Strangers to Ourselves (Part Two)

Naomi is a black woman from Minnesota who threw her two children and herself off of a bridge in a suicide attempt in 2003. She and one of her children were rescued, but the other child drowned. Naomi was convicted of manslaughter and spent sixteen years in prison. This is a story of race, class, marginalization, psychosis.

Aviv provides plenty of family and socio-cultural background for a deep understanding of the contexts within which Naomi’s mental health assessment and treatment approaches impacted Naomi, but also highlights the types of biases that are likely built into our mental health and criminal justice systems.

Naomi was caught in a kind of double bind because her behavioral manifestations of psychosis also critiqued racial bias in society. Her delusions seemed to contain social-cultural truths. Aviv explains that “Minnesota determines whether a defendant qualifies as insane by using the M’Naughten Rule, a standard established in the United Kingdom in 1843, that requires that ‘the accused was laboring under such a defect or reason, from disease of the mind, as not to know the nature and quality of the act he was doing, or if he did know it, that he did not know that what he was doing was wrong.” (p.148) “When Naomi was evaluated at the Minnesota Security Hospital, two doctors concluded that she did not meet the requirements for the M’Naughten defense. Her delusions, they noted, stemmed from astute observations about the society in which she lived. She told the doctors, ‘when the framers of the Constitution were signing the document, they told a Black person, ‘Hey nigger, go get a pen’. On the bridge she said she had felt terrified for her children, because she knew ‘their life would be filled with inferiority, indifference, and ridicule.’ She explained that ‘I did not want them to die. I just wanted them to live better.'” (p.149)

Aviv says, “the evaluators seemed distracted by the truth of her sociological insights. Delusions are not spun from pure fantasy. It would be impossible to separate Bapu’s desire to wed Krishna from her dismay over the way that wives in traditional Indian households were treated; or Ray’s obsession with avenging his failed life and career, his fall from grace, from his expectation that white educated men should not have to contend with such a fate. Naomi’s psychosis drew from reality, too, but her doctors seemed to expect that delusions couldn’t on some level make sense.” (p.150)

The role that race and class may play in psychotic experiences is rarely considered. Revisiting my proposed systems approach to understanding the etiology of schizophrenia, as described in my post, “Back to Schizophrenia Part III”, the diathesis-stress model, which may take the form of genetic, psychological, biological, and situational factors which set up predispositional vulnerabilities, I would add race, class and gender as possible factors. So, in addition to other predispositional vulnerabilities, Naomi was a poor, Black woman.

Aviv says, “Mental-health institutions were not designed to address the kinds of ailments that arise from being marginalized or oppressed for generations. Psychotherapy has rarely been ‘a useful place of healing for African Americans’ wrote the scholar bell hooks. For a black patient to reveal her fears and fantasies to a therapist, trained in a field that has been dominated by middle-class white people, requires a level of trust that hasn’t typically been earned.” (p.130) Aviv says that “Black Americans are systematically underrated for pain, as compared with white patients” and “Their suffering is naturalized, as if they were built for it, a myth with a long history in this country.” She quotes Helen Hansen, a psychiatrist/anthropologist at UCLA, ‘it is woven into the fabric of this country that Black womens’ role is to do the work, to do the suffering, so why would we-the mainstream mental-health field-be chasing them down and asking, Can I treat you for your sadness.'”(pgs.130-131)

Aviv also discusses the historical “idea that emancipation damaged the Black psyche”. “Like the Parisis, the group of Indians thought to have assimilated British colonialism too abruptly, their minds, it was said, were buckling under the shock of transition” (p.136) This self-serving notion obviously presumes that Black people can’t handle being freed and civilized too quickly.

For Naomi, the interplay between social-cultural biases and individual personal suffering created a kind of dead end and escaping with her children by jumping off a bridge seemed her only option.

Laura has a very different background from Naomi. She grew up in a wealthy Greenwich, Connecticut community. She was a high performer in everything she engaged in. Laura had been diagnosed with Bi-polar Personality Disorder and then Borderline Personality Disorder. She was medicated for both of these. At one point Laura was prescribed Naltrexone to block the craving for alcohol, but she was also already taking Effexor (an antidepressant), Lamacal, Seroquel, Amblify, Ativan, Lithium, and Synthroid, a medication to treat hyperthyroidism, a side effect of Lithium. One of the central issues in Aviv’s report about Laura is the possible distinction between a “medicated self” and a “baseline self” (if there is such a thing). Laura was so sedated that she was sleeping fourteen hours a day and feeling dis-connected from what she felt was her “real self ” so she decided to “de-medicate”. Aviv discusses this along with her own continuing use of Lexipro. Laura has continued to manage her symptoms without medication , while Aviv manages her own with the aid of Lexipro.

From the research I have been reading there is no one-size-fits-all approach to medicating or not medicating for various mental illnesses. I personally question whether we can realistically identify a so-called “baseline self”, though most sources do describe what a “medicated self” experience is like. Laura was obviously over-medicated and felt disconnected from her previously non-medicated self. There are certain medications, such as Lithium, which have, in the past, been over prescribed and even abused. It is well known that Lithium was widely used in mental institutions, ostensively to mute symptoms, but to essentially manage and control patients by pacifying them. Yet there is a danger in not judiciously using helpful medications, along with psychotherapy to ameliorate serious mental illnesses.

Hava was the young teen who Aviv had formed an attachment to when she was in the hospital at age 6 for anorexia. As an “Afterword”, Aviv tracks down Hava’s father only to find that Hava had recently died. Aviv uses this afterward to tell more of Hava’s story and to return to her own reflections about anorexia. Aviv learned from Hava’s journals and from her father, David, that Hava had been hospitalized multiple times and was even in a coma after a suicide attempt. She had essentially run out of money and options and ended up living with her father, who was a physician, for twelve years. Hava wrote “I suppose I am one of those people that thoroughly understands myself yet I am a stranger to myself”. (p.233)This nuanced reflection, from which Aviv gets the title of her book, highlights the complicated experiences of identity and mental illness, which Aviv has so astutely represented throughout her book. In puzzling over what may have distinguished Aviv from Hava in how anorexia affected them, Aviv refers to what Louise Gluck, who was anorexic, wrote: “‘The tragedy of anorexia seems to me that its intent is not self destructive, though its outcome often is. Its intent is to construct, in the only way possible when means are so limited, a plausible self'” So Hava constructed her “plausible self” as the dependent anorexic, while Aviv says, “on these terms, perhaps my experience with the illness could be viewed as a success. After I left the hospital, my parents were a little afraid of me. They deferred to my opinions, and everyone established clearer boundaries. At the same time I was given latitude to behave as oddly as I pleased. I never felt stuck in a particular story that others had created for me. I had the freedom to get bored of my behavior and to move on.” (pgs. 229-230) I suspect there is more to the reasons the outcomes for Hava and Aviv have been so different, but their age differences while in the hospital and the ways their significant parental figures treated them once they were released must have played an important role.

