Back to Schizophrenia 4

I had moved away from this topic and on to some other research and writing, but then I watched a film about R.D. Laing, ” Mad to Be Normal”, about the time period from 1965-1970, when Laing operated Kingsley House in London, and it drew me right back into the alternative programs of treatment for people with schizophrenia.

I returned to a few of Laing’s books and Joe Berke’s “I Haven’t Had to Go Mad Here” (1979), as well as John Weir Perry’s “The Far Side of Madness”(1974). Laing, Berke, and Perry subscribed to the view that societal reaction to individuals with psychotic symptoms (or even other emotional/interpersonal disturbances) has typically been to employ various means of control and treatments to transform or even obliterate (electric shock, tranquilizers, etc.) troublesome symptoms. They ask, “troublesome to whom?” According to Laing, Berke, and Perry, it has been “troublesome” to family members, friends, work mates, and the psychiatric profession has been enlisted to “normalize” behavior – sometimes by whatever means possible. In addition, I listened to the recording of my 1993 interview with Joe Berke, which I mentioned in an earlier post about Berke’s book with Mary Barnes, ” Two Accounts of a Journey Through Madness”.

My interest here is in the epistemology of what is considered “mental illness” and how a particular cultural and institutional construction determines approaches to treatments and aspects of marginalization. From Foucault’s notion of discipline and punish (with particular reference to prisons and mental institutions) to Mary Douglas’s ( in her “Purity and Danger”) notion of things out of order being perceived as polluting, people with schizophrenia have historically been warehoused, heavily medicated, and/or otherwise marginalized from any mainstream society. Laing, Berke, and Perry, as well as the relational psychotherapists, Harry Stack Sullivan, Otto Will, and Frieda Fromm-Reichman, approached people with schizophrenia as regular human beings with different behavioral challenges, for whom the need to be able to have genuine communication with others is essential to their healing prognosis. Though Laing’s Kingley Hall and Berke’s Arbours Centre did not use medications, except when a resident was a danger to themselves or others, the development of several anti-psychotic drugs in recent years, has provided options of combination treatments – as explained in my earlier posts. Nevertheless, the temptation to medicate and not provide appropriate psychotherapy for people who have schizophrenia continues to be a significant weakness of contemporary psychiatry.

When I visited one of the Arbours Centre residences in 1993 and talked with several of the guests (residents with schizophrenia), I learned that they had dramatic stories of the contrast between their previous institutional experiences and the structure/non-structure and atmosphere of an Arbours House. The guests experienced what they called a “drug holiday” while at Arbours. They experienced respect. They experienced a balance between structure and freedom. They experienced supportive companionship. They experienced empathic healers who treated them as human beings who had needs for attachment, love, and communication with others.

Back to Schizophrenia Part III

There is enough current research on the part genetics may play in the etiology of schizophrenia to assume that genetics needs to be a part of a systems understanding of schizophrenia. From a purely genetics stance, Siddhartha Mukherjee includes a section on schizophrenia in his book, “The Gene: An Intimate History” (2017). He States:

“Like many other genetic diseases, schizophrenia also comes in two forms – familial and sporadic. In some families with schizophrenia, the disorder courses through multiple generations. Occasionally some families with schizophrenia also have bipolar disorder. In sporadic or de novo schizophrenia, in contrast, the illness arises as a bolt from the blue: a young man from a family with no prior history might suddenly experience the cognitive collapse, often with little or no warning. Geneticists tried to make sense of these patterns, but could not draw a model of the disorder” (p.442).

Again, from a purely genetic stance, Mukherjee works to navigate through the schizophrenic genetic puzzles: “In some families, perhaps, there are fewer gene variants, but with more potent effects – thereby explaining the recurrence of the disorder across generations. In other families, the genes may have weaker effects and require deeper modifiers and triggers – thereby explaining the infrequent inheritance. In yet other families, a single, highly penetrant gene is accidentally mutated in sperm or egg cells before conception, leading to the observed cases of sporadic schizophrenia” (p.446).

I propose that a purely genetic explanation of the etiology of schizophrenia is insufficient, but that some aspect of what Mukherjee suggests likely plays a role – in combination with other factors. I would add the diathesis-stress model, which is a psychological theory that attempts to explain a disorder or its trajectory, as a result of an interaction between a predisposition vulnerability and stress caused by life experiences. A diathesis can take the form of genetic, psychological, biological, or situational factors. This is also, what Christine C. Gispen-de Wind and Lucres MC Jansen explain in their article, “The Stress-Vulnerability Hypothesis in Psychotic Disorders: Focus on the Stress Response Systems” (2002):

“The vulnerability-stress model is an intriguing concept to look into the etiology of psychotic disorders, and in particular, into the ‘nature-nurture’ principle. That stress affects a vulnerable nature may be obvious, but its mechanism is not well understood, and many questions remain to be answered, let alone how to define ‘vulnerability'”. Their article covers the biologic stress response systems, the autonomic nervous system (ANS), the hypothalamic pituitary adrenal (HPA) system, and the immune system and highlights the plasticity of the HPA system as the mediator of adaptation.

An aspect of vulnerability might also include impairments in sensory gating. Sensory gating is the ability of the central nervous system to adapt to sensory stimuli upon their repeated presentation. It is commonly impaired in schizophrenia patients, and may relate to the inability to concentrate, and to the overload of attended stimuli and a reduced ability to suppress processing of irrelevant and uninformative sensory input.

