A Few New Thoughts About Schizophrenia and Mental Health

After reading the January 14, 2021 New York Review of Books article by Gavin Francis -“Changing Psychiatry’s Mind”, a review of Anne Harrington’s “Mind Fixers” (which I reviewed earlier), and Nathan Filer’s “This Book Will Change Your Mind About Mental Health: A Journey into the Heartland of Psychiatry” (which I review here), I read Filer’s book and memoirs by Louise Gillett: “Surviving Schizophrenia” and “Surfacing” (both of which Filer reports on in his book). I also read Bethany Yeiser’s ” Mind Estranged: My Journey from Schizophrenia and Homelessness to Recovery.” While most of these sources cover what I have already brought forth in previous posts, there are a few ideas which these authors cover that I want to explore here.

What each of these sources explore is the essential question of diagnosis in mental illness. Particularly psychosis or schizophrenia. Both Filer and Gillett suggest that the diagnosis and labeling of schizophrenia may create a level of stigma which may be more harmful than the symptoms experienced from a mental illness itself. Filer is a psychiatric nurse in England and Gillett is a former psychiatric patient in England who details her experiences with being diagnosed and labelled as as having schizophrenia.

Another issue which is suggested by Gillett in her two memoirs is the possibility of “spontaneous recovery ” from a psychotic episode or series of episodes. I have previously discussed this with regard to “Percival’s Narrative” and Barbara O’Brien’s “Operators and Things”. Both John Percival and Barbara O’Brien claim to have recovered from their schizophrenic episodes without the influences and interventions from the psychiatric practitioners, medications and institutions. Both of them did however spend time in a psychiatric hospital and receive various treatments prior to their “recovery”. Louise Gillett also spent time in a psychiatric hospital and claims that the institution and psychiatric professionals did not “heal” her and may have even magnified her psychotic episodes by diagnosing her as having schizophrenia.

Because I have read and reviewed several other memoirs of people who have been diagnosed with schizophrenia, I found Gillett’s two books quite superficial in comparison. She does not provide much detail about her symptoms, medications, other treatments. She dwells on what she considers the principal source of her illness to be the stigma of having to bear the diagnosis of schizophrenia. It seems that the word itself carried extra weight for her. I have not found this to be true of others who have had a diagnosis of schizophrenia and written about it. Filer refers to Gillett’s books and discusses the conundrum of possibly needing some accurate diagnoses for mental illness, yet having to deal with the ongoing stigma associated with each serious diagnosis, and the fact that none of the DSM diagnoses are to be considered very accurate. Filer refers to schizophrenia as “so-called schizophrenia” and mental illness as “so-called mental illness.” Filer critiques the “enterprise” of psychiatry in the UK, particularly, though he also includes some significant material on the weaknesses of psychiatric medicine in the U.S. While he has pointed to some obvious gaps in the way psychiatric illnesses are diagnosed, he does not really offer viable alternatives. Without some well considered and monitored diagnostic system (and the history of the DSM should tell us how tenuous this is), there is little hope for a systematic series of treatment approaches.

An irony of Gillett’s almost obsessive focus on the impact of having the word “schizophrenia” as her diagnosis, is that it may further the stigma associated with the term. I have been working to de-stigmatize mental illnesses and some of that process may be to consider the current diagnostic labels as somewhat equivalent to those for most physical illnesses. Why should sharing with others that you have schizophrenia be different from sharing that you have diabetes? Both Wang and Saks, whose books I reviewed earlier, help to “normalize” the label “schizophrenia” and help us to understand how they have navigated their lives without the label or treatments defeating them. I also find Gillett’s claim of recovery without psychiatric help unconvincing. I continue to question the notion of “spontaneous recovery”, particularly without knowing the history and context of a person’s psychotic experiences from multiple perspectives – not simply from a self-report memoir.

