nor is getting fired after years of work and how profoundly that can mess a person up.  You probably have many stories of friends and family where part of the stress is the sheer feeling of the injustice of it all.

But since we can’t change it, we need to do that self-delusion satirized by the play, Candide— that this is the best of all possible worlds. It isn’t. A good deal of the stuff that must be addressed in psychotherapy—and please note that it often is avoided!—has to do with the unspoken and spoken rules of politics, economics, religion, social expectations, and so forth. But that avoidance only adds to the patient’s sense of feeling crazy for feeling bad about what others seem to be putting up with just fine.

Increasingly voices have been raised about this, and operated on the outskirts of the profession for seventy years or more. But they are kept in check with the myths of adjustment and normality. The feminist revolution had to fight against the use of tranquilizers for women who were getting weirded out by the madness of the nuclear household, the isolation, the lack of rewarding work, the mind-numbing challenge of living with kids of any age, and not getting wiggy. But of course,  many did get wiggy and were helped to adjust by a prescribed equivalent of booze.

The Concept of Synergy

A way to appreciate the art of bringing people forth is to recognize that it isn’t just one technique, but the power of mixing many approaches, all of which support the others. This happens for the better or for the worse.

For the worse: The concept of co-dependency was recognized more vividly in treating alcoholics,  but then we realized it applies to all sorts of problems. If others are doing the same thing or are in any way unconsciously benefitting from your problem-behavior, those others will mostly unconsciously reinforce it, make excuses for it. The spouses of some alcoholics would participate in not only the denial system, but buy them a bottle of booze for their birthdays! Bailing out, rescuing, hushing up, many of you have had relatives and friends who’ve gone through these cycles, and they’re often noted—once the field caught on—in all sorts of related problems.

For the better, getting several people who admit it openly to participate in helping each other—self-help groups—not just Alcoholics Anonymous, but all sorts of groups—the mutual effort to move towards wellness—literally, in eating the right foods, avoiding junk foods, etc.—such programs are now going on in some large churches. Government programs were relatively flourishing for a short time in the late 1960s, the community mental health movement. Great hopes. Then funding got cut and cut again, because these people were political outsiders, easily marginalized, lacking sufficient political clout. So that’s drying up. But people need to help people, and we are only lately beginning to emerge from a fiercely individualistic pull-yourself-up-by-the-bootstraps culture.

This happens not only in tribes and teams and orchestras, but in marriages and other settings. I note this to also call to your attention that our culture and educational system profoundly distorts the obvious truth that folks are better at some things and worse at other—that there are major distributions of talent as well as temperament.

Most people have been raised as if they could do everything well if they only tried, and there have been few voices suggesting that this is profoundly crazy. The degree to which effort can compensate for a lack of talent is vastly overestimated. Our industrial work has made work sort of mechanical, and has treated people as robots. This is true also for the role of housewife! Many of you are discovering or feeling safe to admit that certain traditional role components no longer fit your tastes, interest, or temperament, if they ever did to begin with. My wife has hated dishwashing—I like doing it—it hurts her back and bores her—I’m okay with it, etc. Other roles that don’t fit the traditional what men do and what women do or at least they should do—are getting re-negotiated. Some fellows discover that they love to cook. And so forth.

Back to the point that there are scores of phony elements like this throughout our culture that people are only beginning to speak up about—and that not speaking up and accepting the traditional, and generally small minded rather than enlightened view of traditional roles—has accounted for a signifcant amount of stress, tension, and misery.

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