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.

The Double Bind

Gregory Bateson’s idea about double binds began with the work he, Don Jackson, Jay Haley, and John Weakland ( the “Palo Alto” group) did from 1952 to 1954, and published as an essay, “Toward a Theory of Schizophrenia” (p.201) in Bateson’s “Steps to an Ecology of Mind” (1972). His later thinking about the notion of double binds went well beyond the early research focus on family relations with schizophrenic patients. For the purposes of this blog, I will comment only on the application of the double bind theory to the family dynamics of schizophrenic patients as represented in the original Palo Alto group research and a follow-up paper given by Bateson in 1969 at a Symposium on the Double Bind and included as an essay, “Double Bind 1969″(p.271) in “Steps”.

An example from the original research, which has been most often cited, and which best describes the double bind conflict for a schizophrenic patient is given on page 217 in “Steps”:

“An analysis of an incident occurring between a schizophrenic patient and his mother illustrates the double bind situation. A young man who had fairly well recovered from an acute schizophrenic episode was visited in the hospital by his mother. He was glad to see her and impulsively put his arm around her shoulders, whereupon she stiffened. He withdrew his arm and she asked, ‘don’t you love me anymore?’. He then blushed, and she said. ‘Dear, you must not be so easily embarrassed and afraid of your feelings.’ The patient was able to stay with her only a few minutes more and following her departure he assaulted an aide and was put in the tubs.”

This example illustrates the bind that the patient has been put into by his mother’s contradictory messages. She both invites his emotional expression and rejects it. He is caught and does not have an obvious way out of the conflict. Bateson and the rest of the Palo Alto group found similar conflicting messages among other families of schizophrenic patients and their research helped inform the family therapy and family systems movement about communications within families which may be a contributory cause of mental illness.

While we still know very little about schizophrenia and its possible causes, there was far less known in the 1950s/1960s. We need to keep this in mind when judging the assumptions made from the research findings of the Palo Alto group. One assumption Bateson and others made was that the dynamic of the double bind could almost by itself ( though they did acknowledge possible genetic and bio-chemical influences) set up the conditions for a schizophrenic break. We now know there are some genetic and biochemical components to any schizophrenic syndrome. I believe that most psychiatrists do not acknowledge the possibility that double bind conflicts could also contribute to schizophrenic episodes. Double bind conflicts can also contribute to other mental and emotional disturbances and family therapists know this. It is likely that schizophrenia is caused by some aspects of social-interpersonal dynamics along with genetic tendencies. The posts I made on the memoirs of Esme Weijun Wang and Elyn Saks would support this point. Both women have managed their schizophrenia with a combination of anti-psychotic medications and psychotherapy. Another assumption made by Bateson and others was that the essential conflict in a double bind familial situation was between a mother and her son or daughter. This was also part of a period of blaming the mother for all sorts of deficiencies and illnesses. Leo Kanner’s notion of the “refrigerator mother” which implied that a cold and rigid mother may have caused children to become autistic was part of this period. Kanner asserted this in a 1949 paper, “Problems of Nosology and Psychodynamics of Early Infantile Autism” and Bruno Bettelheim, an influential child psychiatrist, later reinforced this idea in his 1967 book, “The Empty Fortress: Infantile Autisim and the Birth of the Self”. By 1969, however, the refrigerator mother notion was already being discredited. Kanner, himself, stated at a conference at the National Society for Autistic Children, that the condition of autism was innate.

Mary Catherine Bateson, Gregory’s daughter, has a chapter, “The Double Bind: Pathology and Creativity” in “Cybernetics and Human Knowing”, Volume 12, No. 1-2, 2005, in which she explains how the double bind theory goes beyond the focus on pathology that marked the original research with schizophrenics, but she also comments on Gregory’s original insights about the “language” of schizophrenics:

“I can remember listening with Gregory to tapes of ‘schizophrenic word salad’ as he commented that there was a structure to this seemingly chaotic rant. Not to put too fine a point on it, he said, ‘there’s a method in his madness’. Gregory came to the conclusion that at the root of schizophrenia there was a logical incoherence, a disruption in thought and communication, that could be seen as either caused or exacerbated by patterns of relationship in the families of schizophrenics. These patterns were referred to as the double bind.” (p.12)

Whether family dynamics or other external influences play a role in the etiology of schizophrenia or not, the double bind theory has influenced family therapists, psychotherapists and psychiatrists to some extent until the present. And while we are currently in a biomedical period, it may be worth considering how family dynamics may contribute to various mental and emotional issues.

