Adam Blatner, M.D.

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

My goal is just to give you a brief overview, perhaps to dissolve some stereotypes that all psychiatrists are psychoanalysts and use couches, etc.

In fact, the field has been as varied as the history of computers or medicine or other major developments. There have been swings of what’s in fashion and what’s out. So here goes.

2. I’m a psychiatrist—The Greek word-root iatros in the word psychiatrist meaning physician—not a psychologist, ology means study of.

3. Other Dimensions of Psychiatry: Psychiatrists did before managed care organize hospitals, clinics, how health delivery services would be organized. They did the kinds of talk therapy that is most of  psychotherapy, but they also did a lot of other treatments.

4 In the 19th century and early 20th century, not so much, but in the mid 20th century, psychotherapy was a big part of psychiatry. Organic psychological organic pendulum swing:
One of the changes that has happened in the realm of psychotherapy is that most psychiatrists have retreated to being more caught up with brain-neurology and with treating the brain with various medicines. In a way that’s been good: Talk therapy hasn’t been found to be particularly effective with the major mental illnesses and continuing research on these conditions is important. However, there are a fair number of the old-time psychiatrists who went into this field because the mind itself is so very fascinating.

 5  But during much of the mid-20th century, psychiatrists were involved in understanding the psychology—the workings— of the mind and its relations to the social network, since this was considered a major factor in mental illness.  So being a psycholoGIST is a type of discipline, but we all do psychology in a sense whenever we wonder why people behave as they do. During this mid-20th century talk therapy was considered a major element in psychiatry.

6 .Types of Psychotherapists.  I made this slide in the early 1990s:  Alas, many psychiatrists have retreated to the arena of physical treatments, evaluations for and adjustments of medications and other types of treatment. I have a friend who’s exploring magnetism’s effect on depression. But this is not psychotherapy. It’s therapy, pharmaco therapy, other treatment, but psychotherapy is now for the most part being done by non-psychologists, often by counselors whose training was as counselors. We won’t go into the politics of all this except to say that many of the pioneers in the first and middle part of the century were psychiatrists, M.D’s, and increasingly advances in the realm of psychotherapy are being made by more experienced psychologists and other non-psychiatrists.

7. Psychotherapy iis helping people.. Talk

8. In a larger sense, it partakes of the art of bringing people forth into their highest potential..
 (Network of People-Helping)
      Even though I’m retired from clinical practice, the art of bringing people forth continues to interest me. It applies in a larger sense to parenting, teaching, leadership in general, coaching, skilled management, and other roles. I think these have something to teach the field of psychotherapy, and psychotherapists in turn have something to teach the larger society.

   So to repeat, many psychiatrists, although not professionally accredited within the academic field of psychology per se, still were dealing with psychology insofar as they really explored how the mind works. Indeed, in England, psychiatry is often called medical psychology.

9.  I heard a colleague say once, “Life is the greatest show on Earth, and physicians have front row tickets.” I thought to myself, “Yeah, and psychiatrists get to go into the locker rooms and interview the players!” It is to me the most fascinating, endlessly fascinating field—and the mysteries continue aplenty.

10. As I say, the art helps us know how to bring people forth in other ways.

11. Psychotherapy, helping, an art..

12. Supplement on Google..

13. So to warm-up. I’ve been interested in comparative psychotherapy, what all these approaches have in common, how they differ. I assisted Zerka Moreno in presenting psychodrama in 1985 at a big ol’ conference of psychotherapists of all sorts back in the later 1980s. Here were some of the pioneers in the field at the time. I’ll tell you more about them as I go on.

14.  An approach I will use is to note how these alternatives play off psychoanalysis. Dialectic is the name of a process where if one person says A, someone else may say not A, not only A, Mostly B, all sorts of alternative statements. It keeps conversation moving along. Then A needs to expand what he says to include his anti-thesis, or treat him as an enemy, or someone else comes along and says here’s how both A and B are partly right— a synthesis.
       So this gives the discussion a bit more than just a list of and then there was...
 Because we continue to explore to clarify what really helps and how.

