Authenticity and congruence

This a continuation of my last post, “How to be more like you,” in which I wrote about phoniness vs. authenticity. Most of us come by the inauthenticity that Fritz Perls described as phoniness quite  honestly, via the process of socialization. As children, we learn from the adult role models in our lives, and we’re often taught to be inauthentic. The template for prescribed phony behavior might be “politeness,” or religion, or social expectations about “correct  behavior” or even “correct feelings.” I’ve known people who were abused and/or  neglected by their parents who still, as adults, felt guilty about not loving them the way they “should.” Many children are taught who they are “supposed to” love, from grandpa to God. Genuine love can’t be forced.

A kiss that is anything other than an expression of affection or love or sexual passion is a phony kiss. Jane may not have even liked Aunt Sadie, but her parents taught her to give her a kiss anyway, whenever she visited. Children are often given admonitions such as: “Don’t cry! You’re a boy!” and “Don’t you get angry at me, young lady!” and “Of course you love him; he’s your grandfather!”

Some people have jobs that require them to act cheerful, no matter what they’re really feeling. Behavior arising from authentic feelings might be judged by others as impolite or inappropriate in certain situations. We’ve all been in circumstances where we felt the need to hide our true feelings; but some people go through life feeling that way every day. They have their reasons.

Con men, sociopaths and bullshitters are purposefully inauthentic. Others have learned to habitually cover up their true feelings; it’s their default mode. One of the ways I would confront a client who was putting on an act in therapy was, “You’re always on stage, aren’t you?” The look in their eyes (busted!) told me that I was on target, and that this was something they needed to know that other people could see through. People whose default mode is authenticity know themselves better than people who constantly put on an act to win approval. They are also more secure and self-accepting. I know this from personal experience, as I used to be a people pleaser, myself. My phoniness arose from feelings of insecurity.

A related concept that was important to me as a therapist was congruence. There are two kinds of congruence. One has to do with they way you come across when communicating. If someone being threatened says to his antagonist, “You don’t scare me” in a soft, tremulous voice, with body language that indicates fear, his verbal message won’t be believed. It’s incongruent with his other modes of communication. If someone says “I’M NOT ANGRY!” loudly, with fists clenched and an aggressive posture, he’s giving incongruent messages. When a person’s words are matched by her vocal tone, facial expression and body language, her message is congruent. People who are seen as charismatic are highly congruent communicators.

As a therapist with training in gestalt theory, I became very good at spotting subtle incongruities in therapy. In gestalt therapy, incongruent messages get challenged by the therapist. If a client claims (incongruently) that it really doesn’t bother her when her husband calls her stupid, the therapist might ask her to say the opposite: “It really bothers me when my husband calls me stupid!” (“But it really doesn’t bother me!” “Try saying it anyway.”) This technique is very effective in getting clients to recognize their true feelings, which often rise to the surface as the client repeats the opposite of their initial rationalized statement.

The other kind of congruence is role congruence. Do you act like a different person in your different life roles, or would family members and close friends recognize you as the same person they know, if they saw you at work? Obviously, some jobs – like a drill sergeant at a military boot camp – require you to take on a badass role that is (one hopes) incongruent with how he behaves in other situations. But under most circumstances a congruent person is recognizably the same person as a worker, a spouse, a parent and a friend. Incongruent persons are role-bound, and might be a tyrant at home and a reasonable person at work – or the other way around. Congruent people are authentically themselves in all the roles in their lives.

The intrinsic reward for being yourself – warts and all – is that when people who know you give you messages (feedback) about who you are, they’re revealing the things you need to hear, to be self-aware. I’ve written before about the paradox of identity. You can’t have self-knowledge in a social vacuum. We need other people who know us, in order to know who we “really are.” They’ll tell us, and if there’s some disagreement, it’s all grist for the mill. A consensus will emerge over time about who you are.

If you were living alone on a desert island, like Robinson Crusoe, how could you possibly know what kind of person you are. How could you know if you’re generous or stingy, witty or dull? We depend on other people in our lives to have an accurate sense of our own identity. Being authentic and congruent helps us to know who we really are, and what we might like to change about who we are.

Your “self” is either a rigid construct – “that’s just who I am!” – or a work in progress. Whatever your age.