Insider: Barbara O’Brien

There are two themes from Perceval’s Narrative which I wish to explore: Bateson’s idea of the double bind (to be discussed in my next post) and the unusual circumstance of an apparent “spontaneous recovery” from schizophrenia, which I will discuss here. Barbara O’Brien’s “Operators and Things”(1976) is the most vivid account of a schizophrenic journey during her six months riding on Greyhound buses across the U.S. while being controlled by “Operators” – her hallucinated voices. O’Brien explains what she knows about schizophrenia (in 1958 when the book was first published) in the opening section of her book. She then explains how she developed schizophrenia and how the operators first came to her:

“I developed schizophrenia abruptly, in the way which is now considered most fortunate for an optimistic prognosis. I awoke one morning, during a time of great personal tension and self conflict, to find three grey and somewhat wispy figures standing at my bedside. I was, as might be imagined, completely taken up by them. Within a few minutes they had banished my own sordid problem from my mind and replaced it with another and more intriguing one. They were not Men From Mars, but the Operators, a group in some ways stranger than Martians could be. I listed to what the Operators had to say, weighed the facts which they presented to me , and decided that there was wisdom in following their directions. I packed some clothes and mounted a Greyhound bus, as they directed, and followed them. Riding off in the bus, I left safely behind me a mess of reality with which I was totally incapable of coping.” (p.9-10)

O’Brien narrates the specific personalities and characters of each of her Operators along her six -month long Greyhound schizophrenic journey. At one point she queries Hinton, one of her chief Operators, about the relationship between Operators and Things:

” Hinton sighed. ‘Things. Yes, of course. think of the word with a capital initial, if you like. It may help your ego a bit. All people like you are Things to us – Things whose minds can be read and whose thoughts can be initiated and whose actions canoe motivated. Does that surprise you? It goes on all the time. There is some, but far less, free will than you imagine. A Thing does what some Operator wants it to do, only it remains under the impression that its thoughts originate in its own mind. Actually, you have more free will at this moment than most of your kind ever have.'” (p.39)

Another Operator, Bert, explains, “the one great difference between an Operator and a thing is the construction and ability of the mind. Operators are born with special brain cells known as the battlement. With these cells, and Operator can extend and probe into the mind of a Thing. He can tap the thing’s mind and discover what is going on there, and even feed thoughts to the Thing’s mind in order to motivate it. The mental difference is one of ability, not one of quality. Operators, like things, may be stupid or intelligent. But that one difference permits the Operators to rule the Things.” (p.42).

O’Brien was “directed” or “guided” by Operators to buy Greyhound bus tickets to various cities and towns, to seek treatment for some ailments, and to continue to maintain her daily life for six months on the road. She wrote “Operators andThings” three years after she stopped having the hallucinations and delusions, which she has discussed as products of her her unconscious mind – Operators are the unconscious and Things are the conscious. She reflects on her “spontaneous recovery”:

“If I were having a slow time tracking down the cause of my schizophrenia, it was clear that once I had unconsciously understood the cause very well. I could cite a spontaneous recovery after six months of continuous hallucinations and delusions, a certificate of sorts, proof that my mind had found the road out of insanity, a feat that is never accidental. If the guideposts that remained in my memory appeared very often to be too much mumbo-jumbo, it seemed at least possible that the appearance of mumbo-jumbo existed because I could not read the strange language. According the the psychoanalyst who treated me, spontaneous recoveries are rare and weird events in advanced schizophrenia and when they occur they present mysterious spectacle- that of a mind walking out of a fourth dimension into which it had been propelled. No matter how many times I went over the story the Operators and told myself that it represented only well-organized fantasy without guidance or planning, the clear indications of guidance and planning persisted in standing out.” (p.145)

Both O’Brien and Perceval claimed to have recovered “spontaneously” from their schizophrenia, though both had spent time in mental hospitals. They both are critical of mental hospital treatments and the psychotherapists or psychoanalysts who worked with them. Approaches to treating psychotic conditions were obviously quite different for Perceval in the 19th century and O’Brien in the 1950s, and they would be considerably different now from what they were for O’Brien. Still, there is no known “cure” for schizophrenia and from current accounts by insiders, such as Elyn Saks and Esme Weijun Wang, there are not likely any single approaches , medications, or other treatments which seem to be effective for all cases.

