Psychiatry: pro and con

I write this as someone who had a career as a psychologist in the mental health system, working within the scientific/medical model of psychiatric treatment. So, I’m not writing to reject psychiatry outright, but to examine its efficacy. I’ve written about the value and limitations of models in previous posts, and about what I call the “model muddle.” Models are just maps, helpful only to the degree that they’re accurate. No one model is demonstrably superior to all other models, in all situations. Every model has its limitations.

First, I’d like to distinguish between psychology, psychiatry and psychoanalysis. Psychology is the study of human behavior, and provides the basic theoretical structure for psychotherapy. Sigmund Freud came up with the concept of “the talking cure,” the notion that dialogue with a caring professional could help to resolve symptoms and treat psychopathology. Psychiatry is a branch of medical science, based on the concept that the accurate assessment of symptoms of mental illness can lead to an accurate diagnosis, which will result in an appropriate treatment. Psychiatrists are medical doctors who specialize in the treatment of mental illness. Freud was a psychiatrist, and psychiatrists who are trained in the system of Freudian psychotherapy are called psychoanalysts.

While I believe that psychiatric (medical model) treatment has helped a lot of people with debilitating metal and emotional symptoms, like any model, it has its limitations. Since the 1960s, the efficacy of psychiatric treatment has been questioned – with good reason. A primary critic was psychiatrist Thomas Szasz, who wrote The Myth of Mental Illness. Another psychiatric rebel was R.D. Laing, and yet another psychiatrist, David Cooper, coined the term “antipsychiatry.” Critics of psychiatry argue that mental illness/madness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. This core of criticism has led to the current antipsychiatry (alt. recovery) movement.

A primary criticism of psychiatry is that psycho-diagnosis isn’t rocket science. It’s imprecise relative to the diagnostic precision for most common physical medical conditions, and can be selective and subjective in its diagnostic criteria. Unlike with physical medical conditions that can be diagnosed by tests and procedures that reveal “markers” of a specific condition (i.e. pneumonia vs. tuberculosis), there are no such markers that distinguish schizophrenia from schizoaffective disorder or bipolar disorder. I’ve known many people with chronic mental and emotional disorders who have gotten a wide range of psychiatric diagnoses, over years of treatment. Ideally in the medical model, an accurate diagnosis results in appropriate and effective treatment. This is less often the case in psychiatry, because there’s more “educated guesswork” involved.

Proponents of the antipsychiatry movement contend that psychiatric treatment is all too often more damaging than helpful to patients. Extreme treatments such as prefrontal lobotomies haven’t proven to be effective; and the negative side effects of some psychotropic medications and mood stabilizers seem to outweigh the benefits for some patients. The term “iatrogenic effects” refers to treatments that do harm.

Another valid criticism of psychiatry is that it’s over-reliant on pharmaceuticals, and that the psychiatric profession has had incestuous ties to Big Pharma. I believe that, as a culture, we’re too dependent on medications as a panacea for health problems related to bad lifestyle choices. Drug company ads suggest that we can eat whatever we want and take pills to control any gastro-intestinal symptoms that result from a poor diet.

Having said that, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need to rely primarily on drugs as the default treatment for psychopathologies.

The concept of recovery from mental illness doesn’t necessarily mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom control or remission. There are recovery centers in cities around the country that offer alternatives to traditional psychiatric treatment, recognizing that community and peer support can be important components of treatment. Such programs don’t preclude psychiatric interventions, but don’t rely on them as the default mode.

Factors such as physical health, stress, social stigma, chemical dependency, poverty, homelessness and nutrition can all play a role in mental health and mental illness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that give people who have been labeled as mentally ill more autonomy and more options for resolving their problems.

You can find out more about the antipsychiatry movement, the recovery model, and alternatives to traditional psychiatric treatment at <>.



The meaning of dreams

We spend roughly one third of our lives unconscious, and when we’re asleep we’re unaware of our immediate surroundings. But sometimes during sleep, we’re aware of ourselves in a realm of illusions. We remain ourselves in our dreams; but the people, animals, places and things we encounter may transform.  A dream has a sequence of events but, unlike a story, it has no contrived plot. So, why do we dream, and what is the meaning of our dreaming? It depends on who you ask.