 

How to be more like you

My title for this post is ironic. How could I possibly know who you are or how you should be “more yourself”?  But surely you’ve known some people who sincerely believed that the world would be a better place if other people were “more like them.” When people think this way, they are probably not  referencing the “self'” that is known to others – warts and all –  but rather an idealized, cherished self-image. I believe that all of us have a cherished self-image that doesn’t necessarily coincide with the consensus image of ourselves as others know us. When you hear someone say something about you and your reaction is “I’m not like that!”, you’ve probably identified a piece of your cherished self-image.

Attachment to this cherished self-image is especially strong in people who have tried throughout their lives to live up to others’ expectations of them – parents or extended parental entities  such as church and culture. Many of us are taught how we “should” or “shouldn’t” feel in this or that situation. This attachment can also be strong in people who have tried hard to shape themselves in reaction to “parental” expectations, i.e. “I refuse to be who my parents (or the church or the State) want me to be.” I’ve known quite a few parents whose cherished self-images kept them from seeing that they were dealing with their own children in just the same dysfunctional ways that their own parents had dealt with them. When you’ve sworn to yourself, “I’ll never do that with my children,” it’s often hard to recognize when you do.

Each of us – even those with low self-esteem – is the hero of our own personal drama, because we all live at the center of our perceived world, and none of us can be completely objective about ourselves. Our “heroic self” may wear the mask of the conquering hero or the rescuer or the wronged victim. But this heroic self is just as much an artificial construct as any image of ourselves projected onto us by others. I remember an epiphany I had as a young man. Seeing my reflection in a mirror, I thought “That’s who they think I am!”

One’s true self isn’t a thing, fixed and immutable, but is best seen as an evolutionary process, a work in progress. Buckminster Fuller put it this way: “I seem to be a verb.” Rather than trying to nail down some finished portrait of one’s self, I think that it is more helpful to have a picture in mind of who you are today, in the here-and-now of your experience and behavior. Your actions, not your thoughts, ultimately define you as the unique person you are.

A concept that was important to me as a psychotherapist was authenticity. In studying gestalt therapy in grad school, I became aware that many of my habitual behaviors were what gestalt guru Fritz Perls called “phony.” I was a people pleaser, always trying to guess what was expected of me in each situation and to behave in ways  that were attempts to please or impress the people around me. I realized that I wanted everyone to like me – even if I didn’t especially like them. But, to the extent that I was phony, if someone seemed to like me, what they liked was my act, not me.

I knew that if I was going to be a good therapist, I had to become more spontaneous and authentic – even if that meant that some people wouldn’t like me or approve of my actions. I stopped making phony excuses for myself, like saying “I really have to leave now,” when I really just wanted to leave. I stopped rehearsing for social occasions such as parties. I learned to walk into a roomful of people with an “empty mind,” primed for spontaneity. I wanted to get to know the person behind the masks that I wore. Some people may have seen me as blunt or curt, or even rude, as I worked on becoming “more myself.” I knew that not everyone liked me, and that was okay. The work that I did on myself enabled me to help therapy clients to identify and confront their own inauthentic behaviors, and to work on changing them.

Gestalt therapy is especially effective for working with people who want to discover their authentic selves. Some gestalt techniques (which I described in a prior post) serve to unmask phony roles that people play, leaving them bereft of their usual defenses, and open to sudden insights. Fritz Perls is perhaps best known for what is called the Gestalt Prayer: ” I do my thing and you do your thing. I am not in this world to live up to your expectations and you are not in this world to live up to mine. You are you and I am I, and if by chance we find one another, it’s beautiful. If not, it can’t be helped.”

More about authenticity, and the related concept of congruence, in my next post.

 

Epiphanies and peak experiences

In previous posts I’ve written about the mystery of consciousness and non-ordinary states of consciousness. In this post I’ll examine epiphanies – an ordinary, though not everyday, state of mind – and peak experiences.

As a retired psychotherapist, I think that some people are resistant to insight; but anyone who is capable of introspection will sometimes experience epiphanies. These are sudden bursts of new awareness, insight, or intuitive understanding of something in our lives, often in the form of “so that’s why I/you/he/she/it ________!” In an older sense, the word can also mean sudden awareness of the presence of a deity or some other supernatural entity; but there’s nothing supernatural about insight epiphanies. I’ve witnessed many moments of epiphany in therapy sessions, and I’ve had a few, myself. Epiphanies can lead to changes in attitude and behavior.