One of the beauties of Aviv’s book is that there is no easy summary of the stories she has told or issues she has raised. We are currently burdened by an avalanche of psychological diagnostic and self-help literature , most with attempts to simplify and offer solutions for various mental illnesses. My own research indicates the tangled web of personal, social, cultural, institutional, medical contexts within which we must all navigate in identifying and working through mental disturbances. Rachel Aviv illuminates this tangled web.

Strangers to Ourselves:Unsettled Minds and the Stories that Made Us (2022) – Rachel Aviv (Review)

Rachel Aviv’s new book is about mental illness and all the messy notions of stigma, the impact of race, cultural prejudices about women, and psychoanalytic vs medicalized psychiatry. Aviv comes close to what my blog is all about: the relationship between psychotherapy and culture. I may be returning to some of her chapters after this post since she has covered some of the ground I covered in my research in India and with the Washington School of Interpersonal Psychoanalysis practiced at Chestnut Lodge by Harry Stack Sullivan, Freida Fromm-Reichman, and Otto Will (I wrote about this in my post “Back to Schizophrenia”).

Aviv tells the stories of five individuals, Ray, Bapu, Naomi, Laura, and Hava, in addition to herself, each of whom has a different set of diagnosed mental illnesses and through each, Aviv explores various critical social, cultural, medical, ethical issues.

Aviv approaches her research much as an anthropologist would, by spending time within social and cultural contexts of the protagonists of her stories. Her work is in the mold of Katherine Boo’s “Behind the Beautiful Forevers” (about slum life in Mumbai) and Anne Fadiman’s “When the Spirit Catches you, You Fall Down.” (about a Hmong family and their interface with the health care system in Merced, California), both of which I have used in ethnography courses because of their brilliant ethnographic research but also their engaging story telling.

Aviv begins with the story of herself being diagnosed with anorexia and briefly hospitalized at the age of six. The issue of how anyone could have anorexia at age six opens into an inquiry of the entire diagnostic enterprise in psychotherapy. She questions whether she had anorexia, though she had refused to eat for enough time to frighten her parents and psychiatrists. This experience acts as stimulus for her ongoing inquiry into what constitutes mental disturbance and how does the psychiatric and psychotherapeutic profession identify, diagnose and treat mental illnesses. What is the interplay between cultural context and situation and mental illness?

Aviv states in her introduction “At times I contemplated devoting the entire book to each life I have written about here, but I wanted to emphasize the diversity of experiences of mental illness, the fact that, when questions are examined from different angels, the answers continually change.” (p.25). This approach distinguishes Aviv’s book from most of the current literature in the mental health field. Though she devotes a chapter to each of the people’s stories, these individual stories provide avenues for Aviv’s investigation of the various complicated issues around the entire mental health enterprise. She summarizes what each story investigates:

” The book begins by telling the story of a man torn between the twentieth century’s dominant explanations for mental distress – the psychodynamic and the biochemical. The rest of the chapters move beyond these two prevailing frameworks: one character tries to understand who she is in relation to her guru and gods; another is reckoning with her country’s racist history and how it has shaped her mind; a third has been so defined by psychiatric concepts that she doesn’t know how to explain her suffering on its own terms.” (p.26)

I will summarize the issues as Aviv has presented them via each person’s story and comment on these issues.

Ray is a man who was diagnosed with melancholia or depression. After years of mostly psychoanalytic treatment at Chestnut Lodge, which was in Rockville, Maryland, Ray sued the establishment in 1982 for failure to cure him. Aviv’s reporting about the history of Chestnut Lodge and the psychoanalytic approach of Harry Stack-Sullivan, Freida Fromm-Reichman, and other psychiatrists at Chestnut Lodge is fair and accurate, yet she accepts uncritically the review from Thomas McGlashan’s 1984 meta analysis of case records from Chestnut Lodge, wherein he judged that psychotherapy was ineffective for schizophrenia. He famously stated, “the data are in and the experiment failed.” I challenged this assessment in my post on “Back to Schizophrenia”. McGlashan’s own commitment to the use of psychiatric medications, no doubt influenced his interpretation of the cases he studied. Also, it has always been extremely difficult to judge the relative success of psychoanalytic treatments, since they involve profound unsettling changes and possible personality transformations. As I reported in my earlier post, the treatment approach at Chestnut Lodge was distinct from most other treatment facilities in that people with psychotic symptoms were treated humanely, with respect. Psychoanalysts at Chestnut Lodge believed that listening to patients’ struggles and concerns and helping them navigate their ways of interpreting their being in the world would be more effective than alternative approaches, particularly using psychopharmaceuticals, which until settling Ray’s lawsuit, were rarely used. After years at Chestnut Lodge, Ray left and began a treatment process with psychiatric medications. He claimed that these medications worked for him, while the psychoanalytic treatment at Chestnut Lodge did not. I suspect that he was helped by his treatment at Chestnut Lodge, but because of narcissistic behavior patterns, he did not acknowledge how he was helped and needed to blame someone for his ongoing depression and inability to form healthy relationships. Perhaps these issues would have been better resolved had he stayed in treatment at Chestnut Lodge. As a result of this lawsuit, the psychiatrists at Chestnut Lodge were forced to begin using anti-psychotic medications. While Ray seemed to improve in some respects as a result of his medications, he continued to manifest obvious symptoms of depression, loneliness, anger towards his father, inability to maintain healthy relationships with others, and aspects of narcissistic personality disorder (not mentioned by Aviv). He could not stop blaming his time at Chestnut Lodge for all of his behavior problems.