Dreams are regarded as sacred and/or prophetic in some cultures, and the interpretation of dreams is an ancient and widespread practice. In many cultures the interpretations have been made by priests, priestesses or shamans, proceeding from the assumption that dreams mean something in our waking lives. Many modern sleep scientists would disagree, believing that dream content is the result of random neural  firings, connected to memory retrieval. One theory about why we dream is that it’s the way the brain sorts and edits new memories for later retrieval.

The history of modern dream analysis in Western culture starts with the 1899 publication of Sigmund Freud’s The Interpretation of Dreams, in which he called dreaming “the royal road to the unconscious.” Along with free association, dream analysis was a component of Freudian psychoanalysis, used as a key for the unlocking of repressed thoughts and feelings. Freudian dream analysis has to do with themes such as wish fulfillment, unconscious desires, and anxiety related to conflicts in the dreamer’s life.

Carl Jung is perhaps best known for his concept of the collective unconscious. Jungian dream analysis is similar to Freud’s, in that it delves beneath the surface content of the dream as described by the dreamer (latent content), to explore the unconscious, symbolic meanings (manifest content). Jung’s system differed from Freud’s, in that Jungian therapists related the dream’s symbolic content to universal mythic themes in the collective unconscious, and archetypes such as The Mother, The King and The Hero.

While in grad school, I attended a leaderless gestalt dream interpretation group. Both theory and method were different from Freudian and Jungian dream analysis. The constant focus in gestalt therapy is staying in the here-and-now of your direct experience; and in the dream group you first related all that you remembered of your dream, in the present tense: “I’m walking on barren ground, in the middle of nowhere. I see a house in the distance and I’m walking toward it. As I get closer, I see that the house is deserted and falling apart. The wood creaks beneath me as I walk up the steps to the porch. The wood is rotten and I’m afraid I’ll fall through the floor, but I have to go inside. . . .” After the whole dream had been related in this manner, the dreamer would then take on the role of objects from the dream: “I’m a house in the middle of nowhere. I look good from the distance, but I’m actually falling apart. Nobody would want to live in me. . . .” After the dreamer finished, a group member might ask what it feels like to be this house, and the group would discuss possible meanings, before going on to the next dream object.

Things that happen to us  in our dreams often mirror circumstances that arouse our anxieties in our waking lives. Fear, anxiety, helplessness, frustration, and shame (e.g. naked-in-public dreams) are frequent emotional states experienced in dreams. Most of us have gone to school, and I expect that we’ve all had school dreams. I’ve done some stage acting, and I imagine that every stage actor has had some variation of a recurring dream theme from my acting days:  I’m onstage, the curtain is about to open on a full house, and I can’t remember what play I’m cast in, let alone my first line of dialogue. I’ve had very few nightmares as an adult, but a frequent theme in the dreams I remember is frustration, e.g. I need to get somewhere from where I am in a foreign city, but I’ve misplaced my luggage (or my car key) and can’t leave until I recover it. And then I can’t find my car, and the streets and buildings keep changing. It’s such a relief to wake up and realize that I’m right where I need to be, with no immediate problem to solve.

I’ve had some dreams that were so vivid, I’ve had to convince myself that they weren’t real. Researching the subject, I’ve come to believe that they were hypnogogic hallucinations, which occur in the twilight state between consciousness and unconsciousness, before falling asleep. Similar hallucinations that occur in the twilight state between sleep and wakefulness are called hypnopompic hallucinations.

Another unconventional dream state is lucid dreaming, where the dreamer becomes aware of being in a dream, and can control its content. I’ve had a few lucid dreams and have heard many claims that it’s a learnable skill. Some proficient lucid dreamers say that they can fly in dreams, overcome any adversary, and have sex with anyone they want. If you want to learn more about lucid dreaming, I highly recommend Richard Linklater’s 2001 animated film, “Waking Life.”

Dreams are but one of the mysteries of consciousness, and I believe that what they “mean” is ultimately subjective. Ancient shamanic tradition has it that Dreamtime is a real world parallel to our own, and that those who can “journey” in Dreamtime can heal people and work magic in the waking world. Whatever clues or signals dreams may hold in regard to our waking lives, their interpretation is culture-bound, and there are no authoritative answers to our questions about this mysterious, otherworldly phenomenon.