It is possible that six of the Galvin family children had varying degrees of predispositional vulnerability for possible schizophrenia and combined with familial and other social stresses, schizophrenic symptoms became manifest, while such vulnerabilities were either not at all a factor or were minimal enough that the other six children did not succumb to schizophrenia. Since genetics alone cannot explain the expression of schizophrenia in the Galvin family, I believe the diathesis-stress model is likely and the stresses within the family seem quite obvious. Perhaps the dynamics of early interpersonal relationships between the Galvin parents and their first two boys played a role in the environmental stresses. This would uphold at least some of the interpretations of the Interpersonal Psychiatrists, such as Freida Fromm- Reichmann, Harry Stack Sullivan, and Otto Will. The older two boys who did have symptoms of schizophrenia had then affected the other most vulnerable siblings. There were ongoing serious battles between and among some of the boys, and as illness impacted all family members – those with schizophrenia and those without, the pressure on the non-schizophrenic parents became increasingly challenging. Their need to keep as much of this a secret as possible must also have had an effect on those most affected with symptoms.

Since we know there is no known cure for schizophrenia and that medications alone may have as many deleterious affects as ameliorating ones, I suggest as part of a systems approach to treatment for schizophrenia, combining therapeutic work on communications and relationships, along with the best available symptom management medication (this will change over time and will need to be calibrated to each specific person). Bateson’s papers on schizophrenia in “Steps to an Ecology of Mind”(1972) suggest the ways that people with schizophrenia communicate and characterize the types of double binds created by parents as possible clues to understanding and treating patients. While the Interpersonal Psychotherapists subscribed to an early mother-infant relationship contributing to schizophrenia, they approached the treatment of people who were seriously ill much as psychotherapists might approach helping non-psychotic people with their personal relationships.

It is well known that Freud did not believe that psychoanalysis was appropriate with people suffering from psychosis, yet Freida Fromm-Reichmann, in “Psychoanalysis and Psychotherapy” (1960) said that Freud did not close off the possibility: “He (Freud) expressed the hope for future modifications of psychoanalytic techniques which would make it possible to do intensive psychoanalytically oriented psychotherapy with schizophrenics” (p.176). And this is what she and other Interpersonal Psychotherapists believed they were able to do at Chestnut Lodge, Austen Riggs, and other psychiatric hospitals which treated people with schizophrenia.

Elyn Saks, in her memoir (reviewed in an earlier post), made a convincing argument for combining psychoanalytic treatment along with medication for her to manage her ongoing struggles with schizophrenia, even while she has developed a very successful life and career. She did not write about the specific psychoanalytic approach she has been involved with, but it may be somewhat similar to what Christopher Bollas discloses in his book, “When the Sun Bursts: The Enigma of Schizophrenia”(2015). Bollas has practiced psychoanalysis with people suffering from schizophrenic for well over thirty years. Based on his experience, he writes about how to approach de-coding the language of someone with schizophrenia. His position has been, along with that of Bateson and the Interpersonal Psychotherapists, that there is a logic to the language of schizophrenia, and that the schizophrenic patient wants someone, such as a clinician, to recognize this and be able to communicate with them. Most people with schizophrenia have been institutionalized or otherwise isolated, with no one to communicate with them. Bollas has this to say about his understanding of the condition of people with schizophrenia:

“We shall never know whether schizophrenia is the outcome of phylogenetic, genetic, intra-uterine, early infantile, infant-mother, linguistic, sex shock, family, or accident-in-the-real causes. Clearly it is yet another form of being human.

However, we do know something about how schizophrenics perceive reality, how they think, how they behave, and how they relate. We know a great deal about why they resist many forms of treatment, but we also know how, why, and when they seem prepared to work with a clinician.

Whatever the genesis of schizophrenia, the first distinct outcome is a split in the self in which one part functions in an ordinary manner and another part develops a radically different way of perceiving, thinking, and relating”(p.181).

Bollas summarizes my own position regarding the importance of psychotherapy along with medication in the treatment of schizophrenia:

“Although medications may prove valuable in the course of psychotherapy, nothing helps schizophrenics more than a single one-on-one commitment by a fellow human being who has taken the time and endured the training to know how to read them, be with them, understand them, and talk to them.”(p.187).

I hope that my systems approach to the etiology and treatment of schizophrenia is helpful for those touched in one way or another by this devastating illness. I will revisit this topic as any new and relevant information becomes available.

Back to Schizophrenia Part II

Is there a way to think about the etiology, the de-coding/unwrapping and possible treatment options of schizophrenia which avoids the single model approach? Considering the multiple memoirs from insiders (patients and therapists) and theoretical and medical approaches I have already reported, and considering the fact that we have not yet “solved” the schizophrenia “dilemma”, how might we pull together bits and pieces of data into some understandable systemic whole? In my previous post I referred to Harrington’s statement that a group of researchers in 2008, who identified and critically assessed all known facts about schizophrenia concluded that the facts did not, as a group, lead logically to any coherent explanation of schizophrenia. She also said that these same researchers in 2011 claimed that the field seemed to be operating like the fabled six blind Indian men groping different parts of an elephant and coming up with different conclusions. “In fact they admitted, in the current state of knowledge, one could not rule out the possibility: ‘that there may be no elephant, more than one elephant, or many different animals in the room'” (p.182). I will propose a possible way through this dilemma.