Bapu was a woman from Chennai, India. Her story, as related by Aviv, involves a parental matched marriage to an older man, her life as the equivalent of a servant among her In-laws, Bapu’s alienation from her in-laws, her repeated running away to become a spiritual follower of various ashram gurus, and her mental health diagnosis of schizophrenia and hospitalization to attempt a “cure”. The topics explored in Bapu’s story include the relationship between spiritual/mystical experiences and those of psychosis; the role of women and marriage in India; how madness or mental illness is dealt with in India.

I interviewed two psychiatrists, two psychologists and a psychoanalyst, during a research trip to India in February, 2003. Among several themes each therapist mentioned in common is the custom of patrilocal (a wife living with her husband’s relatives upon marriage) arrangement along with a dowry system (the opposite of bride price, where a wife’s family must compensate in money or goods the husband’s family). These two practices put enormous pressure on a bride’s family and on the bride. Bapu’s case was a bit unique because she had her own house upon marriage and her in-laws came to live in her house. But she was nevertheless a stranger in her own house. Her husband and his relatives relegated her to the equivalent of a domestic servant. One of the most common complaints of female therapy patients in India (according to my interviewees) has been conflict between young wives and their mothers-in-law. Because of the patrilocal system new wives are expected to serve at the will of their mothers-in-law, typically in the mother-in-law’s house. It is not uncommon for new wives to run away. It is possible that part of Bapu’s reason for repeatedly running away and either taking up residence at various ashrams or temples, or in homeless situations, under the assumed rationale of seeking spiritual transformation, was to escape the oppression of her in-laws. Seeking some kind of spiritual existence in a culture of gods, demons and mystics may be interpreted as a symptom of a form of psychosis, such as schizophrenia. Hallucinations and delusions being symptoms of schizophrenia, are typically manifested by mystics who have been spoken to or commanded by a god or gods. Delusions of grandeur and paranoia, and hearing the voice of God are regularly associated with religious mystics – even leaders of mainstream religions (e.g. Jesus, Moses, Joseph Smith, etc.). Aviv quotes one psychiatrist, Dr. Manon (who I also interviewed), who said, “In schizophrenia too much religion is not good” (p.79). I believe she meant that people with a preconditional vulnerability to schizophrenia would have too much cultural reinforcement for being swallowed into spiritual delusions and thereby magnifying their symptoms. Aviv seems to question this, but I think Manon had already had plenty of experience with psychotic patients and her own cultural patterns to identify this phenomenon.

Russell Shorto, in “Saints and Madmen” (1999), discussed the possible similarities and differences between psychosis and mysticism. He quotes Tony Stern, a Martin Buber scholar: “I think there is a fine line between the two conditions, and perhaps the underlying process is the same- so that essentially the question is what do you do with it, how you respond to it. If you look at the great mystics, I can’t think of one who did not show signs of what today would be considered severe psychosis or manic-depressive illness.” (p. 97). Shorto also refers to a distinction made by Tomas Agosin: the psychotic delusion is grandiosity; “a mystic is humbled by his experience, a psychotic inflated” (p.71). From Aviv’s description of what Bapu communicated in her journals and the fact that Bapu became more like a holy person (as perceived by her community) in her later years, I think she was humbled and not inflated by her experiences.

Aviv suggests that psychoanalysis may not be a good fit for Indian culture and she mentions the original contact that Freud had with Girindrapekhar Bose (though she does not provide his name), the founder of the first psychoanalytic society in Calcutta, India. Aviv does not dive deeply enough into this topic and she almost brushes it aside by stating, “But Freud’s psychoanalysis proved largely incompatible with a culture for which mysticism is often essential to people’s lives.” (p.80) Bose actually developed a theory and practice which paralleled that of Freud, but without ever meeting Freud or reading his books. He contacted Freud via letter once he had read some of Freud’s books. Freud was thrilled that he had a devotee in India. This is well reported in Ashis Nandy’s book, “The Savage Freud” (1995). Nandy (who I interviewed in 2003) is known as a political psychologist and some of his analysis points to the influence of colonialism. He said, “Psychoanalysis came to represent something more than a therapeutic technique that could be adapted to the mental health problems of the burgeoning, partly decultured, urban bourgeoisie, even though that is how Bose often viewed it, especially when writing for his international audience. Psychoanalysis also had to serve as a new instrument of social criticism, as a means of demystifying aspects of Indian culture that seemed anachronistic or pathological to the articulate middle classes, and as a dissenting western school of thought that could be turned against the West itself. ” (p.83). Nandy says that his essay about Bose tells how “Bose’s unique response to Freud’s theories was shaped by the psychological contradictions that had arisen in Indian culture due to this colonial impact and the cultural contradictions within psychoanalysis itself” (p.83). So while Aviv may be somewhat correct about psychoanalysis being largely incompatible with a culture still imbedded in mysticism, she has not considered the ongoing influence of Western culture in general and Western theories and methods of healing.

Sudhir Kakar, India’s foremost psychoanalyst, whom I interviewed in 2003, spent three years as an ethnographer investigating the many and varied approaches to healing mental illness among India’s traditional healers and those with various emotional, mental illnesses.The results of his research are reported in his book, “Shamans, Mystics, and Doctors: Psychological Inquiry into India and its Healing Traditions.”(2002). As a trained psychoanalyst with a practice in Delhi, Kakar is able to compare Western and traditional Indian approaches to healing mental illness. Kakar states, “what makes the majority of Indian approaches to mental health different from the dominant Western view on the subject is their emphasis on the relational. In the Indian prescriptive lists (for example in Ayruveda) one is struck by the number of ideals of mental health that prescribe the person’s behavior in relation to others, especially family and community. A restoration of the lost harmony between the person and his group, we saw earlier, was one of the primary aims of the healing endeavors in the local and folks traditions.” (p.274). Kakar mentions a number of other distinctions between Western psychotherapy and traditional Indian approaches to mental health, and though his book is more than twenty years old, most of what he identified as differences are still in evidence while Western influenced psychotherapies continue to exist alongside traditional practices. I will revisit this topic in a future post.

I will continue my reflections on Aviv’s book in the next post.