15. It’s a big field, and there are stories within stories. This is also on my website.

16. Part of the problem is that by the late 1980s there were hundreds of therapies. You don’t hear about them so much because evidence based methods have squeezed down what insurance companies would pay for in a way analogous to the pressure for marketing produce has reduced the variety, ripeness, and taste of many vegetables and fruits.

17. Of course, the problem is that the mind is even more complex and mutli-faceted than an elephant. All of the theories are a little bit right, some more so for some people some of the time. All of the theories and methods don’t cover every eventuality. So the parable of the blind men and the elephant applies to not only religion, and psychotherapy, but all forms of reflective philosophy and psychology—and these categories overlap also with sociology and anthropology and other fields.

18. I like these words of Carl Jung— he wrote them in a foreword to another book—not important. What fits is the awareness of the way knowledge, fields, studies evolve. We don’t have a hero who makes a discovery that is sufficient and stands for all time. We open a door and then explore beyond, building beyond. Sometimes the pioneer makes mistakes that need to be rectified. The process of dialectic, refinement, and extension continues.

19. So here’s how Sigmund Freud progressed. We’ll start with him and with psychoanalysis. He may have been wrong in many ways, but he opened some doors that were ready to open, mainly the idea of let’s look at our thinking, our illusions, our tendencies to self-deception.

20. Here are some of Freud’s points. They were compelling to a number of folks back then. I don’t agree much with them, but I do agree a bit—and that bit is very important.

21.  What many may not know is that psychoanalysis did not remain static or orthodox. Like the US Constitution, the amendments may be as important as any element in the body of the document—like the Bill of Rights or the rights to full citizenship regardless of race.. That sort of thing. Another analogy lies in the ups and downs of what people take to be Christianity, and others argue about. So too, psychoanalysis has undergone a good deal of reorientation — most psychoanalysts don’t get much into Freud’s original theories.

22. Early on Carl Jung split off. Jung was going to be Freud’s picked successor, but he ended up being too independent-minded and Freud kept imagining that these were symptoms of rebellion rather than creative thoughts beyond his own knowledge. I imagine Freud feeling, “But it feels so right, it can’t be wrong (in Debbie Boone’s You Light Up My Life song) ... Carl can’t mean to suggest that I am (gulp) limited.” Yes, I think Freud was a bit to attached to his own theory to let other possibilities get developed within his organization.

23. Anyway, Freud did organize and that gave him a leg up and then some over those colleagues who didn’t create organizations. This is a big part of history. If Paul hadn’t organized it, would Christianity survived?

24. Here are some of that group during the second decade of the last century.

25. Alfred Adler was also a favorite of Freud’s and also an independent figure. Freud thought of himself as a father, but Jung and Adler thought of him as a pioneer with good ideas. Father was stretching it a bit, except in Freud’s own imagination. Anyway, I think Adler had some wonderful ideas that flesh out depth psychology a lot! He was more social and more aware of the power of social embeddedness. Mainly, he advocated the best example of healthy thought—community feeling, we-ness— Adler of course had a German word, Gemeinschaftegefuhl, a feeling for the natural social group, a desire to be helpful rather than competitive. I agree that this might be the key shift that helps us back into sanity as a culture.

26   Melanie Klein, a pioneer of plsy gtherapy ...infant psychology    A bit weird   had her own family and professionally arbitrary ideas.

27 Otto Rank was with Freud through his mid years, helped as secretary, but also began to have ideas that were a bit too independent and he too dropped out of the mainstream but continued to talk about his approach for another decade or so. Ya think maybe it wasn’t always their fault?

28. In the 30s another loyalist turned sour. Wilhelm Reich made a major contribution in noting that people can armor their whole body—that neurosis was a psychosomatic process. Like “up tight” in different ways. He was very right. But then he veered off thinking that libido, sexual energy, was vitality and needed to be channeled orgone, and that’s a whole story of his being persecuated in the USA for being a phony by the food and drug administration..

29. The stor of Freud’s escape from Vienna after the Nazis took over is good, sad. Moreno was already bitte, in pain fro a cancer of the palate from habitually smoking his schimmelfennig cigarillos.  