Peak experiences – a term coined by Abraham Maslow – transcend mere epiphanies. Like epiphanies they are generally spontaneous, unplanned experiences. Some, but not all, fall into the category of mystical experiences. Apparently, not all people have them. They can’t be reliably induced, like hypnotic or psychedelic states of consciousness, but certain conditions may trigger them or cultivate their likelihood. Athletes may experience them when they’re “in the zone” and performing at the peak of their abilities, and I imagine that Alex Honnold had one he free climbed El Capitan, in Yosemite. When peak experiences occur, they can be quite profound and moving. They can be life-changing.

I’ll give some examples from my own life. My longest-lasting peak experience was a day in my youth when I solo hiked 25 miles of wilderness trails at Bandolier National Monument, in New Mexico. It was the most challenging hike of my life, but I’ve never felt more strong, confident, self-reliant and alive. The best way I can describe it is that I felt like I belonged in that wilderness, as surely as every rock and tree and rabbit that I saw. I got back to the campsite at twilight, rubber-legged with fatigue, but exhilarated.

Other peak experiences I’ve had involved a profound sense of oneness with the universe, or the sense of being in the presence of something “holy.” One occurred on a winter day when I was living on the second story of a Victorian-era house in Talladega, Alabama. There were deciduous trees in all directions surrounding the house, their branches now bare. I suddenly found myself serenaded by the sound of raucous  bird cries, and looking out a window, I saw all of the tree branches in sight covered with black birds. (I wasn’t a birder back then, so I can’t tell you what species.) I ran from window to window, discovering rows of black birds on every limb of the surrounding trees. I wept for joy, bathing in the sound and awed by the sights I saw, looking out each window – at one with what I was witnessing.

Another “mystical” peak experience occurred while I was working. I was employed as a mental health counselor in rural Alabama. An elementary school teacher of “homebound” disabled students asked me to accompany her to the home of one of her students, to evaluate her learning potential and see if I could make any recommendations. The girl was nine or ten, blind, spastic, and severely developmentally disabled.

The family was poor, and lived in a house in the woods – simply furnished but immaculately clean. The girl’s mother took us to the parlor, where the girl – dressed in pajamas as I recall – was strapped to a wooden armchair to prevent self-injury. Her unseeing eyes darted around in response to sounds; her head and limbs jerked spasmodically; her mouth was slack and her face expressionless. I felt inadequate to the task at hand, but watched intently as the teacher interacted with the child – holding her hands, stroking her cheek with a finger, and talking to her. I saw no signs of comprehension, and the girl’s facial expression remained blank.

Then the teacher produced a portable 45 rpm record player from her accessory bag and plugged it in. She placed a record on the turntable, turned it on, and placed the needle in the rotating groove. The song that played was “I’m a little teapot/short and stout./Here is my handle/here is my spout.” Clearly, the teacher had played this song many times before, because the girl’s face lit up in a smile and she made happy noises. And in that instant, I knew that I was in the presence of God.

I was, and remain, an agnostic. But I have no other words for what I felt – what I knew – at that moment. I can’t identify any changes in my philosophy or in my life that resulted from my epiphany (in the older sense of the word), but I’ll never forget the lesson I learned from that child. The best I can put it in words is, “if there’s a God, it’s EVERYTHING.” This is identical to the Hindu concept of Brahman: there is nothing that is not God.

When people ask me if I believe in God, and I have the time, I respond, “Define God.” To me, whether there “is” or “is not” a God is a matter of definition. If there is a God, I don’t believe It has a gender or a preferred name, but is beyond comprehension. If I were any kind of theist, I’d be a pantheist. Pantheists are always in a holy place.

More about mystical experiences in my next post.

 

Non-suicidal self-injury

I think that one of the most baffling phenomena in the repertory of human behavior, to people outside the mental health field, is self-mutilation. Most of us fear and avoid physical pain and disfigurement, and it’s hard for us to understand why anyone would intentionally hurt themselves of self-mutilate. Over the course of my career as a psychologist, I discovered that there are a variety of motivations and explanations for self-harm.