Freud and Jung (Review)

Just when I moved away from my posts on Jung, I picked up my copy of “Freud and Jung: Years of Friendship, Years of Loss”(1990) by Linda Donn. This was my second reading and I had forgotten how appropriately succinct and enlightening it was. At under 200 pages, Donn has done a terrific job of using interview material and correspondences among the inner circles of Jung and Freud – particularly between Freud and Jung. The net effect of the correspondences reaffirms most of what I have already covered in my post on the reasons behind the split between Jung and Freud, though there is one feature of Freud’s thinking and actions which I did not adequately discuss: his consistent, dogged diplomatic attempts to keep Jung within the fold of the psychoanalytic movement.

In one of Jung’s letters to Freud, he cautiously initiates some of his reluctance to address why he is beginning to distance himself from Freud: “I still have resistances to writing to you at the right time… The reason for the resistance is my father-complex, my inability to come up to expectations, (one’s own garbage, says the devil).” (p.119) In response, Donn says, “Freud did his best not to pressure Jung. He tried not to write too often or too soon. He would save a letter and mail it after a safe interval. Or send it right away and explain that psychoanalytic business had made the letter necessary. But once in a while he would chastise Jung. Freud wrote: ‘I am merely irritated now and then- I may say that much, I trust – that you have not yet disposed of the resistances arising from your father-complex, and subsequently limit our correspondence so much more than you would otherwise. Just rest easy, son Alexander.'(likely referring to Alexander the Great). ‘I will leave you more to conquer than I myself have managed, all psychiatry and the approval of the civilized world, which regards me as a savage.'” (p.119)

I believe that Freud had already sensed Jung’s backing away from the sexual libido theory and he needed to carefully cultivate Jung’s commitment to the psychoanalytic movement, since Freud still believes Jung is his only viable heir.

Dunn continues: “But after each flare up there was calm again. Disagreements over definitions of the libido and the frequency of their correspondence were tempered with humor. mild reproach and the inevitable apology, and quickly lost among other, more immediate concerns.” (p.119)

Leading up to the 1910 Congress to be held in Nuremberg, Freud was beginning to sense possible disaffections from his attempts to keep the psychoanalytic movement alive among the Christian Swiss. At the last minute during final Congress planning with Jung , Freud finds out that Jung has sailed to America to see a patient. Donn writes, “Freud leaned that another Swiss friend, Oskar Pfister, would not be able to attend the Congress. ‘I still have not got over your not coming to Nuremburg,’ Freud told Pfister in alarm. ‘Bleurer is not coming either, and Jung is in America, so that I am trembling about his return. What will happen if my Zurichers desert me?'”(p.120)

Meanwhile, the Viennese analysts attending the Congress were upset that Freud was promoting Jung to head up the international movement and they gathered at a closed door meeting during the Congress to stage a protest. Donn says, “When Freud learned of the protest meeting, he went at once to Stekel’s room. Accounts differed over what happened next; Franz Wittels’ was the most restrained. ‘Most of you are Jews’ he remembered Freud saying, ‘and therefore you are incompetent to win friends for the new teaching. Jews must be content with the modest role of preparing the ground. It is absolutely essential that I should form ties in the world of general science. I am getting on in years and am weary of being perpetually attacked. We are all in danger… They won’t even leave me a coat to my back. The Swiss will save us – save me, and all of you as well.'” (p.122)

Psychoanalysis would not have taken off and had such an impact if it were not for Freud’s persistence and attempts at diplomatically bridging the gaps of various idealogical and power groups among the eastern and western European analysts. Another example of this is referred to by Donn, ” It was not for pleasure that Freud had made the long journey to Bavaria at Christmastime in 1910. The psychoanalytic movement had suffered serious setbacks since the Nuremberg Congress, particularly in Switzerland. Bleuler, who had been among the first to acknowledge Freud’s theories, now refused, along with most of the Swiss, to join the new organization dedicated to Freud’s psychoanalysis. Bleuler’s influence over his Swiss colleagues was significant, and his stature in academic psychology would have lent Freud’s association an austere luster. Here in Munich, amid the robust festivities of the German Christmas, Freud would do his best to win him back.” (p.125) Apparently, Jung had only slight influence among the Swiss at this time, so Freud needed Bleuler.

Meanwhile Freud was taking a risk by placing most of his trust and hopes in Jung. Donn says, ” The precarious future of the analytic movement now depended, through attrition and by design, on one-man: Carl Jung.” {p. 127) Even when it became progressively obvious that Jung was wavering in his support for the libido theory, Freud went out of his way to accommodate some of Jung’s suggested “adjustments”. Donn says, ” Despite Freud’s reservations about tampering with the libido theory, he did his best to be open-minded. When Jung wrote him, ‘the essential point is that I try to replace the descriptive concept of libido by a generic one’, Freud had a ready answer. ‘ I am all in favor of your attacking the libido question and I myself am expecting much light from your efforts. Often , it seems, I can go for a long while without feeling the need to clarify an obscure point, and then one day I am compelled to by the pressure of facts or by the influence of someone else’s ideas.'” (p.141) This statement seems quite different from the pictures often painted about Freud’s stubborn insistence on complete adherence to his sexual libido theory. Unfortunately it seems it was too late to pull Jung back from his own ambitions. Donn says, “It seemed to Freud that he had reached the end of a rope. ‘I certainly knew about his ambition’, he wrote to Ferenczi, ‘but I hoped to have pressed this power into my service through the position I created for him and am still preparing. The prospect of doing everything myself as long as I live and then failing to leave behind a worthy successor to carry on, is not very comforting.'”(p.141)

Freud was beginning to panic over the possible defection of Jung and other Swiss and he needed to be sure he could at least insure his hold on his closest allies. Donn says, “In the spring of 1913, it was by no means certain who in the end would stand at the side of Freud and at the side of Jung. The question included not only Oskar Pfister and Ludwig Binswanger, men who were expected as Swiss to be torn in their loyalties between their countryman, Carl Jung, and the man they loved and admired, Sigmund Freud. Questions of loyalty surrounded even the members of Freud’s secret council. Only three years before, Ernest Jones had vacillated over Freud’s theory of sexuality. Now, under Jung’s leadership, he and others were offered a strong alternative. Jones appeared to have been won completely to the cause, but Freud was uneasy at times. ‘I am not at all contented’, he would complain to Jones, ‘that you bear Jung’s insolence without remonstrating’. Freud was even briefly unsure of Karl Abraham. ‘Abraham has been here for three days’, Freud wrote on one occasion. ‘I am not informed how far Rank succeeded in gaining him to join our band’. Freud would give gold rings to the members of his secret committee, symbols of loyalty, and Karl Abraham would receive one of them.” (p.164) The members of Freud’s secret Committee included, Otto Rank, Karl Abraham, Max Eitington, Ernest Jones, Sandor Ferenczi, and Hanns Sachs. Among these most loyal followers, even Otto Rank and eventually Sandor Ferenczi changed their positions regarding the sexual libido theory. Rank broke with Freud, while Ferenczi remained a friend. Jones became Freud’s first biographer and translated many of Freud’s writings into English. Abraham, Eitington, and Sachs remained loyal.