Why am I interested in schizophrenia? While studying psychology in undergraduate school , I worked as a counselor at The Lawrence School for emotionally disturbed children in VanNuys, California (1959-1961), and as a volunteer on the children’s ward at the Camarillo State Hospital in Camarillo, California. The Lawrence School was one of the first of its kind in the U.S. Our objective was to take children in early elementary school grades and prepare them to be mainstreamed after the sixth grade. If they were too disturbed and /or organically impaired, so that the prognosis was not positive, we could not take them and the only option for them usually was a state hospital. We did not typically place diagnostic labels of these children, but many were likely on the autism spectrum, with several other disturbances, some with possible symptoms of schizophrenia. While it is not thought that schizophrenia shows up before adolescence, there may have been pre-psychotic symptoms with some of our children. While working in the children’s ward at the Camarillo State hospital, I had access to the records of the children I worked with. Most were given a diagnostic label of “Schizophrenia Reaction, Childhood Type”. I believe that this was because psychiatrists at that time knew almost nothing about how schizophrenia might affect children. Since most children had obvious psychotic symptoms or were extremely autistic, the label was used as a “holding place” until more was known. Meanwhile, these children were essentially being “housed” in an institution because their families could not manage them. Treatment options were minimal. I don’t remember if the children were medicated as were the adults at the hospital. I do remember that I was fascinated with trying to communicate with the most disturbed children. One boy had become a Bumble Bee and would buzz the ward non-stop. The staff ignored him. I decided to buzz alongside him to see if he would notice and perhaps talk to me. He definitely noticed, but he never talked. This at least hinted to me that he was aware of what was happening around him, while he was living as a bee.

Many years later, while I was in graduate school, I was studying with Gregory Bateson and using some his ideas for my dissertation. I became intrigued with his development of the “double bind theory”, which came out of the research with families with schizophrenia that he, Don Jackson, Jay Haley, and John Weakland, had done from 1952-1954 through Stanford University. I have posted earlier on the double bind theory. Bateson’s idea about this actually goes well beyond the research with families, but it was the family dynamics around mental illness which provided observable material for this theory. While this research was very influential for the family therapy and family systems movement, the emphasis on the etiology of schizophrenia resting with family dynamics and particularly on the influence of the mother, caused ongoing backlash from families with schizophrenia in their midst. It is true that the interpersonal psychotherapy psychiatrists also identified the mother as a primary agent within a family unit, but their interpretation was based more on developmental psychology and the early mother-child relationship. The Bateson group noticed the roles played by each member of a family grouping, and in families where a father was mostly absent and ineffective, the burden for raising children fell mostly on the mother. This was certainly true of the Galvin family in Colorado Springs. What I learned from revisiting the papers that Bateson published about schizophrenia in “Steps to an Ecology of Mind”(1972) is that he considered the possibility of genetics influencing the occurrence of schizophrenia within families, though this genetic influence will still need environmental or interpersonal influence as well. In posing the dilemma between genetics and environment, Bateson asks if simply noting which family member becomes hospitalized with schizophrenia will tell us that they have a particular gene for schizophrenia:

“We cannot simply assume that the hospitalized members carry a gene for schizophrenia and that others do not. Rather, we have to expect that several genes or constellations of genes will alter patterns and potentialities in the learning process, and that certain of the resultant patterns, when confronted by appropriate forms of environmental stress, will lead to overt schizophrenia” (p.259). This statement and Bateson’s next one ( part of his 1959 lecture delivered at the Institute for Psychosomatic and Psychiatric Research and Training in Chicago), presages current thinking about the relationship between genetics and environment in the etiology of schizophrenia: “In the most general terms, any learning, be it the absorption of one bit of information or a basic change in the character structure of the whole organisms, from the point of view of genetics, the acquisition of an ‘acquired characteristic.’ It is a change in the phenotype, of which that phenotype was capable thanks to a whole chain of physiologic and embryologic processes which lead back to the genotype”(p.259).

My interest in schizophrenia comes from my work with emotionally disturbed children and from the family systems research and from the mystery of the etiology and treatment approaches.

I propose a systems approach to understanding schizophrenia, which includes genetics and biochemistry, vulnerability markers or endophenotypes, impairments in sensory gating, early parental-child relationships, family dynamics, and communication theory. I will explain the connections among these variables in my next post…

Back to Schizophrenia

I am revisiting my previous material about schizophrenia because there are two new books which raise some important issues and current research regarding this mental illness. “Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness” (2019) by Anne Harrington covers some material I have covered in previous posts and she also moves further into the current state of biological psychiatry with separate sections on Depression, Bi-Polar Disorder, and Schizophrenia. I will focus specifically on this latter section for this post. “Hidden Valley Road: Inside the Mind of an American Family”(2020) by Robert Kolker investigates the case of the Galvin family from Colorado Springs who had twelve children, six of them diagnosed with schizophrenia. Kolker traces the history of various psychiatric/psychotherapeutic approaches to understanding and treating schizophrenia, particularly with the Galvin family children.

Neither Robert Kolker or Anne Harrington are clinicians or former patients, therefore they are not what I have referred to as “insiders”. Kolker is a journalist, and Harrington is a professor of the history of science.

While Kolker spends a good deal of his reportage on the lives of the individuals in the family and I believe this appeals to a wide readership. He brushes over highlights of the history of theories, interpretations, treatments, and research regarding schizophrenia, he ends up spending the last half of his book reporting on the unfolding advances in genetic research. He is careful not to assume anything conclusive (since there is nothing conclusive), but he essentially discards family dynamics as a possible significant ingredient in the outcomes of what happened in the Galvin family. The mother, Mimi, obviously created double-binds, and both parents covered up the illnesses of their children with distractions, denials, and secrets. Both parents failed to protect their young girls from the predatory behavior of Jim (the second oldest brother). One son committed murder-suicide. I believe there was more denial than Kolker reports. The direct and indirect trauma was ongoing and insidious throughout the lives of all children. So with or without so-called markers for a genetic predispossession, the family dynamics played a role in the various outcomes – those with established diagnoses of schizophrenia and obvious symptoms – and those without.