Esalen and the human potential movement

In previous posts I’ve written about humanistic psychology, which has been called the Third Force in modern psychology, after Freudian psychodynamic psychology and Behaviorism. The founders – including Abraham Maslow, Carl Rogers, Fritz Perls, and Rollo May – seeing that psychology was primarily focused on psychopathology, wanted it to also focus on psychological health and personal growth. Esalen Institute, an isolated  retreat on the Pacific coast near Big Sur, California, is considered by many to be the birthplace of humanistic psychology. I’ve wanted to visit Esalen, a retreat center for growth and learning, since my graduate education in a humanistic psychology program. I’ve just returned home from a writing retreat at Esalen, and it felt like a weekend on holy ground.

Esalen Institute was founded by Michael Murphy and Richard Price in 1963. The land on which Esalen is located was owned  by Michael’s family for generations, and the two of them had a vision of a center for holistic learning. The place is called Esalen because for thousands of years the area was the home of the indigenous Esselen people. Accordingly, Esalen is considered sacred land, and is treated with reverence by residents and visitors. It’s isolated, far from any town, and doesn’t have cell phone service or television. There are hot springs down by the rocky shore, and everyone knows that clothing is optional at the baths. When I soaked, naked, in a pool, looking out at the Pacific sunset, I had the sense of participating in an ancient cleansing ritual.

Humanistic psychology has also been called the human potential movement. The only required course in my psychology Masters program was “Human Growth and Potential” – known by the students as “Gro and Po.” Although most of my coursework involved psychotherapy and psychological testing, I could understand why Gro and Po was required. Psychology had to be about more than psychopathology and the remediation of symptoms. Indeed, our equivalent of an “Abnormal Psychology” course was “Unconventional Modes of Experience,” lest there be any stigma regarding “abnormal.”

While psychanalytic theory and Behaviorism were dogmatic and monolithic, humanistic psychology was more like a tree, with many roots and branches. It was holistic in its orientation to the study of human behavior, focusing on mind and body as a unity, and exploring the factors that enhance creativity and enable self-actualization. It was holistic in studying both Eastern and Western philosophies and practices, recognizing the benefits of things such as yoga and Buddhist meditation, long before they became popular. Existentialism and phenomenology also influenced the human potential movement.

From the beginning of the movement, Esalen has been its Mecca. Fritz Perls did a five year residency in the late sixties, leading gestalt therapy seminars. Other eminent persons who influenced the development of humanistic psychology and had Esalen residencies were Gregory Bateson, Joseph Campbell, Ida Rolf, Virginia Satir, Rollo May, and Alan Watts. Today people go there to study massage and body work, wellness and alternative medicine, psychotherapy, meditation, and a variety of other subjects. I went there to work on being a better writer, and came home with my spiritual batteries re-charged.

A lot of what was new and esoteric back in the sixties and seventies has gone mainstream. Among the extra-curricular classes available to students in the psychology graduate program at West Georgia College (now the University of West Georgia) were massage, hatha yoga, zen meditation, clowning, tai kwan do, and vegetarian cooking. The program was allied with the Philosophy Department, and there were opportunities to study existentialism and phenomenology. In my therapy courses, I learned about psychoanalytic theory, behavior modification, client-centered therapy, gestalt therapy, transactional analysis, sex therapy, and trance work. Once I was a working psychotherapist, my therapeutic orientation was existential, and I was very eclectic in terms of therapeutic style and techniques. I consider myself very fortunate to have attended the West Georgia College psychology Masters program.

Contemporary concepts like emotional intelligence and positive psychology couldn’t have emerged from Freudian psychodynamic theory or Behaviorism. The humanistic psychology movement created a new paradigm for human growth and potential as a legitimate area of study within the science of psychology. I think that the regard for Freud’s contribution to psychology and psychotherapy will diminish over time, relative to the contributions of humanistic pioneers like Abraham Maslow, Carl Rogers, Fritz Perls, and Milton Erickson.