Much has been written about the politics of the psychoanalytic movement and it is clear from Donn’s research into the correspondence between Jung and Freud and between Freud and his other colleagues, that Freud used all of his persuasive powers to shape and promote psychoanalysis into one of the most influential ideas in human history.

Insider: Galit Atlas and “Emotional Inheritance: A Therapist, Her Patients, and The Legacy of Trauma.”(2022)

Galit Atlas, Ph.D. is a psychoanalyst in New York , who has just published a new book about emotional inheritance. She has brilliantly and elegantly shared stories of various types of intergenerational trauma of her therapy patients mixed with some of her own life experiences, particularly growing up in Israel and being part of the Israeli army. I have written about case studies or case stories as part of my post on “fictive healing”. I have also posted reviews of Irvin Yalom’s work, some of which include “Love’s Executioner”(1989) and “Momma and the Meaning of Life” (1999), and Lori Gottlieb’s “Maybe You Should Talk to Someone” (2019). There are also plenty other collections of case stories by other therapists. What distinguishes Atlas’s book from others is that she has followed the thread of intergenerational trauma throughout her patients’ stories while sharing an intimate glimpse into a psychoanalytic therapeutic process and the relationship between a therapist and her patients. She does this without obvious use of analytic jargon. And she shares her own experiences not to highlight them but to help contextualize how she works to help her patients move through their dilemmas. I had written about Lori Gottlieb’s clear explanation of therapy terms, such as transference and countertransference. Atlas has explained what these terms mean without ever using the terms but telling the story of each therapy session and the dynamics of the therapeutic relationship. Another distinction between Atlas’s book and most others, to include those of Gottlieb and Yalom, is that she keeps the focus on her patient’s stories without displaying the cleverness of her analytic interpretations or interventions. She almost always supports her patients in their interpreting and moving through their own conflicts.

During a time in the U.S. when psychoanalysis has been falling out of favor for several decades (though as I have written elsewhere psychoanalysis is still popular in Argentina, Israel, France, and possibly a few other countries), Atlas has been able to sneak into her stories the depth and effectiveness of a psychoanalytic process without announcing it as psychoanalysis, and any particular school or approach of psychoanalysis. Her own approach is relational psychoanalysis and she mentions this but only briefly. I believe she has done a great service to the psychoanalytic community by featuring the process in an engaging storytelling manner to a general audience. Along the way there are a number of terrific, almost throwaway, comments with profound meaning. Here are some examples:

Summarizing one of her patient’s journeys as an illustration of emotional inheritance, she states “In the end, we come to realize that it is the unexamined lives of others that we ourselves end up living” (p.262).

“Sex and money are two topics that people usually try to avoid, not only in their lives, but in therapy too.” “Any unwelcome feeling can be expressed through sex or money: aggression, hostility, the need for domination and power, as well as fragility, narcissism, and trauma.” (p. 243).

“Unprocessed abuse keeps the intergenerational cycle going”. “Healing – breaking the cycle of abuse- is often filled with resistance to the possibility of change. That possibility intensifies the conflict between the part of the self that strives for future liberation and the part that is connected to the past and to previous generations.” (p. 223).

“Paranoid thoughts are a result of our aggressive feelings, feelings that we couldn’t tolerate and needed to get rid of by attributing them to another person. the more aggression is disowned and projected onto others, the more frightened we become of those people.” (p.215).

“Confusing the therapist with intense feelings, evoking fear, or even presenting intense erotic fantasy can serve as a defense strategy to make sure the therapist is unable to think, and therefore unable to know anything real about the patient.”(p.209)

“Heterosexual culture often overvalues solidness, which is associated with erection, masculinity, independence, and activity, while it devalues fluidness, which is associated with femininity, vulnerability, passivity and even contamination.”(p.164).

“A dynamic communication evolves that includes moments of mismatch and potential misunderstanding, followed by moments of re-attunement and repair.”(p.142)

“When our minds remember, our bodies are free to forget.” (p.119)

Referring to Freud’s writing about melancholia and mourning, Atlas says: “melancholia, according to Freud, is an unconscious process in which, instead of detaching and withdrawing the emotional investment from the lost person, the melancholic preserves and keeps that person alive inside them through identification with the dead. If the person is me and I am them, then there is not loss. Keeping the lost person caged inside denies the loss, but at the same time it holds the melancholic person forever captive to it. As a result she loses parts of her own investment in life and vitality.” (p.75)

All of the above quotes are imbedded within case stories, thus they relate directly to what is going on between the therapist and her patients, yet, as can be gleaned from each quote they convey significant insight into the various conflicts, issues, insights, and possible resolutions of the knotty human behavior conundrums we can all relate to.

For various reasons, trauma and Post Traumatic Stress Disorder (PTSD) as a topic in its many manifestations, has become almost too familiar to a general population. One of the benefits of this is that those who have suffered from PTSD or other related trauma symptoms are more likely to seek help from therapy, since social stigma about this and other psychological illnesses has been somewhat reduced. A possible downside of such broad social references to trauma and PTSD is that there may have become an over interpretation about what trauma is and who has been traumatized by whom. There is ongoing debate among psychologists about what might constitute trauma, PTSD, types of trauma, various treatments for various types of trauma symptoms, etc. Current research indicates that one size (trauma and treatment) may not fit all (types of trauma and types of treatments). As more people who have experienced various types of trauma in their lives share their stories in memoirs, documentary films, fictional representations, and in undergoing serious therapy, such as that of Atlas’s psychoanalysis or other treatment modalities, we will likely be able to parse particular kinds of trauma which will be responsive to particular kinds of therapy. As in some of my other posts, I have indicated that a systems approach will be the most successful in the long run. Allopathic drugs have not been particularly helpful, and certain CBT treatments are not the answer, but MDMA (Ecstasy) has shown some promise and a combination of careful clinical use of MDMA plus various alternative healing modalities, such as yoga, meditation, and so on, plus talk therapy (psychoanalysis) may be the most effective.