30. The interesting thing about how it and a bunch of central european psychoanalysts came over to the Usa is that meanwhile the doctors’ lobby was just getting their act together. There had been an infusion of emigrees, psychiatry was feeling its oats, other specialties had been getting organized, and they passed a rule that only psychiatrist mds could be psychoanalysis, as if to say, don’t try this at home. I won’t get into it but I think it was foolish, and beginning in 1960s increasing numbers of nonMDs were allowed to join and in the 70s the psychoanalytic associations gradually became mostly non-MDs.  The reason this is important is that psychoanalyiss became th hot big thing for treating major mental illness, since other approaches seemed not to be that effective.

31. Meanwhile independent minded psychiatrists —one American , two from Europe— developed more popular forms of psychoanalysis----they were called “neo-Freudians.  I don’t know how to describe it—not like the protestands versus the catholics in the 16th century, but maybe like the methodists versus the anglican-episcopalians.

    Two points   These folks infused some fresh new ideas and kept the momentum going. For the next twenty years psychoanalysis was the hottest intellectual frontier—also in literary circles! The best and brightest medical students were attracted!

   Sullivan had more of an awareness of the interactive process and moved towards making our understanding a bit more embedded in social psychology.. Not the couch but talking.

32 Karen Horney did a lot of things— broke out of the not really anti-feminist but low awareness of how women really worked, and popularized psychoanalysis in several books. I found her relatively readable and somewhat sensible as a teen.

33. Erich Fromm was important because he made a bridge to humanistic psychology, was willing to criticize psychoanalysis and also appreciate it, and noted some cultural dynamics such as the temptation to have, to possess, rather than to live.  I’ve found his work thought-provoking, because he invites us to question some of the economic and political cliches that are driving us to the edge of ecological unsustainability—though he wrote before that danger appeared..

34. Otto Kernberg became more prominent in the 1960s writing about how patients get caught up in expecting the worst from others and whaddaya know, they subtly set it up so they get it. Like sullivan, it emphasized a school called object relations—a misnomer, because people aren’t objects. But the root was the object of my affection .. And how we sort of imagine both sides unconsciously. I’m gonna sit write down and write myself a letter... 
Indeed, during the 1970s a lot of attention was being given to very difficult patients who left their analysts feeling ragged and jerked around. They were called “borderline” because they weren’t really crazy, but they weren’t mild neurotics either.

35, so here’s this chart again and the point is that the field is dynamic and there are cross influences, and people trying to resolve the tensions—remember the dialectical— and my point is only that it wasn’t a one-dimensional orthodoxy but a lively and unfolding history.

36. And all that is just psychoanalysis. Meanwhile, the field was spinning off other branches—that old dialectic process. And like biological evolution, there was cross-fertilization from other fields.

37. Behaviorism—this was not a therapy to begin with, but a way of thinking about psychology that had been popular in academia.

38. It sort of began with Ivan Pavlov in Russia around 1905 who wrote about how ringing a bell could become a conditining stimuli that would make a dog salivate even if it didn’t see the food.
            There’s a whole sub-discussion about how behaviorism became fashionable in child guidance in the 1920s and don’t spoil the child messed us up and Dr. Benjamin Spock’s baby and child care saved us. Yes, you could pick up your baby, mothers!

39. Operant conditioning. You can teach all sorts of things by making the steps small enough and rewarding each effort. There are some good principles here and it led to a real movement in psychotherapy in the 1960s. You could teach pigeons to play ping-pong.  It was used in working with autistic and retarded kids.

40. It’s called behavior therapy, but really it comes from another angle. It’s hard to be scared if your relaxed. So an MD psychiatrist mixed relaxation and imagination training and fought against anxiety attacks and phobias. Worked well for well-defined cases.

41. Albert Bandura brought in the power of modeling. What I like here is that within the protected socioeconomic cocoon of academia and psychotherapy during a time when those professions were still respected, desirable, and esteemed—and not yet subjected to managed care— many approaches were devised—these are only a select few. And one of my points is that what we learned in this fertile period applies to bringing people forth, parenting, teaching, managing, how we work with people well beyond the clinical context.  And that’s my special interest.

42. So the point of dialectic is that people by the 1950s and 1960s were playing off of psychoanalysis—it was too individual oriented, let’s include families and groups; it was too depth-imagination, let’s get some principles of learning; it was too this or that, let’s correct those lacks. That’s the good thing about dialectic as a general process.