The concept of emotional intelligence suggests that there are other kinds of intelligence than cognitive intelligence. Accurate empathy and compassion are important factors in human relating, and are deserving of scientific study by students of human behavior. I had initial objections to the whole notion of positive psychology, thinking, “psychology is neither positive nor negative.” But then I came to realize that it’s an outgrowth of the impulses that inspired humanistic psychology. The study of psychological wellness and peak performance, of thriving, of human creativity and the process of self-actualizing, is a legitimate pursuit within the field. Psychodynamic theory and Behaviorism will always have their place in psychology, but they need to be viewed in the context of the psychology of growth and human transformation.

Ericksonian hypnotherapy

Dr. Milton Erickson was one of the giants of psychotherapy, as evidenced by the fact that the largest convocation  of psychotherapists in the world, the Evolution of Psychotherapy conferences (held every four years), are organized by the Milton Erickson Foundation. He has been called the father of modern hypnosis. He not only developed a powerful alternative to traditional hypnosis, but introduced a new model of solution-focused brief psychotherapy.

I explained traditional hypnosis in a previous post. Ericksonian hypnotherapy was something new. Whereas traditional hypnotic inductions are characterized by commands and direct suggestions, implying that the therapist wields some kind of power over the “subject,” Ericksonian inductions use indirect suggestion, metaphors, and storytelling to induce trance states, circumventing client resistance to complying with the imperative voice. (You should, you will, etc.) Trance-inducing suggestions like “Your eyelids are getting very heavy and you want to close your eyes” were replaced by indirect suggestions such as “As you relax, you may find that you want to close your eyes.” Instead of hypnotic prescriptions for a person in trance, an Ericksonian hypnotherapist might say such things as “… and as you practice self-hypnosis, you may find that it’s easier for you to ________ .” Erickson also developed non-verbal methods for inducing trances.

Erickson’s life story is remarkable. Long story short, he was stricken with polio at age 17. Told that he would never walk, he taught himself to walk again. Told that he was too disabled to work, he went to medical school  and became a psychiatrist, and later a psychologist. He trained himself to be acutely aware of changes in peoples’ posture, respiration, vocalizations, skin tone (blanching or flushing) and pupillary dilation. He learned to “read people” and their immediate responses to his therapeutic interventions, adjusting his techniques to the unique individual and situation.

Erickson recognized that trances occur naturally every day in all of our lives. (There are many kinds of trance states, including confusion, daydreaming, rumination and jealousy.) He learned to induce them in non-traditional ways and to utilize the power of the subconscious mind to focus on solutions to the presenting problem that brought the person to therapy. He could induce a trance with a handshake or a story. Sometimes he used a confusion technique, framing his words with a deliberate complexity that caused confusion. This put the listener off-guard and receptive to suggestions aimed at the subconscious. The immediate results of some of his interventions would appear miraculous to someone unaware of the techniques being employed.

A well-told story can put listeners in a trance. Erickson was a master storyteller, as well as a master at crafting strategic metaphors that were aimed at the subconscious mind, pointing toward solutions. His verbal presentations – whether in conversation or telling a story – were often layered, talking about one thing on the surface, but using metaphors designed to become embedded at the subconscious level. Sometimes he’d prescribe specific activities related to the metaphors he employed, to amplify the embedding.

An example of this is a case history I remember reading, about a client who was an alcoholic. Erickson first asked questions until he felt he had a good understanding of the client’s life situation and his history of problem drinking. Then he gave a rambling discourse about cacti. “There are many varieties of cacti, but they all have one thing in common. They hardly ever need rain, because they have an amazing capacity to retain all the moisture they need. It’s like they’re never thirsty.” Having planted a strategic metaphor about thirst and resiliency, he then directed his client to take a hike on a specific nearby hiking trail (Erickson lived in Phoenix) the next day and study all of the different kinds of cacti. As I recall the case history, the client got and stayed sober after this strategic intervention. There are many such documented stories of Erickson’s successful brief therapies.

In his later life Erickson suffered from post-polio syndrome and lived with daily, severe pain, which he controlled using self-hypnosis. He knew first-hand how to harness the amazing powers of the subconscious mind, and taught many others how to do this. He frequently taught his clients self-hypnosis, for pain control as well a for anxiety and other psychopathologies. He was the founding president of the American Society for Clinical Hypnosis, and had a major influence on brief therapy, strategic therapy, family systems therapy, and Neuro-Linguistic Programming (NLP).