Insider: Perceval’s Narrative

“Perceval’s Narrative: A Patient’s Account of His Psychosis, 1830-1832” (1979), is edited, with and Introduction by Gregory Bateson. This is likely the first account by a person with diagnosed schizophrenia, and it is a remarkable document. John Perceval was the son of a prime minister of England, who was assassinated when John was 9 years old. John, the fifth child of 12, was involuntarily incarcerated in an asylum in Bristol, England, when he was 27 years old. He was in the military. He was severely disturbed by religious conflict. He went briefly to Oxford, then joined an evangelical Christian cult. He began acting in a disordered manner and was placed under restraint in December, 1831. He remained in the Bristol institution until May, 1832 when he was moved to an asylum in Sussex, England. He remained there until the beginning of 1834.

Because of John’s intelligence and ability to articulate his journey into and out of his mental illness, we have his recorded narrative. I will share just some of his own descriptions of his mental state and insights into his condition and then comment on a few critical theoretical issues raised by Bateson in his Introduction.

The following is part of Perceval’s narration of the beginnings of his psychosis:

“I was tormented by the commands of what I imagined was the Holy Spirit, to say other things, which as often as I attempted, I was fearfully rebuked for beginning in my own voice, and not in a voice given to me. These contradictory commands were the cause, now, as before, of the incoherency of my behavior, and these imaginations formed the chief causes of my ultimate total derangement. For I was commanded to speak, on pain of dreadful torments, of provoking the wrath of the Holy Spirit, and of incurring the guilt of the grossest ingratitude; and at the same moment, whenever I attempted to speak, I was harshly and contumeliously rebuked for not using the utterance of a spirit sent to me; and when again I attempted, I still went wrong, and when I pleaded internally that I knew not what I was to do, I was accused of falsehood and deceit; and of being really unwilling to do what I was commanded. I then lost patience, and proceeded to say what I was desired pell-mell, determined to show that it was not fear or want of will that prevented me. But when I did this I felt as formerly the pain in the nerves of my palate and throat of speaking, which convinced me that I was not only rebelling against God, but against nature; and I relapsed into an agonizing sense of hopelessness and of ingraditude.” (p.x)

Bateson’s comment on this part of Perceval’s narrative, points to the impossible bind Perceval’s voices have put him in – a “double bind”. This notion refers to the choices presented to Perceval, that even if he does the “right” thing, he is blamed for doing it for the wrong reasons. Bateson suggests, “And his final word, ‘ingratitude’, suggests that this pattern of unconscious expectation- that every course will lead to rejection- has probably been early installed by the behavior of parents and siblings.”(p.xi) I will discuss the implications of Bateson’s suggestion and the larger context of his notion of the “double bind” in a follow-up post. For now, John Perceval’s narrative provides insights into his mental illness, but not necessarily it’s cause (we still do not know what may cause schizophrenia). Later in Perceval’s narrative his voices seem to offer alternatives to the double bind:

“At another time my spirits began singing to me this strain. ‘you are in a lunatic asylum, if you will’ – ‘if not you are in,’ &c.&c. ‘That is Samuel Hobbs if you will – if not, it is Herminet Herbert,’ &c.&c. But I had been so long deceived by my spirits that I did not now believe them when they spoke the truth. However, by listening and finding that the patients called him Samuel Hobbs, and by other accidents, I discovered at last that I was yet on earth, in natural, although very painful, circumstances in a madhouse. My delusions being thus very much abolished, I soon after got liberty during the day-time “(p.146)

Bateson comments, ” Here the voices are doing what Perceval wished his brother had done – accepting the fact of the delusion and reinforcing the doubt. They are also presenting real alternatives between which the patient can and must choose, while indicating their willingness to accept either choice. Perceval remarks that it was very unpleasant to have the voices do this, but he is honest enough to perceive that every time they do it he makes a step toward recovery. Here then Perceval presents, in two diagrammatic thumbnail sketches, the recipes, first for inducing his insanity, and then for curing it.” (p.xi)