Atlas has helped us understand the inner workings of how one’s parents, grandparents, and other relatives who may have experienced some trauma can manifest in each person who continues to experience traumatic symptoms, and how we might be able to seek help from a psychotherapist who can accompany us in navigating the challenging journey of recovery.

The Importance of Erich Fromm: A Review of “The Lives of Erich Fromm” by Lawrence J. Friedman (2013)

On Multiple levels, Erich Fromm’s writings were prescient and as relevant currently (2021) as they were in the 1940s through the 1970s. Fromm was a psychoanalyst, social psychologist, political activist and public intellectual – perhaps the most influential one in the U.S. during the 1950s through the 1970s. Lawrence Friedman’s biography of Erich Fromm is a thoroughly engaging and balanced investigation into the many “lives” or areas of involvement of Fromm.

A key to Fromm’s impact is what Friedman states in his Prologue: “Fromm’s ‘life’ as a social critic and ‘public intellectual’ was facilitated by his remarkable capacity to convey complex thoughts in psychoanalysis, ethics, theology, political theory, social philosophy, cultural creations, and much more in simple, direct prose, that appealed to the latent ideals and fears of his time.” (p.xxi) I will not be commenting on most of Fromm’s books, but just to note here that his “Art of Loving” from 1956 has sold over twenty million copies, and “Escape from Freedom” (1941),according to Friedman, the “deepest and most important of Fromm’s books, which excavated the social psychology of authoritarianism during the age of Stalin and Hitler, has sold more than five million copies.” (p.xxii) And most of Fromm’s more than twenty books have sold in excess of a million copies.

Fromm was the rare social scientist/philosopher who influenced and was influenced by a number of disparate individuals and groups: Margaret Mead and her interdisciplinary circle of anthropologists and psychologists, often referred to as the culture and personality group; the Frankfurt Institute group, including, Theodore Adorno, Max Horkheimer, Herbert Marcuse and others; the sociologist David Reisman ; psychoanalysts Karen Horney and Freida Fromm-Reichmann, each of whom Fromm was married to; his twenty-three years in Mexico (1950-1973), where he established the Mexican Psychoanalytic Institute and prepared numerous Mexicans to become psychoanalysts; D.T. Suzuki, who mentored Fromm in his brand of Zen Buddhism; Martin Buber, who influenced Fromm and Freida Fromm-Reichmann in the 1920s to open a “therapeuticum’ for Jewish patients in Heidelberg; Fromm counted as friends, Adlai Stevenson, William Fulbright, Philip Hart, and Eugene McCarthy, all of whom sought his advice on world affairs.

Fromm remained committed to both Marx’s and Freud’s central ideas throughout his career. While he eventually distanced himself from Freud’s libido drive theory, he incorporated many other psychoanalytic insights into his own social character theory. Freidman states, “Fromm’s theoretical alternative to Freud was a vaguely outlined concept of ‘social character’ where external social structures recast inner impulses and provided a person his orientation in life.” (p. ) Fromm continued to wrestle with how to incorporate or discard Freud’s libido and instinct drive theory as he developed his own theory of social character. Freidman quotes Fromm: “Character can be defined as the form in which human energy is canalized in the process of assimilation and socialization… the character system can be considered the human substitute for the instinctive apparatus of the animal” (p.xxv) And: “Socially produced drives are specifically human and have to be explained as reactions toward a particular fit of social conditions and not as ‘sublimations’ of instincts” (p.xxvi) Freidman claims that Fromm continued to modify his concept of social character for the rest of his life, but when he first developed it, while he was still a connected scholar with the Frankfurt Institute in 1939, Fromm felt it was mandatory to pursue an alternative to the libidinal theory, and this led to his dismissal from the Institute. Freidman states, “Fromm’s colleagues at the Frankfurt Institute, clinging to the literal wording of Freud’s early texts even as Freud departed from them, felt betrayed and called for Fromm’s termination.”(p.xxi).

I have asked myself why I am so drawn to Fromm and his ideas. The conception and construction of this blog about psychotherapy and culture may provide evidence of my attempts to bridge individual psychology and social theory and my own experience as a practicing anthropologist and psychotherapist has led me to appreciate how Fromm spent his life (or lives?) writing about this very notion of the relationship between the individual and social human. I have written about Gregory Bateson being a kind of ‘bricoleur’ as he moved thorough a number of intellectual disciplines. I now regard Erich Fromm as a both an intellectual and activist ‘bricoleur’. He consistently applied theory to practice and he was able to reconceive and reconstruct his theories and practices based on new political and social conditions wherever he was living and working (Europe, Mexico, the U.S.). I am particularly interested in Fromm’s combining Marxian and Freudian concepts and in his formulations about authoritarian personalities and Fascism, though I will comment on of some of his other ideas as I continue posts.

Fromm wrote “Escape From Freedom” in 1940 and his prescience about the rise of fascism and authoritarianism is particularly potent currently as we are experiencing similar patterns throughout the world more than 80 years later. We might question whether Fromm’s interpretation of what causes authoritarianism fits the rise of Hitler and Musolini in the 1930s and 1940s or Bolsanaro, Trump, Putin, and Duterte in the 21st century, but his cultural, psychological character notions deserve close consideration. Fromm argued that since the enlightenment humans had been experiencing enhanced personal freedom, but that this freedom often set up unmanageable anxiety and uncertainty. Freidman says, “it was less burdensome to delegate new found freedoms to authority figures and to embrace the false securities they promised (i.e. simply conform to external social pressures) than to trust one’s own powers of rational decision making.” (p.66). Fromm also proposed that the dynamic of forfeiting one’s freedom to an authority figure or institution likely set up a neurotic strategy of sadomasochism as a way of coping. Large populations under authoritarian leaders and systems may experience powerlessness and may in turn displace their anger and frustration on those who are perceived as “other” (immigrants, women, socially/culturally different). Freidman says, “Freedom required that the individual summon the energy and courage to make spontaneous, productive, reasoned and life-affirming use of his autonomy, Fromm argued. One must not delegate choices to authority figures that offered sadomasochistic appeals and demanded social conformity.” p.83)