In fairness to Harrington, her book is primarily about biological psychiatry and not psychotherapy or psychoanalysis, so my comments about how she lightly touches base with psychoanalysis and family therapy and then presumes them to be fairly dealt with may expect too much. Yet, the epistemology of linearity in the historian’s chronological treatment diminishes a more nuanced and complete understanding of how both psychoanalysis and family therapy contributed to and continue to contribute to a dynamic picture of the complicated disease we still refer to as schizophrenia. Psychoanalysis and family therapy are dealt with almost as straw men to be put in place as historical failures in treating schizophrenia.

An example of Harrington not being a clinician is her bad habit of lumping people who suffer from a variety of mental illnesses that may not rise to the level of psychosis as “worried well” – a hackneyed reference which would not be used by either a clinician of a patient.

There is also a “cherry-picking ” problem. Harrington refers to Thomas McGlashan’s meta-analysis of case records from Chestnut Lodge, a psychiatric hospital near Washington, D.C. which cared for schizophrenic patients, “The Chestnut Lodge Follow-up Study: Long-term outcome of Schizophrenia and the Affective Disorders” (1984). She summarizes his conclusions with this “he reviewed the case records of some 446 patients and found that they showed, he said bluntly, that psychotherapy was ineffective for schizophrenia” and in McGlashan’s words, “‘ the data are in and the experiment failed'”(p.181). What does “failed” really mean? Yes, McGlashan was a clinician at Chestnut Lodge, and yes, he followed the psychotherapeutic approaches of Harry Stack Sullivan, Frieda Fromm- Reichmann, and Otto Will, generally known as Interpersonal Psychotherapy. His analysis of cases assumedly included those of these three clinicians, (each of whom had a period of directing the hospital), as well as other psychiatrists. I have not read his study, though I have read case material from Sullivan, Will, and Fromm-Reichmann. Without knowledge of the Interpersonal Psychotherapy treatment approach, an evaluation of “success” or “failure” seems a simplistic conclusion. Context is significant. To begin with, McGlashan had likely already been considering a medical-biochemical approach to treatment with schizophrenic patients and moving away from psychotherapy. He did shift into an enterprise of early medical intervention with pre-schizophrenic patients, which ultimately did not succeed. To be fair to the clinicians who devoted their careers to helping severely ill patients, the Interpersonal Psychotherapy practiced at Chestnut Lodge includes published accounts of their process as well as what they considered successes and failures with patients. While I might question some of the theoretical assumptions of Sullivan and Fromm-Reichmann, their shift away from some classical psychoanalytic positions and their humane treatment of all patients who they treated, deserve more intentional consideration.

Carlton Cornett, in “Being withPatients” (2017), writes about Harry Stack Sullivan and Otto Will, as well as Frieda Fromm-Reichmann and a few other clinicians who worked with schizophrenic patients and generally followed the approaches of Sullivan. He refers to Otto Will’s approach to treating patients, ” He noted that the more you come to know a patient, the less he will seem like a disease or disorder and will then take the form of an unhappy, despairing, and discouraged person confused by his relationships with others”(p.120)

Cornett summarizes his interpretation of Interpersonal Psychotherapy:

“Interpersonal psychotherapy is composed of a variety of elements that are treated as mutually exclusive: social learning theory, behaviorism, psychoanalysis, attachment and cognitive theory. I tend to favor the psychoanalytic aspects over others, but I know that all contribute significantly to the whole. How Interpersonal Psychotherapy primarily differs from psychoanalysis is its practical emphasis. It avoids the oft-disputed question of whether one’s technique is appropriately ‘analytic’ for the more important question of whether we are helpful” (p.160).

The case material from Sullivan, Will, and Fromm-Reichmann, indicates evidence of various successes in helping seriously disturbed patients overcome most of their symptoms, gain insight into their life challenges and relationships and manage their affairs outside of the hospital environment. The treatments did not include medication or any other experimental practices, such as electric shock. We now know that some combination of the most current medications, plus some form of psychotherapy, may be the most effective treatment at this time, but we also know that bio-psychiatry and pharmacological treatments alone have not provided answers for the sufferers of schizophrenia. Harrington includes in her chapter on schizophrenia sections on serotonin, dopamine, amphetamines, genes. she concludes with:

In 2008 a group of researchers launched a multipart project designed to identify and critically assess all ‘facts’ currently established for schizophrenia. Each was graded on a 0-3 scale for reproducibility, relevance for understanding schizophrenia, and durability over time. Some turned out to be more robust than others, but none got full marks. More important, even the most robust individual facts pointed in a range of different directions; they did not, as group, lead logically to any coherent explanation of schizophrenia” (p.182).

I will continue my investigation into schizophrenia, to include a proposed systems approach to understanding and treating this challenging disease, in my next post.

Insider: Irvin D. Yalom

I intend to reflect on several books by and about Irvin Yalom, one of the best known and still living psychotherapists in the U.S. In some ways, Yalom has influenced more people inside and outside of psychotherapy than any other contemporary psychotherapist because he is not only the originator in the U.S. of both existential psychotherapy and group psychotherapy approaches, but he has also published a series of fictional accounts of psychoanalysis and other types of psychotherapy, as well as several volumes of case stories.

Irvin Yalom published “Becoming Myself: A Psychiatrist’s Memoir” in 2017 at the age of 85. I will review some of this book, along with Ruthellen Josselson’s biography of Yalom, titled: “Irvin Yalom: On Psychotherapy and the Human Condition”(2008), and comment on several Yalom’s fictional works.