Albert Ellis

In my post “The Gloria Sessions” I wrote about a three-part video series titled “Three Approaches to Psychotherapy”  in which a brave young single mother named Gloria had brief therapy sessions with three of the twentieth century’s giants of psychotherapy. The three therapists were Dr. Carl Rogers (client centered therapy), Dr. Fritz Perls (gestalt therapy), and Dr. Albert Ellis (rational therapy). Little did I know  when I saw the series in grad school that I would actually meet two of these luminaries. I’ve already described my encounter with Carl Rogers. I’ll conclude this post with an account of my brief exchange with Albert Ellis.

Ellis is best known as the creator of Rational Emotive Behavior Therapy (REBT), and is widely considered one of the most influential psychotherapists since Freud. I first came across his work as a teenager, when I read his 1958 book Sex Without Guilt, which made the case that guilt about responsible sexual behavior is irrational. This was my first introduction to rational thinking, which made a lot of sense to me. However, parts of the book were (in retrospect) just his claptrap notions, like his theory of homosexuality – which was still considered a mental illness back then. He corrected his errors in later editions of the book.

Ellis was a foundational pioneer of what is now known as cognitive behavioral therapy (CBT), and I consider his A New Guide to Rational Living to be his single most important book. (He wrote or co-authored more than eighty books and many academic papers.) When I watched him in “Three Approaches to Psychotherapy,” I didn’t like his therapeutic style. He was the opposite of sensitive, gentle, avuncular Carl Rogers; he was a fast-talking, abrasive New Yorker, who seemed impatient in his dealings with Gloria. But I couldn’t argue with his logic, and Gloria seemed to get something from the session.

Although behavioral therapies weren’t popular in my humanistic Masters program, I started learning and practicing rational thinking in the eighties, and began teaching it in my clinical practice. Being a rational thinker has spared me a lot of unnecessary pain, and I’ve been known to say that if I had a Gospel to preach as a therapist, it was the Gospel of Rational Thinking. REBT focuses on the rational analysis of irrational and self-defeating beliefs and behaviors. Ellis continued to write and lecture and do therapy until shortly before his death in 2007, at the age of 93. He has been charitably described as having a “provocative personality.” I was in the audience for several of his presentations at Evolution of Psychotherapy conferences over the years, and witnessed his provocative style first-hand.

For one thing, his presentations were laced with profanity, and his response to any objections about his language was usually  along the lines of “F _ _ _ you!” If you didn’t like the words he chose, that was your problem. He was still the abrasive stereotypical New Yorker I’d first seen on videotape in grad school; but I’d come to appreciate his personality and his delivery, as well as his contributions to psychotherapy. He made the point in his public speaking that it’s what you say that  matters, not so much how you say it. In his own way he echoed Fritz Perls’ idea, “I am not in this world to live up to your expectations and you are not in this world to live up to mine.”

At an Evolution of Psychotherapy conference I happened to find myself on the same elevator as Dr. Ellis and his small entourage. Seizing on the opportunity, I asked him, “Dr. Ellis, didn’t you write a book titled Sex Without Guilt?” “Yes I did. Did you read it?”  “Yes I did.” “Did it help you?” “I’ve read several of your books and I think I’m a better man for it.” Dr. Ellis grinned at me and said, “I’ll bet you’re a sexier  man for having read Sex Without Guilt, too!”

I don’t know about that, but I do know that Ellis’ influence made me a better therapist. He enhanced my ability to reach some clients, helping them to understand that they didn’t need to feel guilty about being a sexual person, with sexual feelings and needs.

The role/goal model

There are many models of human behavior in the field of psychology, among them the psychoanalytic, behavioral, gestalt, and dialectical models. Most have their utility, but none of them is “the best,” or explains everything. A model is just a description or a map and, as I quoted in a prior post, “the map is not the territory.” I haven’t written about what follows in any formal or comprehensive way yet, but I’ve come up with the bare bones of my own model. I think it’s original, and helpful in explaining certain unconventional or extreme behaviors – as well as many common ones. I call it the role/goal model. It has to do with motivation and it’s rooted in social psychology.