While Fromm was still involved with the Frankfurt Institute group, he and they were committed to Freud’s essential drive theory and to Marx’s early writing “Economic and Philosophical Manuscripts” (1844). Fromm later (after he broke with the Frankfurt group and with Freud’s libido theory) wrote “Marx’s Concept of Man”(1961). Friedman says, “Fromm used ‘Marx’s Concept of Man’ to argue that the young Marx of the ‘Economic and Philosophical Manuscripts’ filled Freud’s conceptual gaps by offering a thoroughgoing critique of the capitalist society and values that orthodox Freudians had uncritically accepted. Fromm found Marx deeply sensitive to inner, and often unconscious, psychological motivation. Fromm’s Marx was essentially a socialist humanist and a formulator of what he called ‘productive social character’.” (p.223)

In further explaining Fromm’s embracing humanist ideas of Marx, Friedman states: “In characterizing the 1844 Marx, Fromm was essentially expounding his own prophetically tinged credo for the 1960s. Marx’s essential concept was to transform man from an alienated laborer who detested his routine work and consumed to fill a sense of inner emptiness. Estranged man worked simply to have goods and services, not to be a vibrant, loving, creative, and productive entity. For Marx, ‘true’ socialism represented ‘the emancipation from alienation, the return of man to himself, his self-realization’. Only through humanistic socialism would man cease to be miserable, cease being an estranged cog in the process to enhance productivity and profits for the few; he would transcend the chronic ‘antagonism between man and nature, and between man and man’.” (p. 223)

Fromm presented a paper, “Marx’s Contribution to the Knowledge of Man” in Paris in 1968, and published in his 1970 book, “The Crisis in Psychoanalysis”. In this paper/article, Fromm argues his case for Marx’s dynamic humanist depth psychology. There are hints in the paper/article about Fromm’s later reckoning of Freud’s and Marx’s approaches to psychology. Fromm says, “Marx saw, and in this respect more deeply than Freud, that consciousness is the product of the particular practice of life which characterizes a given society or class. It is ‘from the beginning a social product’, like language, it arises ‘from the need, the necessity for intercourse with other men, While man thinks he is determined and motivated by his own ideas, he is in reality motivated by forces behind his back and of which he is not aware.'” (p.74) Fromm further states, “Marx’s concept of consciousness and ideology led to one of the most essential parts of his theory of revolution. In a letter of September, 1843, he speaks of consciousness as ‘a thing which the world must appropriate, although it does not want to do so… our motto must be then: reform of consciousness not by dogmas but by the analysis of the mythical consciousness unclear to itself, be it religious or political’. The destruction of illusions and the analysis of consciousness – that is to say, awareness of the reality of which man is not conscious, are the conditions for social change.” (p.74)

Fromm followed this with: ” Awareness of reality as a key to change is for Marx one of the conditions for social progress and revolution, as it is for Freud the condition for the therapy for mental illness. Marx, not being interested in problems of individual therapy, did not speak about the awareness as a condition for individual change, but considering his whole psychological system, it is by no means a tour de force to make this connection.” (p.75)

Most of what Fromm draws from Marx’s 1844 paper is not widely known or understood, but Fromm makes a clear case that Marx , while focusing on social dynamics, had preceded Freud in his position regarding illusions and embracing reality. I subscribe to the same world view. Humanity has not changed significantly since either Marx or Freud established their theories. The world in 2021 is awash in illusions, fake news, scams, conspiracy theories, religious fundamentalism, and bold political lies. Alienated man is all around us. Inequality is rampant throughout the world. The confrontation with illusions and embracing of reality that both Marx and Freud argued for has not taken hold to any significant degree. My blog continues to engage individual behavioral issues and social cultural influences. A psychological, cultural, economic, social revolution awaits us.

Reviews: Lauren Slater – Welcome to My Country & Prozac Diary

I have written elsewhere about psychotherapy “insiders”, which refers to therapists and patients/clients who have written memoirs, or case studies/ case stories about their experiences with the therapy process and mental illness. One of the best insiders for providing an appreciation and understanding of the experiences of both a person suffering from mental illness and a therapist working with those who suffer from mental illness, is Lauren Slater, I reviewed her most recent book, “Blue Dreams” earlier. For this post I will refer to her books, “Welcome to My Country” (1997) and “Prozac Diary” (1999).

“Welcome to My Country” is both about Lauren’s own breakdowns and ongoing depression and the various issues and insights about her clients in her psychotherapy practice, while “Prozac Diary” is all about her own history with depression and her “relationship” with Prozac. This is the best account, among many, of an inside view of depression and reactions to psychiatric medicines. I have used Slater’s book, along with Andrew Solomon’s “The Noonday Demon” for my “insiders” material on depression, which also interrogates the relationship between bio-chemical treatments and psychotherapy. “Prozac Diary” and “The Noonday Demon” are best for discussing the “illness-treatment”relationship and identity issues. Also, the issues of creativity, productivity, and self-worth, which may include the illness (depressions) or at least the dynamic of dealing with the “edge” – pain is worth investigating. Once Prozac or other psychotropic drugs may have removed the pain, what happens to the self or an identity which was previously known and which may have required some “pain” for the creative “whole” person? Both Solomon and Slater discuss this. Does Prozac create a different person? When influenced on a regular basis by a psychotropic drug, will it affect the person as a self – the psychology of one who is in the world and relationships with other people?

Slater comments on people who said something like, “Prozac helped me become the person I was meant to be”. But Slater says, “And yet for me it was not that simple. My personality, yes, had always consisted of suppressed energies and curiosities, but also of depressions, echoing intensities, drivenness that tipped into pain, With the exception of the counting and touching obsessions, which I was only too happy to be rid of, I missed these things, or parts of them anyway, for they were familiar to me as dense fog and drizzle, which had its own sort of lonely beauty, as does a desert or the most mournful of music.”(p. 44).

I will post other material on depression later. There are quite a number of excellent accounts from other insiders, to include William Styron’s “Darkness Visible”, Anthony Storr’s “Churchill’s Black Dog”, Kathy Cronkite’s “On the Edge of Darkness”and several books by Kay Redfield Jamison.