Yalom’s “Becoming Myself” provides background and insights into his various career shifts and accomplishments. It is too infected with name-dropping for my tastes, but because I have read so many of his books and intersected with many of the same people he mentions, I appreciated making connections between why he pursued existential psychotherapy, group psychotherapy, then used his psychotherapy and philosophy interests to write novels, and why he continued to practice psychotherapy and teach.

Josselson’s book about Yalom includes an interview with him and excellent summaries of his philosophical approaches to existential and group psychotherapy, as well as insights into most of his clinical stories and novels. The best summary statement of Yalom’s position regarding existential therapy is one Josselson provides from Yalom’s book, “Staring at the Sun” (2008):

“Psychological distress issues not only from our biological substrate (a psychopharmacological model), not only from our struggle with suppressed instinctual strivings ( a Freudian position), not only from our internalized significant adults who may be uncaring, unloving, neurotic (an object relations position), not only from disordered forms of thinking (a cognitive-behavioral position), not only from shards or forgotten traumatic memories, nor from current life crises involving one’s career and relationship with significant others, but also- but also- from a confrontation with our existence.” (p. 66-67)

Yalom was able to engage with patients from multiple perspectives, yet he did not prescribe medication, though he was an M.D. psychiatrist, and he focused on the existential givens: coming to terms with our eventual death, with our aloneness in the universe, with finding meaning in life and with recognizing our freedom and taking responsibility for the lives we lead.

Yalom stated that he “never intended to create a new field of therapy. My interest was to increase all therapists’ awareness of existential issues in their patients’ lives. (p.199). Existential psychotherapy has become an approach and field of psychotherapy nevertheless. The existential givens, which most existential psychotherapists employ to frame their approach to therapeutic insights and healing, are informed by the ideas of a number of significant philosophers. Yalom was particularly influenced by the philosophy of Nietzsche. Because of his interest in Nietzsche, Yalom found that using fiction as a means of exploring the ideas of psychoanalysis and those of Nietzsche would be a fine way to share his understandings with a large public. He published the novel, “When Nietzsche Wept” in 1992. He had originally hoped to fictionalize an encounter between Nietzsche and Freud in 1882, but Freud was still in medical school when Nietzsche had need of a therapist, so Yalom blended fact and fiction for an encounter between Nietzsche and Josef Breuer, who was Freud’s professor, and likely the originator of “talk therapy”- later psychoanalysis. Yalom said “fiction is history that might have happened” (p.239). Brought together by Lou Salome, who appealed to Breuer to help Nietzsche with his suicidal despair, Breuer and Nietzsche end up assisting each other. Each of them had been struggling with romantic obsessions. “Yalom saw in Nietzsche’s philosophy a movement toward an interior, self-actualizing process, toward the possibility of realizing one’s own potential. Nietzsche’s instruction for the necessary inner work was, ‘Become who you are’. What could be a more succinct statement of the goal of existential psychotherapy” (Josselson, p.81). “When Nietzsche Wept” sold well over 2 million copies worldwide and established Yalom as a fiction writer.

Another philosopher who influenced Yalom was Arthur Schopenhauer. While Nietzsche’s philosophy gave Yalom an opportunity to explore particular life affirming existential issues in psychotherapy, Schopenhauer’s philosophy presented an opportunity to postulate a life-denying, life is suffering position and in his novel, “The Schopenhauer Cure” (2006), these two positions are interposed within a fictional group psychotherapy process. This gave Yalom a way to probe the dynamics of group psychotherapy and draw upon his vast experience as a group therapist.

A former patient of psychotherapist, Julius Hertzfeld, is invited to join a therapy group that Dr. Hertzfeld runs. This former patient, Philip Slate, is a sex addict and claims to have been cured by Schopenhauer’s philosophy and now has his own therapy practice using as his therapeutic framework Schopenhauer’s notion that life is an endless cycle of wanting, satisfaction, boredom, then wanting again, desires endlessly plague us and cannot be fulfilled. Dr Hertzfeld is facing his own mortality and invites Philip to join his therapy group to persuade him, with the help of the group, of the importance of human relationships to meaning in life. Josselson (2008) says that “The Schopenhauer Cure” “is the one volume in which Yalom combined his existential and group therapy interests. It was Yalom’s intention that “The Schopenhauer Cure” also serve as a companion volume to his group therapy textbook and the fifth edition of “The Theory and Practice of Group Psychotherapy” is studded with cross references to pages of “The Schopenhauer Cure” that provide illustrations of a number of group therapy principles.”

Yalom’s “Lying on the Couch” (1996) turns the tables by investigating therapists rather than patients. His characters represent types which explore a number of issues that contemporary therapists have dealt with, such as transference-countertransference, the boundaries of sexual propriety, the role of money in relationships with patients, personal woundedness, such as obsessive-compulsive behavior, and the politics within a psychotherapeutic community. While this is fiction, Yalom probes much of the same territory as Gottlieb did in her “Maybe You Should Talk with Someone” (2019).

It is difficult to fully assess the impact that Yalom has had within and beyond the field of psychotherapy, because his fiction, non-fiction, teaching, and therapy practice have all influenced a wide variety of people. He has claimed that his autobiography will be the last book he writes, yet because of the meaning writing has provided him, one wonders if he may have even more material to explore. There are two quotes from his “Becoming Myself”(2017) which I believe represent the core of Yalom’s existential philosophic principles.

“The greater the sense of unlived life, the greater the terror of death” (p.294).

“I take very seriously the idea that, if one lives well and has no deep regrets, then one faces death with more serenity”(p.295).