Based on Perceval’s own narrative, it would seem that he “spontaneously recovered” from his schizophrenia and that the so-called curative factors were somehow built into his delutionary voices. Bateson even suggests that Perceval’s mental illness may have been an initiatory ceremony: “But it would appear that Perceval was a better, happier, and more imaginative man after his psychotic experience and I have suggested that the psychosis is more like some vast and painful initiatory ceremony conducted by the self.” (p.xix) This interpretation of Perceval’s journey provides the basis of lines of thinking about a psychotic experience as an almost sacred journey of discovery. And part of this line suggests that schizophrenia can be brought about by conflicts within families which may construct double binds, and that the way out of the conflicts may be to provide alternatives to the double binds. This line of thinking, which has been taken up by some family systems and family therapy approaches, and credited to Bateson, is still active, even in this era of bio-chemical-genetic interpretations of the causes and potential cures for psychoses.

Insiders: “The Center Cannot Hold” by Elyn R. Saks

Elyn Saks is a professor at the University of California Gould School Law and and adjunct professor of psychiatry at the University of California at San Diego School of Medicine. She is extremely accomplished by any measure. That she has done this while managing serious mental illness is remarkable. In a piece she wrote for the New York Times in 2013, she said,

“Although I fought my diagnosis for many years, I came to accept that I have schizophrenia and will be in treatment for the rest of my life. Indeed, excellent psychoanalytic treatment and medication have been critical to my success. What I refused to accept was my prognosis. Conventional psychiatric thinking and its diagnostic categories say that people like me don’t exist. Either I don’t have schizophrenia (please tell that to the delusions crowding my mind), or I couldn’t have accomplished what I have (please tell that to USC’s committee on faculty affairs). But I do have and I have. I am not alone. There are others with schizophrenia and such active symptoms as delusions and hallucinations who have significant academic and professional achievements.”

Saks provides some of the best descriptions of what living with schizophrenia has been like in her best selling book, “The Center Cannot Hold” (2007).

“This experience is much harder, and weirder, to describe than extreme fear or terror. Most people know what it is like to be seriously afraid. But explaining what I’ve come to call ‘disorganization’ is a different challenge altogether. Consciousness gradually loses its coherence. One’s center gives way. The center cannot hold. The ‘me’ becomes a haze, and the solid center from which one experiences reality breaks up like a bad radio signal” “No organizing principle takes successive moments in time and puts them together in a coherent way from which sense can made. And it’s all taking place in slow motion.” (p13).

Saks has become a significant spokesperson for combining medication and talk therapy for managing schizophrenia.

“Medication has no doubt played a central role in helping me to manage my psychosis, but what has allowed me to see the meaning in my struggles – to make sense of everything that happened before and during the course of my illness, and to mobilize what strengths I may possess into a rich and productive life- is talk therapy. People like me with a thought disorder are not supposed to benefit much from this kind of treatment, a talk therapy oriented toward insight and based upon a relationship. But I have. There may be a substitute for the human connection – for two people sitting together in a room, one of them with the freedom to speak her mind, knowing the other is paying careful and thoughtful attention – but I don’t know what that substitute might be. It is, at the heart of things, a relationship, and for me it has been the key to every other relationship I hold precious. Often, I’m navigating my life through uncertain, even threatening waters – I need the people in my life to tell me what’s safe, what’s real, and what’s worth holding on to.” (p.331).

Saks may be considered the ideal spokesperson for those who may believe one can overcome schizophrenia, but she honestly confronts that notion with her own experiences of both success in managing her illness and constant reminders of the limits and challenges she must deal with.

“My life today is not without it’s troubles. I have a major mental illness. I will never fully recover from schizophrenia. I will always need to be on antipsychotic medication and in talk therapy. I will always have good days and bad, and I will get sick.” (p.335).

A friend of Saks asked her if there were a pill that would instantly cure her, would she take it. She thought of the poet, Ranier Maria Rilke, who would decline psychoanalysis saying, ” don’t take my devils away, because my angles may flee too”. And she responds, “My psychosis is a waking nightmare , in which my demons are so terrifying that all my angels have already fled. So would I take the pill? In a heartbeat.” (p.336).