    Existentialism is an umbrella term for a cultural movement we all heard a lot about. Problem was that all these folks hardly agreed or had an organization. What they shared was a glimmer of awareness that people were creating their own overall meaning systems, and often those did not fit well with the interpretations of psychoanalysts of any school, or behaviorists. What you needed to do was find what the client’s own language was and work with that. Withhold preconceptions!

43. Viktor Frankl emerged in America as one who survived the Nazi concentration camps, and his thrust was that attitude is important. Lots more people are talking this way nowadays, but back then it was kind of new. If bad stuff happened, somehow it was okay to be not just grumpy but a bit nasty. Let’s look at that. The more you are grumpy, the more bad stuff happens? Coincidence? I think not.  He had a lot of other things to say and teach and again several sessions could be given over just to his ideas.  And that’s part of what attracted me. This ferment was exciting philosophy and also applicable in how we live our lives. What a combination!

44.  Another dialectical tension playing off from psychoanalysis was that the one-to-one session was by no means the only way to do it. Accelerated by the pressures in the VA in dealing with WW2 vets, more attention was given to the power of the group, the power of people to help each other. The problem is that the therapist was a bit more out of control, which was hard for some.

45   It was probably no coincidence that AA got started during these mid-20th century decades. People can help each other.

46 Jacob Moreno was one of the pioneers. He not only wanted people to help people, but he used a kind of role playing to keep them involved with each other, calling it psychodrama. I’ve written several books about these methods.

47. We need to mention hypnosis, which was perhaps the first kind of psychotherapy 200 years ago, and was used occasionally. It hasn’t caught on widely enough because I’m not sure why. It may be hard to teach, to get the knack. I have no doubt that the psychology here is very important, and some folks occasionally get that knack, and try to teach it. That Freud used it and then stopped using it probably inhibited research in this, but I think it’ll come back.

48. Milton Erickson was a genius. A physician, psychiatrist, paralyzed below the waist, fascinating man, often he hypnotized in subtle ways without the client realizing it. Not a matter of sleep, sleep, but other suggestions. I don’t know how to summarize this except to note that there is much more to be learned in this field.

49. Here is a slightly enlarged phot, and to the upper right is a young man—not so young now—who has been organizing these conferences and probing the nature of people-helping, Jeff Zeig.     Judd Marmor was at the hospital where I took my internship and I picked up a little of his spirit of modernizing psychoanalysis. Others to be described later.

50. Now next is another example of dialectic, of reaction to what many felt to be foolish constraints of psychoanalysis and also behaviorism

51. From this perspective, the emergence of a third force in American psychology, Humanistic Psychology, was in a sense a dialectic antithesis to psychoanalysis and behaviorism. People in this camp considered both the first and the second forces were too reductionistic, psychoanalysis resting too much on early life impressions— a psychology of the child. Behaviorism was a psychology of the rat. What about higher aspirations? Are they to be brushed aside?  Not if these folks had anything to say.
52. Abe Maslow  was a brilliant and analytically trained psychologist who saw beyond the limitations of analysis.

53. Rollo may is another important thinker—these guys as I say speak to the problems of our time, of meaning making. Humanistic psychology draws on existential psychology. One could easily devote a few hours to each of these figures and their writings and efforts.

54. Carl Rogers is yet another who also helped build a bridge to the group, to the encounter group. My wife once took a summer internship in Pittsburgh with the other Mr. Rogers with the cardigan sweater on the TV show, you know, he really is as nice as he seems on television. Anyway Carl is also an authentic nice what you see is what you get. He also began to ask what is really essential for therapists—being authentic was one element. So laid some foundations for analysis of what works in therapy.

55. All this fed into a mixture of group work, encounter groups, sensitivity training, some role playing principles, special places for holding these workshops— and was popular for about ten years between around 1965 through 1975, with a build-up and cool-down of the fashion before and after that period. Elements have continued to this day and I thought it was great.

  How many people here ever heard of a place called Esalen Institute?

56. Will Schutz wrote a couple of books and integrated a variety of methods with group work to make the encounter group process a meaningful experience.

57. At any rate, there was a proliferation of new types of therapy during this era. It was a heady time!  Over here is the encounter group which then fed into self-help groups addiction groups, Gestalt Therapy, Transactional Analysis, etc.