Some people harm themselves because they are in a psychotic state of mind. It may be that voices nobody else can hear tell people to hurt themselves, or that self-harm is the result of delusional beliefs. I’ve known a man who gnawed off several fingers and another who gouged out his eyes for incomprehensible reasons, while psychotic. Other people injure themselves impulsively, because their distress impairs their judgment and they don’t know what else to do; so they bang their heads against the wall, or punch through a pane of glass.

Yet others learn from experience that cutting, or otherwise hurting, themselves provides immediate relief from overwhelming emotional pain; and it becomes a habit. The brain often responds to pain by releasing endorphins, whose molecules resemble morphine. (I recently learned that one reason some people enjoy eating really hot peppers is that the pain gives them an endorphin high.) This substitution of physical pain for emotional pain is hard for many of us to understand, but it reliably meets a need for some people. It can be viewed as a kind of masochism, with the distinction that it’s not done for pleasure, but rather for relief from pain.

What I would say to a client when I learned that they were self-mutilating was something like, “I believe that if you knew better ways to cope with your emotional distress, you’d use them, instead of hurting yourself. So let’s work on finding better ways.” Non-suicidal self-injury (NSSI) is a pathological behavior for many people diagnosed with Borderline Personality Disorder, and its elimination is one of the first goals of the most effective treatment available for people with that diagnosis – Dialectical Behavior Therapy (DBT).

DBT is the creation of Dr. Marsha Linehan. She designed it to help people who feel like they’re living in Hell, as a way out. Each patient in a DBT program is assigned an individual therapist, and is required to attend skills training groups twice a week. Two of the skills modules that are geared to the elimination of  NSSIs – or parasuicidal behaviors – are distress tolerance and emotion regulation. Borderline traits and symptoms are characterized by emotional imbalance. In learning to tolerate distress and regulate emotions, the clients learn how to achieve emotional balance. They no longer have to rely on the endorphin rush they get from cutting or burning themselves, once they’ve found better ways to cope with emotional distress.

The most extreme instance of self-mutilation I ever encountered in my career, not involving psychosis, was a long-considered and carefully executed self-castration. I speculate that the man’s motivation was related to either or both fear of a strong sex drive and/or disturbing sexual fantasies and urges. A fundamentalist Christian, he believed himself to be tempted by demonic “powers and principalities,” in a battle over his soul. He was quite intelligent and had a rationale for his agenda.

When he’d asked a surgeon to castrate him, he’d been told that no doctor could ethically accommodate his request, as there was no medical reason for the surgery. So he studied books on surgery until he felt confident that he could operate on himself. He decided to castrate himself in two  separate surgeries, coached his wife to serve as his surgical assistant, and set up a surgical suite in their home. The first surgery went off without a hitch. I never would have encountered the man if he hadn’t botched the second surgery. When he and his wife couldn’t stop the bleeding after he’d severed his remaining testicle, they had to call 911.

The local hospital contacted me to evaluate him. He was medically stable and ready for discharge, but his doctor wanted me to make a recommendation regarding any possible suicide risk. The man showed no signs of either depression or psychosis. He was pleasant and cooperative, explaining his rationale for castrating himself and answering all of my questions. He seemed somewhat embarrassed by having been found out, but seemed to have no other regrets about his actions. He persuasively denied any suicidal thinking, and he didn’t meet the criteria for involuntary psychiatric commitment. So I recommended that he be discharged. I gave him my card and told him that I was available if he wanted to follow up, but he never contacted me.

As an adult, I’ve never referred to mentally ill people as “crazy” – only behaviors. This was an example of how a legally sane person can do a carefully-considered, but crazy, thing.

Who is a psychologist?

I have a masters degree in psychology, and was trained in the profession by doctoral psychologists. I worked for over thirty years as a clinical psychologist in the public sector, but there are psychologists with PhDs and PsyD degrees who would have you believe that I’m not a “real” clinical psychologist. That’s because I can’t be licensed as a clinical psychologist in South Carolina – as in most states – with a masters degree.

I’m thankful to the American Psychological Association (APA) because I got my first job as a mental health counselor as a result of  a job interview at an APA convention. (I was subsequently certified by the state of Alabama as a psychometrist – qualified to administer, score and interpret certain psychological tests.) But I’ve since come to view the APA as a professional guild, as well as a professional association. It serves to protect private practice psychologists with doctoral degrees from competition by masters-level psychologists. There’s no established scientific basis for excluding masters-level psychologists from licensure, if they can meet the other requirements.