Insider: Lori Gottleib’s “Maybe You Should Talk To Someone”.

Lori Gottlieb is a psychotherapist in Los Angeles and writes a “Dear Therapist” column for the Atlantic. Her new book (2019), which has been reviewed in a number of recent publications, is a classic “insider” series of reflections on her therapy stories working with clients and her sessions with her own psychotherapist.

Alex Kuczynski, in the May 12, 2019 New York times Book Review, summarizes Gottlieb’s book as “an irresistibly candid and addicting memoir about psychotherapeutic practice as experienced by both the clinician and the patient”. “Gottlieb explores her patients’ inner demons – a young newlywed diagnosed with terminal cancer, an older women who finds life meaningless and intends to commit suicide on her next birthday, a self- absorbed Hollywood producer, a woman stuck in a cycle of alcoholism and damaging relationships – and simultaneously peers into her own psyche with Wendell, a middle-aged, cardigan sporting psychotherapist.” This is a fine summary, yet the book is also about much more. As a psychotherapist and someone who reads the history of and current trends in psychotherapy, I am familiar with Gottlieb’s many insights and references. But she is such a terrific story-teller and explainer, that I was hooked by her style and presentation and at times, read as if I was a beginner to determine how the book might be understood outside the field of psychotherapy. For example, she explains a number of very insider terms, such as transference and countertransference, within a case story context that most anyone could grasp. She also sprinkles in various insider facts while staying with the story flow and without becoming didactic. On page 19, “(Fun fact: the countries with the most therapists per capita are, in descending order, Argentine, Austria, Australia, France, Canada, Switzerland, Iceland, and the United States.)” I have explanations for a number of these country stats and will discuss them later. Gottlieb also says, on page 37, “About three-fourths of clinicians who do therapy (as opposed to research , psychological testing, or medication management) are women.” This is a fun fact that I intend to look into later.

On page 47, she explains the notion of a “presenting problem”: Referring to her therapist, Wendell, she says, “He knows what all therapists know: That the presenting problem, the issue somebody comes in with, is often just one aspect of a larger problem, if not a red herring entirely. He knows that most people are brilliant at finding ways to filter out the things they don’t want to look at, at using distractions or defenses to keep threatening feelings at bay. He knows that pushing aside emotions only makes them stronger, but before he goes in and destroys somebody’s defense- whether that defense is obsessing about another person or pretending not to see what is in plain sight – he needs to help the patient replace the defense with something else so that he doesn’t leave the person raw and exposed with no protection whatsoever. As the term implies, defenses serve a useful purpose. they shield people from injury … until they no longer need them. It’s in this ellipsis that therapists work.” This is one of the best explanations available.

Another well-known fact among psychotherapists, but not necessarily well-known to people who have not been in therapy, Gottlieb mentions on page 36, “Study after study shows that the most important factor in the success of your treatment is your relationship with the therapist, your experience of ‘feeling felt’. This matters more than the therapist’s training, the kind of training they do, or what type of problem you have. “

Here is an example of how Gottlieb teaches us without seeming didactic:

“Carl Jung coined the term “collective unconscious” to refer to the part of the mind that holds collective memory, or experience that is common to all humankind. Whereas Freud interpreted dreams on the “object level”, meaning how the content of the dream related to the dreamer in real life (the cast of characters, the specific situations), in Jungian psychology, dreams are interpreted on the “subject level”, meaning how they relate to common themes in our collective unconscious.” (p.128)

Gottlieb sought out Wendel, her own therapist, essentially because of her being abandoned by a long-time boyfriend. She describes a session and the potency of Wendell’s intervention:

” ‘Are you ready to start talking about the fight you’re in?’ Wendell asks. “‘ You mean the fight with boyfriend?’ I begin.” ” ‘ Or with myself – ‘ ” “‘No , your fight with death.’ Wendell says.”

“For a second I’m confused, but then I flash to my dream about running into Boyfriend at the mall. Him: ‘Did you ever write your book?’ Me: What book? Him: ‘ the book about your death’. Oh.My.God.

“I have a feeling that Wendell has been storing up this question, waiting for just the right moment to float it out there. Therapists are always weighing the balance between forming a trusting alliance and getting to the real work so the patient doesn’t have to continue suffering. From the outset, we move both slowly and quickly, slowing the content down, speeding up the relationship, planting seeds strategically along the way. As in nature, if you plant the seeds too early, they won’t sprout. If you plant too late, they might make progress, but you’ve missed the most fertile ground. If you plant at just the right time, though, they’ll soak up the nutrients and grow. Our work is an intricate dance between support and confrontation.” (p.154)

This inside reflection on the therapy process is one of the very best descriptions I have read. Whether one is a therapist, a patient in therapy or someone intrigued with how therapy might work, this description puts the reader into the room and in the relationship.

Later in the book Gottlieb comments on our current variety of distractions in the U.S.: “The second people felt alone, I noticed, usually in the space between things – leaving a therapy session, at a red light, standing in a checkout line, riding the elevator – they picked up devices and ran away from that feeling.” She then mentions another well-known point about psychotherapy, but one which can bear repeating, particularly in our over- technologised and over stimulating social environments wherein loneliness and aloneness are exacerbated by avoiding authentic encounters and relationships with others. She writes, “The therapy room seemed to be one of the only places left where two people sit in a room together for an uninterrupted fifty minutes. Despite its veil of professionalism, this weekly I-thou ritual is often one of the most human encounters that people experience.” (p.260)

This quote acts as an appropriate lead-in for my next few posts, which will review and interrogate some of Irv Yalom’s works as well as his recent autobiography, “Becoming Myself: a Psychiatrist’s Memoir”. (2019)

The Culture of Psychotherapy

A number of years ago, I had planned to complete a book about what I termed, “The culture of Psychotherapy”. This was to be a book by an anthropologist doing research among psychotherapists. While I have not completed that particular book, I have incorporated much of the research into the current blog about psychotherapy and culture. I have attached a draft of the Introduction to the planned book so that the reader can know where I was heading and where some of that direction can be found in my posts for this blog.