We all play multiple roles in our lives, some of the more conventional being spouse, parent, employee (or boss), host, and caregiver. Other roles have to do with one’s profession or skill set, and yet others are unconventional and highly specialized. Behaviors appropriate to one role in a person’s life – for instance sexual expression within a marriage – are inappropriate in other roles. If a drill sergeant behaved at home like he did at work, it would be domestic abuse.

Many behaviors are motivated by the desire to feel good about ourselves for fulfilling the expectations of a given role, whether that role is father, wife, breadwinner, merchant, healer, or evangelist. You may not feel like getting up when the alarm goes off at six, but in service to your role as family provider, you get up on time and prepare to go to work, day after day. The goal of such persistent behavior is the feeling of satisfaction you get from providing for your family’s material needs. You know that if you don’t get up and go to work most workdays, you won’t get a check on payday. You’ll fail to meet the goal of the breadwinner role, your family will suffer, and you’ll feel terrible about yourself.

Many times in my life I’ve heard people say things like, “He did that for no reason!” In fact, people don’t do things without a reason, and a more accurate statement would be “He did that for reasons I don’t understand.” We might have a hard time grasping what would motivate a person to torture animals, or purposefully start a forest fire, or shoot schoolchildren, or coax cult followers to drink a fatal dose of poison. I think this model helps to make such behaviors comprehensible.

The role/goal model explains conventional or extreme behaviors by identifying the role that a person perceived herself to be in at the time of the behavior, and the goal of that role-appropriate behavior.  For instance, a mother who has never acted-out violently in her life might inflict severe bodily harm on a stranger, if he was threatening her children with violence. Some roles, like mother, are conferred by circumstance; other roles are self-conferred and may be secret, or unrecognized by others. Self-conferred roles include Rescuer/Hero, Tragic Hero, Devil, Martyr, Outlaw/Rebel, Victim, Player, and “Secret Agent.” Identifying the role and the goal explains almost any behavior that isn’t due to psychotic mental processes.

By Secret Agent I don’t mean a literal spy {although “spy” is an example of a rare and highly specialized role), but someone who acts in secret, or has a perceived “secret identity.” I think that role descriptor helps to explain many aberrant behaviors, such as serial arson or serial rape. Examples: “They think I’m a Nobody, but I burn down forests.” “Women trust me because they think I’m a nice guy.” People like this get off on not only the feeling of power they experience when they commit their crimes, but on their daily feelings, when they think “Nobody knows who I really am” or “She doesn’t know that I want to rape her.”

A less extreme example is the role/goal analysis of an obnoxious, Bible-thumping street preacher who thinks he’s preaching on the street because God wants him to. What motivates him to persistently shout at strangers who don’t want to listen to him? The role/goal model posits that he’s in the evangelical role, and what could be more important than saving souls? The behavior is motivated by the attendant feeling, not the sure knowledge that souls will be saved. People in such a self-appointed role believe that their objective (i.e. saving souls from damnation) is what’s driving their behavior, when in fact their role-appropriate, goal-directed behavior is motivated by the feeling that they’re doing the most important work of all, God’s work.

The goal of the Hero is to be admired for his achievement or strength. The goal of the Tragic Hero is to get sympathy and to justify his helplessness in the face of insurmountable odds. The goal of the Victim is to gain something by being pitied. The goal of the Martyr is to be admired for her sacrifice. The goal of the Player is to get over on people. The goal of the Rebel/Outlaw is to get away with breaking the rules. The goal of the Devil is to raise Hell. The goal of the Rescuer is to feel powerful and to take credit for someone else’s survival or success. None of these roles exists objectively, but in subjective perception and the attainment of consequent, predictable emotional states. The feeling state is often the  goal of the behavior, although it will be rationalized as role-appropriate and goal-directed.

Emotional expression is modulated by both role and goal. An emotion is suppressed if it’s seen as inappropriate to the role or unhelpful in reaching the goal, i.e. never let them see you sweat if you’re in the Hero role. The emotion is exaggerated for effect if it’s seen as role-congruent and/or helpful in reaching a goal, i.e. the Boss’s display of anger, or the Victim’s tears.