The central issue is demonstrated competency, but the APA contends that a doctoral degree is the established educational standard for licensure. No body of scientific evidence exists which demonstrates that doctoral-level psychologists achieve better outcomes in the provision of psychological services than masters-level psychologists. But the APA doesn’t want the competition, and has opposed all efforts in various states to allow masters-level psychologists to be licensed. In South Carolina, a hard core of doctoral psychologists even tried to “trademark” the prefix psycho (as in psychotherapy, psychological testing, etc.) for the exclusive use of doctoral psychologists.

I know this because I was the acting chairperson of the South Carolina Association of Masters in Psychology (SCAMP), a state chapter of the North-American Association of Masters in Psychology (NAMP), when the licensed psychology establishment proposed legislation that would exclude any psychologist without a doctoral degree from the possibility of professional licensure in the field. To insure passage of their “practice act,” it was written for them by one of South Carolina’s most prestigious law firms, and they hired a lobbyist to promote it in the state legislature. SCAMP didn’t stand a chance.

But it didn’t stop us from trying. We did research on the availability of psychological services throughout the state, indicating that South Carolina was underserved, and that masters licensure would make psychological services available to more people. We argued that only those masters-level psychologists who could achieve the same scores on licensing exams as the doctoral-level psychologists should be eligible for licensure. We were even open to an initial period of supervision by licensed psychologists, leading to eventual licensure for independent practice. Perpetual supervision of masters-level psychologists in private practice would have been a new revenue stream for licensed psychologists, but a period of supervision leading to independent practice was unacceptable. The psychology practice act only affected private sector psychologists. In the public sector, masters-level psychologists routinely did things that they’d been deemed unqualified to do in private practice, by the practice act.

SCAMP had some significant support when testimony was presented in legislative subcommittee hearings. A publisher of certain widely-used psychological tests testified that masters-level psychologists were competent, with appropriate training,  to administer, score and interpret their tests. Dr. Logan Wright, a former president of the APA, testified in support of masters-level psychologists being eligible for licensure as psychologists. In spite of this, the South Carolina Psychological Association got the legislation they wanted. The law didn’t  prohibit appropriately -trained masters-level clinicians in private practice from doing any testing; you just couldn’t call the service “psychological testing.”

For years I worked as a mental health counselor, but routinely did psychological testing as part of my job. I eventually got licensed as a professional counselor; but for most of my career, I was hired as, and performed as, a clinical psychologist. My colleagues who were licensed psychologists always treated those of us with masters degrees as peers; and although we couldn’t be licensed as clinical psychologists, we did essentially the same work as the licensed psychologists. For legal reasons, our psychological evaluations were co-signed by licensed psychologists; but in all my years of doing testing, I never needed to have my work corrected, and never got critical feedback from my licensed colleagues. Whenever I was hired by a psychologist, I was supervised by licensed psychologists, and always got excellent performance evaluations from them.

So, although I “work like a clinical psychologist, talk like a clinical psychologist, and have frequently been seen in the presence of known clinical psychologists,” I can’t be licensed as what I am: a competent, experienced clinical psychologist. I never regretted not getting a PhD, as I was able to do all of the things I was trained to do, as a public sector psychologist. My last clinical supervisor – a licensed clinical psychologist –  explicitly told me that I knew as much about psycho-diagnosis and psychotherapy as any licensed psychologist he’s ever known. Shortly before I retired, he nominated me for an award honoring the outstanding clinical service provider in the state of South Carolina.

Although SCAMP is just a footnote in the history of psychological practice in SC, NAMP is still going strong, advocating for the licensure of qualified masters-level psychologists. Nine states now allow masters-level psychologists to practice independently in the private sector, although usually with a qualifier like “Psychological Associate” in the title. All this to say that you don’t have to get a PhD or PsyD in psychology to be a “real psychologist.” The central issue in determining who is a psychologist is demonstrated competency in the profession, not one’s academic degree.

Exposure Therapy

Most everybody knows what you’re supposed to do if you’re thrown by a horse. If you want to keep on riding, you get back up on horseback right away, to overcome your fear of being thrown again. The only way to get over your fear of drowning, if you swim in the deep end of the swimming pool, is to leave the shallow end and swim in water over your head.