58. You might wonder if anyone was wondering about what was the underlying theme in all these. Was one right and all the others wrong, or what?  Hint: people have been more intensively exploring what they all have in common, and something similar has been happening in religion, too, but that’s another topic.

59. Okay, with the dialectic—remember ol’ Wilhelm Reich? He took psychoanalysis deeply into the way the body reinforces character—up-tight.
     60. Well Alexander Lowen built on this, didn’t get overly caught up in Reich’s other theories, and the field called “Bioenergetic Analysis” was born.

61. A number of body workers have learned about it, and you don’t have to be a therapist to consider ways to loosen up. Again, what I like about this proliferation is that they opened up new aspects of personal development that hadn’t been thought about by most people before—well, some, maybe, with dance-movement therapists.

62 Another major trend has been towards conjoint family therapy, conjoint meaning we see them all together. This and variations became increasingly popular in the mid-1960s.

63. Among these figures were a goodly number of people who explored family therapy from different frames of reference. It was a time when small group interaction in natural groups such as families began to identify pathogenic patterns—stuff we now call “enabling” when it happens in addictive families.

64. Nathan Ackerman was one pioneer, coming from psychoanalysis. A lot of these guys had been mainstream analysts, but also independent thinkers, and they drifted away from orthodoxy.

65. Murray Bowen was another and his angle was to notice how some parents in some families pushed their kids to be just like themselves. So he attended to the process of people becoming their own person. I have a theory that some folks don’t really get into recognizing what is more and less authentic about themselves until midlife and that’s what is going on for some folks who suffer from a midlife crisis. Or as one lady – a client—said to me, “I’ve always been somebody’s something.”

66. Virginia Satir became popular among counseling students because of her book “People-making,” and related approaches.

67 What I like is that she integrated the psychodrmamatic technique of making an imagined sculpture of the people in your network and applying that to families—i.e., family sculpture as shown here.

68. Jay Haley was younger and in Palo Alto when I came for my psychiatry residency and I found his book, Strategies of Psychotherapy enlightening.

69. Here some of them are in 1985.

70. Another noted figure was Salvadore Minuchin.

71. Murray bowen in right upper side.

72. Taking the theme of playing off psychoanalysis as a dilectical process, Eric Berne in the early 1960s was developing his method of TA, Transactional Analysis, which combined interpersonal work, a kind of what I think of as role theory, a reframing of id, ego and superego as the inner child, adult, and parent ego state, and exploring the dynamics of manipulations. Others around that time also wrote about “games”—not in the sense of nice play, but more unconscious patterns of manipulation.

73. Another approach that became popular in the late 1960s through the1990s was gestalt therapy, Gestalt being a German word for getting the whole feeling, feeling closure, completion. Fritz Perls was a scallywag and a brilliant but provocative character who impressed others. He used some techniques from psychodrama but didn’t generally acknowledge this.

74. Arnold Lazarus was one of the first to really articulate the value of eclecticism. Now it’s the most common identity of psychotherapists—less of a need to ally with only one system. I agree with this—to do so would be like the doctors of yore who bleed you for just about anything. As ol’ Maslow said, “Those who only know how to use a hammer have a tendency to treat everything as if it were a nail.”

75. Albert Ellis started off in the 1950s in New York where he confronted clients with their unrealistic expectations. He was pretty abrasive, but it worked in that culture.

76.  Later, no direct relation, another ex-analyst named Aaron Beck, realized that half of what was wrong with a lot of clients was the continuation of a number of bad thinking habits, and as long as these were operating, real change couldn’t happen. And insight wasn’t enough. Some actual practice was needed. What I’ve liked about Dr. Beck’s approach is that it was more educational. I would like all kids in the 10th grade to take a class—not as therapy, but just practice in thinking more logically.

77. Willam Glasser wrote several books on reality therapy, confronting young men and especially teenagers with consequences, etc. There was a positive and helpful mood that was present, the opposite of the cliche of the analyst behind a couch. All these folks used more direct dialogue approaches, no couch.

78.  Several psychotherapists found that imagining scenes vividly could move things along. This has become a staple of pop psychology and visualizing for spiritual prosperity, but back then it was radical.