Healing Fictions Bibliography/Filmography

           The following is a suggested list of books and films for those interested in a sampling of representations of psychotherapy. I invite readers to suggest other sources to add to this list.



Case Stories: Freud

Freud, S. Dora: an analysis of a case of hysteria.

Freud, S. The rat man.

Freud, S. The Schreber case.

Freud,S. The wolfman and other cases.

Case Stories

Akeret, R.U. Tales from a traveling couch.

Baur, S. Confiding: a psychotherapist and her patients search for stories to live by.

Benetar, J. Admissions: notes from a woman psychiatrist.

Corsini, R. J. Five therapists and one client.

Dinnage, R. One to one: experiences of psychotherapy.

Greewald, H., ed. Great cases in psychoanalysis.

Haas, S. Hearing voices: reflections of a psychology intern.

Kates, E. On the couch: great American stories about therapy.

Kottler, J.A. and Carlson, J. The mummy at the dining room table: eminent therapists revel their most unusual cases.

Hammerschlag, C.A. The dancing healers: a doctor’s journey of healing with native Americans.

Peseschkian, N. The merchant and the parrot: mideastern stories as tools in psychotherapy.

Rubin,T. I. Shrink: the diary of a psychiatrist.

Shem, S. Mount misery.

Siegal, S. and Love, E. The patient who cured his therapist and other tales of  unconventional therapy.

Stream, H. S. Behind the couch: revelations of a psychoanalyst.

Weinberg, G. The taboo scarf.

Yalom, I. Love’s executioner.

Yalom, I. Momma and the meaning of life.


Barnes, M. and Berke, J. Two accounts of a journey through madness.

Bateson, G. Percival’s narrative.

Chernin, K. A different kind of listening: my psychoanalysis and its shadow.

Gordon, E. F. Mocking bird years.

Greenberg, J. I never promised you a rose garden.

H. D. Tribute to Freud.

Israeloff. R. In confidence: four years of therapy.

Jamison, K. R. An unquiet mind: a memoir of moods and madness.

Kardiner, A. My analysis with Freud.

Kaysen, S. Girl interrupted.

Manning, M. Undercurrents: a therapist’s reckoning with her own depression.

Reiland, R. Get me out of here: my recovery from borderline personality disorder.

Rogers, A. A shining affliction.

Saks, E. The center cannot hold.

Salome, L. A. The Freud journal.

Slater, L. Welcome to my country.

Slater, L. Prozac diary.

Slater, L. Lying.

Shannonhouse, R., ed. Out of her mind: women writing on madness.

Styron, W. Darkness visible: a memoir of madness.


Boxer, S. In the floyd archives.

Michaels, P. Psych: a novel of the young Freud.

Rosenfield, I. Freud’s megalomania.

Stone, I. The passions of the mind.

Wheelis, A. The doctor of desire.

Yalom. I. When Nietzsche wept.

Yalom. I. Lying on the couch.

Yalom, I. The Schopenhauer cure.


Analyze This (1999) Billy Crystal / Robert De Niro

Analyze That (2002) Billy Crystal / Robert De Niro

An Unmarried Woman (1978) Penelope Russianoff / Jill Clayburgh

Don Juan De Marco (1995) Marlon Brando / Johnny Depp

Equus (1977) Richard Burton / Peter Firth

Final Analysis (1992) Richard Gere / Kim Bassinger

Good Will Hunting (1997) Robin Williams / Matt Damon

I Never Promised You a Rose Garden (1977) Bibi Andersson / Kathleen Quinlan

Lars and the Real Girl (2008) Ryan Gosling/ Patricia Clarkson

Ordinary People (1980) Judd Hirsh / Timothy Hutton

Prince of Tides (1991) Barbara Streisand / Nick Nolte

Spellbound (1945) Ingrid Bergman / Gregory Peck

Healing Fictions

I have written an essay about how psychotherapy has been depicted in films, TV, novels and memoirs which was part of some presentations I have made at various conferences. Psychotherapy has been depicted in films and TV in some intentional and unintentional comedic ways (e.g. Analyze This) as well as some astonishingly realistic ways (e.g. “In Treatment”). In considering psychotherapy cases or stories, my essay uses James Hillman’s framework for “healing fiction” in his book of that title, as well as Mikhail Bakhatin’s notion of dialogic discourse to examine what happens in all psychotherapy and how it is depicted beyond the therapy room.

See the attached essay and let me know if you have thoughts about the material.


Insiders: Mary Barnes/Joe Berke; Beulah Parker;Susan Sheehan

The three books I will be referring to here are variations from single insider accounts by people with schizophrenia. “Two Accounts of a Journey through Madness” (1971) combines Mary Barnes’s reflections on her schizophrenia and her therapist, Joe Burke’s account of his experience with Mary. “A Mingled Yarn” (1972) is Psychiatrist Beulah Parker’s reporting of a family with a person with schizophrenia, based largely on one of the family member’s account. “Is There No Place on Earth for Me” (1982) is reporter, Susan Sheehan’s account of the life of Maxine Mason (pseudonym Sylvia Frumpkin) and her struggles with schizophrenia.