The clinical term for this principle in psychology is exposure. Exposure is the antidote to avoidance, our very human tendency to reduce anxiety by avoiding activities and situations that tend to trigger anxiety. Avoidance is like a drug that immediately and reliably reduces anxiety or fear. For example, Tom is attracted to his high school classmate Jane, and wants to ask her out. He’s told himself that today’s the day he’ll get up his nerve and approach her, but he avoids doing it as the day goes by. As the end of the school day nears, he gets more and more anxious. But the moment he decides to postpone it until tomorrow, his anxiety dissipates. Avoiding and postponing work in the short-term, but serve to entrench our anxieties and fears in the long-term. Avoidance is one of the defense mechanisms  identified by Freud.

According to Dr. Marsha Linehan,  whose Dialectical Behavior Therapy (DBT) treatment of Borderline Personality Disorder has been empirically shown to be highly effective,, exposure is a necessary component of all effective cognitive behavior therapies. Two of the skills training modules in DBT, emotion regulation and distress tolerance, help to prepare clients for exposure to things they typically avoid.

Exposure therapy can be effective in treating Generalized Anxiety  Disorder, Social Anxiety Disorder, Obsessive-Compulsive Disorder (OCD), Post Traumatic Stress Disorder (PTSD), and phobias – irrational fears. It involves habituation to the feared stimulus/situation. Imagining exposure to successive approximations of the stimulus/situation (imaginal exposure) and teaching heightened awareness of physiological responses such as heartrate and muscle tension (interoceptive exposure) can be accomplished in the therapist’s office. Exposure to the actual stimulus/situation “out in the world” (in vivo exposure) is often the third step of exposure therapy. Being aware of the thoughts, emotions, and physiological responses involved prepares the client for in vivo exposure. Gradually working your way from the shallow end of the pool to the deep end involves exposure to “successive approximations” of the thing most feared. Jumping – or being thrown – into the deep end is an example of “flooding.”

The therapeutic method known as systematic desensitization was pioneered by South African psychologist Joseph Wolpe. After doing a behavior analysis of thoughts, feelings and physiological responses involved in a phobic reaction, he did relaxation training until the client felt some degree of control over his typical responses. Then he worked with the client to develop a hierarchy of fears, from the least fear-inducing to the most fear-inducing thoughts/experiences. Using this hierarchy, he would work with the client on relaxing as they went through successive approximations, leading up to the thing most feared.

Here’s an example of how I might use this method with a client who had never flown in an airplane, due to her phobia about flying. (Because flying is statistically much safer than driving, fear of flying is considered  an irrational fear, or phobia.) Having assessed Louise’s typical thoughts, feelings, and physiological responses/anxiety symptoms, and having trained her to relax, I might start a session with a relaxation induction, leading to a guided fantasy based on her hierarchy of fears. Louise has been instructed to close her eyes, to raise her right index finger whenever she felt an increase of anxiety, and to lower it when the anxiety decreased.

“You’re in your apartment and you’re packing for your flight . . . . Now you have your bags packed and you’re waiting for a taxi to the airport . . . . And now you’re at the airport and you hear the boarding call . . . . Now you’ve stashed your carry-on and are seated, buckling your seatbelt, etc.” Whenever Louise would raise her finger, I’d switch from the guided fantasy to the relaxation induction: “And as you breathe slowly and deeply, you can feel your muscles relaxing, and your anxiety is replaced by a calm feeling . . . . ” When the finger went down, I’d pick up where I left off on the guided fantasy.

Over time, Louise learns that she has increased control over her response to fearful thoughts, getting gradually closer and closer to the thing she fears most. Once she can imagine herself staying in control as the airplane takes to the skies, we might go on to in vivo exposure therapy, which might involve me accompanying her – at least at first. Some private practice therapists specializing in the treatment of phobias might even accompany his client on his first flight, coaching and encouraging him.

People with severe OCD often engage in compulsive rituals to reduce their anxiety. Exposure therapy can help them to learn that they don’t have to rely on these rituals to reduce their anxiety. People with anxiety disorders can use the principles of successive approximation to gradually desensitize themselves to stimuli/situations that used to trigger anxiety. Exposure therapy can similarly help people with PTSD to control physiological arousal in response to stimuli/situations that used to trigger fear. But in order to overcome an irrational fear, you have to eventually face it.

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 <madinamerica.com>.