79. Others that got more publicity than they deserve flourished for a few years , got some celebrities talking aboout how great it was, and then it passed. Primal therapy was thatl]]

80. During the 70s other therapies became more organized. For decades, centuries, asylum managers often had small groups that put on plays or made music or art, and it seemed to help. When mixed with Moreno’s principle of improvisation, these modalities in the 1960s began to help people find their own creative resources.

81. Meanwhile all sorts of specialized groups were forming. We have many groups in Sun City and clubs in Georgetown—getting together and sharing war-stories is common. Now folks find common cause with others over the internet.

82. I know I’m racing but the point is to give a bit of an overview. A related point is to get the sense that people have been probing so many different angles of what will be helpful, and a corollary is that different strokes for different folks—there is no one thing that works for everyone.
    Transpersonal Psychology grew out of humanistic psychology and will become stronger in the years to come: Although it was still not in intellectual fashion, some brave souls dared to support spirituality, meditation, mysticism—trans is beyond doing it just for your ego...
     And this can be integrated with a more liberal religious tradition, but invites the spirituality to be part of the healing and thriving.

   83. Meanwhile psychoanalysis has also continued to evolve and grow .

84. Positive psychology has been a trend starting in the mid-1990s and growing since then. It’s not enough to discover and work out the knots in your soul, to extract the weeds in your soul’s garden. It’s important also to plant healthy plants, to learn and practice skills of gratitude and other kinds of more positive thinking. I like this in general—I’m sure it can be overdone; Barbara Erenreich wrote an essay that gave me pause, but it really said that if the principle is applied in an non-discerning way, it’s just another slogan.

85. There’s new stuff on the horizon, books in our library, the field is alive, and a long, long way from the weird psychiatrist and the weirder client on the couch cartoon.

86 Implications of the Psychotherapies

87. Preventive psychotherapy—teach this stuff in the schools!

88. What will it take to support Cathy so that she can reflect>

89.  My latest thinking is action exploration. A category that includes many approcaches.

90. My friend Sally Bailey in Manhattan Kansas sort of saw this.

91. Here’s what I’ve been trying to put together.

8. Psychotherapy is the art of helping people through talk—my bias is towards using a kind of improvised role playing called psychodrama, or as I call it, “action exploration.” Others use art or dance or music or poetry—to think and feel more freely, and with less pain. I respect the place of medicine, but I also am aware that lots of folks suffer more because their inner programs or maps or how they put the world together is not as effective as it might be. So that’s where the job of people-helping comes in. This twist puts me out of the mainstream of psychoanalysis a little, but not yet into the biological. I’m sort of in-between, which has helped me to reflect on many different factors involved in people-helping.

9. For a supplement to this talk, Google Blatner Psychotherapy History and you’ll get much of this. This is a vast field and could fill a whole semester for those who really wanted to dig into this. What I’m presenting here is just an overview, in the service of cultural literacy. You’re not expected to remember a thing other than to realize that in the fields of psychology, psychiatry and psychotherapy, lots has been happening, evolving, and in a larger sense, this reflects shifts in the world-view that’s happening in our life-time, such as from a more reductionistic and mechanistic view to a more holistic world-view.

10. The field has evolved a lot in the last century. The mid-part was dominated by Freud, the post-Freudians, psychoanalysis, the couch, weird theories of what the mind is about, and so forth. And although that peculiar approach gained dominance for a while in the field, it never actually involved more than a minority of the profession. Maybe 20% max were accredited as psychoanalysts around 1958, which was close to the apex of this trend, and another 50% sympathetic, but not formally trained, but lots has happened since, and now it’s less than 5% accredited and most psychiatrists are hardly sympathetic with Freud, although a few of his ideas have held up to further research. We are largely consumed by irrationality, though not in the ways he described. Back to that later.

I’ll be talking about psychoanalysis as a core from which others diverged or contrasted themselves. I myself am part of a stream that contrasts itself with the psychoanalytic technique but I appreciate many of the elements of depth psychology. It’s invigorating to be in the middle, but invigorating but also a bit slippery and difficult—people keep wanting to classify you in a way that’s are you with us or against us.

Okay, let’s carry on.
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