In reflecting on both her being with depression and her role as a therapist, Slater, in “Welcome to My Country”, makes an observation which goes to the heart of the psychotherapy “enterprise”:

“What after all, is therapy, if not a story of progress? Such a story could be harmful to people who are bound to feel like failures in a  milieu where the expectation of improvement is so clearly etched. Perhaps the therapist’s job is not to help grow but to help shed, chipping away at the marbled mind until the original nubs and spurs emerge. Instead of thinking in terms of development, maybe we should be thinking in terms of sloughing, making the padded self thinner and thinner, until a true skeleton juts out.”(pgs 140-141)

Blue Dreams – Lauren Slater

I will be reviewing a number of memoirs by psychotherapists and people who have experienced psychotherapy as clients or patients. For a book that I originally conceived as “The Culture of Psychotherapy” one of my chapters is devoted to what I refer to as the “Insiders” – those on both sides of the couch, so to speak. I will share some comments and interpretations of various memoirs in future posts, but I want to begin with reviewing a recent book by my favorite insider memoirist, Lauren Slater. “Blue Dreams: The Science and Story of the Drugs that Changed Our Minds” (2018) is only part memoir. It is primarily about mind drugs and mental illness. Lauren Slater knows both better than most, as she has been both a long time patient both on and off various drugs, as well as a psychotherapist, helping others navigate their challenges with mental illness. Later I will comment on a few of Slater’s previous memoirs, particularly “Welcome to My Country” (1997)    and “Prozac Diary” (1998).

“Blue Dreams” is an engaging and  thorough tracing of the history of using various psychiatric drugs to deal with various mental illnesses. Slater has experienced numerous medications to treat bipolar and obsessive-compulsive disorders. She draws on both her own experiences and the research on the efficacy in trials and with ongoing patients in psychiatric care. Her conclusions are decidedly mixed about long term efficacy of any drugs, to include the once considered “miracle drug” – Prozac. The book’s chapters follow a general chronological path from Thorazine and Lithium through SSRIs to MDMA (Ecstasy) and Deep Brain Stimulation. Slater wants psychiatry to move toward discovering answers to “why” and not just “how”. She says: “I’d rather see psychiatry come up with a few theories that finally pan out, theories that illuminate the pathophysiology or etiology of depression, the structure of schizophrenia, the reason for the retreat that autism so often is.” “What, for instance, causes schizophrenia? How durable is the dopamine hypothesis, and what does it mean that when it comes to schizophrenics, drugs which dampen dopamine seem to diminish hallucinations and drugs that increase dopamine appear to make schizophrenic symptoms worse, even though, when researchers compare dopamine levels in so-called normal subjects with those in schizophrenic subjects, they find no correlation between high dopamine levels and psychiatric problems in the general population? Perhaps more compellingly, the low-serotonin story suffers the same fate. We have been told that depression and OCD are the results of too little serotonin in the brain, and that this is the reason why serotonin boosting drugs such as Prozac work. But some depressed people have a lot of serotonin while some well-adjusted people have less.”

Slater sums up her view of the possible future of psychiatry in her chapter ” Where We’re Headed”: “I think the future of psychiatry is, strangely enough, right here, in tiny tabs of acid and chalices of psychedelics such as ayahuasca, psilocybin, and MDMA. ” She also reviews the newest psychedelic that psychiatry has turned to – ketamine, a drug typically used by anesthesiologists during surgeries, but now being used (ketamine infusion therapy) only for those patients who are treatment resistant.

In a favorite passage of hers which looks back and points forward in psychiatry, Slater says, “Our next golden era of psychopharmacology, I predict, will be with psychedelics, drugs not discovered, but rediscovered. And in some strange way they reunite us with the father of psychoanalysis, Sigmund Freud, who believed that awareness was the vehicle by which we could be cured of our ills. At once brand-new and ancient, psychedelics allow us a radical awareness of our place and purpose in the universe; they actually seem to set us straight, these tie-dye drugs of the long-gone hippiedom.” Whether Slater is right about this or not we may be opening back up to psychedelics and we may approach them quite differently from our hippie past. We may also discover the “why” of some mental illnesses in the process?


Labyrinths: Emma Jung

There have been plenty of biographies of Carl Jung and plenty as well of other leading figures in the history of psychotherapy. I will be reviewing a number of them later, but because “Labyrinths: Emma Jung, Her Marriage to Carl, and the Early Years of Psychoanalysis” (2016) by Catrine Clay is the first biography of Emma Jung and her role in Carl’s life and the psychoanalytic movement, I feel it is fitting to feature her now. During this time in 2018 when we are gradually recognizing and giving credit to women who have contributed so much in many different fields, Emma Jung, as the wife of Carl has rarely been mentioned in literature about the psychoanalytic movement. Emma. She was a wealthy heiress and fell in love with Carl when she was just seventeen. Her wealth enabled him to accomplish a number of things he would otherwise not have done. But it was her steadfastness, tolerance and intelligence which withstood his various affairs and long time quasi marriage to Toni Wolff, that helped Carl succeed. She supported him and her children, and acted as Carl’s thinking partner during the early years of his relationship with Freud. She traveled with Carl for some of his trips to Vienna to work with Freud and she had a series of personal letter exchanges with Freud herself. She stood by Carl when he finally broke with Freud. She eventually embraced his relationship with Toni Wolff. She became an analyst herself in her forties and one of her first analysands was Barbara Hannah, who was Carl’s first biographer. Emma’s approach as an analyst was different from most others: one analysand said, “She approached the problem you brought to her quietly, even tentatively, but there was no fumbling. To be “right” did not appear to interest her. She met you where you were at”.

I have read quite a number of works about the various figures in the psychoanalytic movement and the social/political rifts which were part of the early years. Reading about Emma’s role in helping Carl and herself in shaping the movement, regardless of the split with Freud, is essential in contextualizing what we already know. It really wasn’t all Carl.


I will be posting occasional reviews of books, articles, films and television programs about psychotherapy. These reviews will be in random order and not in time sequence – in other words, some reviews will be about books from many years ago, while others will be very current. An example of a current review will be of the book by Catherine Clay (2016), “Labyrinths: Emma Jung, Her Marriage to Carl, and the Early Years of Psychoanalysis”.