In “Two Accounts”, Mary Barnes describes her “madness” in one of the clearest and most insightful reflections I’ve encountered:

“Much of me was twisted and buried, and turned in upon itself, as a tangled skein of wool, to which the end had been lost. The big muddle started before I was born. It went on, getting worse. My mother and I battled with feelings. My father was in it; then my brother barged in. My two sisters came and the mess got bigger. When I was grown up in years, I got a vague idea there was a big split in me between my head and my heart. I seemed to go around thinking big thoughts in my head quite cut off from the life in my heart.” (p.3)

She later describes some the family dynamics which may have played a role in her illness:

“Life was like ice, brittle ice. The whole family wanted this ice to melt, wanted to be loved. But we feared if the ice broke we would all be drowned. Violence and anger lurked beneath the pleasantries. On the surface we were a kind family. Physically we were well cared for, good food, lots of milk, fruit and ages, clean clothes and a big enough house. Deep down we were torn up with hatered and strife, destroying, killing each other” (p.5)

Mary survived multiple hospital stays and treatments of the era in Britain, but her long association with Kingsley Hall, which R.D. Laing inaugurated and with psychiatrist Joe Berke, who worked at Kingley Hall, an alternative communal living treatment center for people with schizophrenia in London, helped to transform her. She later became a famous artist.

Joe Berke describes when he first met Mary:

“Although trained as a nurse and later as a teacher of nurses, Mary eventually took up a second career as a hospitalized schizophrenic. Specifically because she wished to give up both professions, and come to terms with herself as a woman, she eventually created the situation by which we met, and I assisted her project of emotional disruption and resurrection.” (p.75) In a subtle way this statement illustrates the shift in approach toward a person with mental illness from a psychiatrist. Joe expresses his support for Mary’s “project” of healing herself.

Joe Berke later comments on his experience with families of schizophrenics and double binding: “In all cases where one or more family members had been labelled schizophrenic a unique pattern of communication could be made out. People did not talk to each other, but at each other, and tangentially, not directly. There was a continual shifting of position. Parents seemed impervious to the point of view of their children and vice-versa. One particular feature of such families and an essential weapon in the hands of parents bent on destroying the autonomy of their kids (and later vice versa) is known as double binding. Double binding is a means of putting another in a strait jacket of guilt and anxiety in order to prevent him from doing something you have already told him it is OK to do. It is a marvellous tool for driving someone mad.”(84).

I interviewed Joe Berke in 1993 in London and went with him to one of his Arbors Centers to interview some of the “guests” – patients with schizophrenia who live in a home community with ongoing therapist presence. Both Joe and the guests I interviewed claimed that the supportive and non-judgmental home community environment of Arbors, which was modeled after some of R.D. Laing’s ideas and Kinglsley Hall, was critical in their overcoming the symptoms of schizophrenia and the effects of their previous hospitalizations and medications.

Psychiatrist Bulah Parker chronicled a California family, the Carpenters, in “A Mingled Yarn, published in 1972, a year after “Two Accounts”. Eliot Carpenter had schizophrenia and his sister, Amy, who became a psychologist, acted as the insider for Parker’s account. Dr. Parker was influenced, as was Joe Berke, by the current double bind interpretations of family dynamics.

“The conflicting directives of his parents placed Eliot Junior in a double bind; pleasing one parent would lead to rejection by the other. Conflicting directives caused him to develop a split personality.” (xii) “There is now considerable evidence that persons will not become schizophrenic unless communication within the family is disturbed or distorted, though they may suffer from other serious psychopathological conditions. We have already noted how Eliot Junior was placed in a double bind that led to a divided self.”(xiv). I suspect that Dr. Parker was influenced by both Bateson and Laing.

Susan Sheehan’s book about “Sylvia Frumpkin” (Maxine Mason) is a great example of a reporter-cum-ethnographer capturing the internal and external life of a woman with schizophrenia. From the book jacket of “Is There No Place for Me?”(1982):

“Sylvia Frumpkin was born in 1948 and began showing signs of schizophrenia in her teens. She spent the next seventeen years in and out of mental institutions.In 1978, reporter Susan Sheehan took an interest her and for more than two years, became immersed in her life: talking with her, listening to her monologues, sitting in on consultations with doctors – even , for a period, sleeping in the bed next to her in a psychiatric center. With Sheehan, we become witness to Sylvia’s plight: her psychotic episodes, the medical struggle to control her symptoms, and the overburdened hospitals that, more often than not, she was obliged to call home.”

By the 1980s some thinking within the psychiatric world may have begun moving more toward a genetic and bio-chemical understanding and away from a strictly family dynamic explanation for possible causes of schizophrenia. Robert Coles wrote the Introduction to Sheehan’s book and has this to say:

“No one knows how it comes about that Sylvia Frumpkin has the kind of life we find chronicled in this book. Genes matter, some scientists say. Family life is important, others insist. Early childhood experiences count heavily, a number of doctors emphasize. But there is still plenty of room, one suspects, for speculation and research, room even for words such as ‘luck’,’chance’,’destiny’. Why, one wonders, this person and not that one? It is clear that many who seem to have everything against them genetically and environmentally seem to come out reasonably well psychologically, while others, with everything seemingly going in their favor, end up with exceedingly vulnerable, even fragile minds.” (p.xiii).

I believe that Coles’s statement may sum up my own current view and it may highlight the difficulty with coming to any conclusions about the etiology and management of schizophrenia. It is instructive, however, to review the available “insider” accounts over time. We may still hope for some breakthroughs in understanding this illness and in how to treat the debilitating symptoms.