Bethany Yeiser’s “Mind Estranged: My Journey from Schizophrenia and Homelessness to Recovery” is a more encouraging report of how determination and eventually finding the right psychiatric help and effective medications can overcome the debilitating symptoms of schizophrenia. This is a summary of her background from the “About The Author” section of her book:

“Bethany Yeiser hold’s a bachelor’s degree in molecular biology with honors from the University of Cincinnati. Prior to becoming homeless, she published three articles in biochemistry. She began full-time college at age fifteen and transferred to a well-known university on the West Coast at seventeen. Bethany spent three months living and volunteering in the slums of Nairobi, Kenya and Lagos, Nigeria during the summer of 2002. On her return, in October, 2002, she incorporated a small nonprofit organization to channel money into indigenous African medical missions.It raised several thousand dollars to build a new clinic in Nairobi, Kenya in August of 2003.

“Bethany is an accomplished violinist. She has performed in orchestras, worked for recording studios, and taught violin. Bethany was diagnosed with schizophrenia in 2007 after spending four years as a homeless person, including one year spent with only one change of clothes, and living in a churchyard. Today, she is an invited speaker at numerous conferences for physicians and health care providers who seek to learn more about schizophrenia. Bethany has studied ancient Hebrew and Mandarin Chinese.”

This is obviously a promotional piece, yet the message about her homelessness and mental illness is that it can be overcome and she can continue to have a rich and challenging life. After some years of receiving various treatments with psychotherapy and medications, Bethany was prescribed Clozaril and “by April 2008, my long-awaited miracle finally occurred and the voices were quieter. I was becoming free of the screaming chorus of children’s voices and other characters that lived in my mind for two and a half years. They have been with me nearly every minute I was awake. It was possible for me to go out in the community again and begin making friends. I went to social events with confidence, met new friends and spent time with them. I almost felt like my old self again, the way I felt during high school and during my first semester at the university. After a year on Clozaril, the voices were virtually gone. I was healthy and thin again. I had recovered.” She later states that she is not “healed” but “recovered”:

“I do not consider myself healed from schizophrenia, but I am fully recovered. I want to be a spokesperson for people desperately impaired by psychoses, and bring the good news that, today, mentally ill people can have happy and productive lives. I hope that someday, psychiatric patients will be treated with compassion like people with infections, cancer patients and people with all other diseases of the body.”

I still plan to post a separate piece on the DSM and what I might term the “diagnostic enterprise”, but I am aware of the need not to “throw out the baby with the dirty bathwater” – we need to continue to recalibrate our diagnostic processes and assumptions, while obviously excising patently wrong and harmful categories and terms. For now, schizophrenia – as fuzzy as it still seems – has no viable replacement term or diagnostic category. People have schizophrenia and we need to help them.

Responses to Queries and Comments about Addiction

I have received quite a few comments and queries about my two posts on addiction. These were sent to me directly. Because there are several important points which people have made, I would like to address them here.

  1. What is the relationship between drug addiction and depression? I answered this by indicating that I will have a series of posts later on depression, but that substance abuse is regularly a way of self-medicating for depression, bipolar illness or other mental illnesses.
  2. Could I elaborate on and clarify my thinking about the meaning of schizmogenesis? I will do so below.
  3. Why did I refer to the 6 principles about AA and not indicate the 12 steps? My response to this is indicated below.
  4. Why did I not discuss the “Higher Power” issue in AA? I answered this in conjunction with my answer to the 12 steps. Indicated below.
  5. How can we change an entire cultic group – not just individuals within a cult? My response to this is indicated below.
  6. What are the best ways to transform an individual who is addicted within a cult? My response is below.
  7. What are some examples of predispositional vulnerabilities? My suggestions are below.
  8. How does my theoretical framework account for non-drug, non-cultic addictions such as addictions to media screens – TV., Computers, smart phones? Lots of discussion about this among readers. My responses are indicated below.

I have used Gregory Bateson’s definition of schizmogenesis, because I have been building my theory based on his use of the term in his “Cybernetics of Self” article. I don’t believe anyone is certain about Bateson’s idea beyond his use in this article and a few other sources. I have referred to schizmogenesis in my own publications and I still find it useful in explaining an addiction process. Bateson said it meant ” progressive directional change”. Symmetrical schizmogenesis would be two parties, say alcoholics, matching each other drink for drink in a competitive progressive manner. It is symmetrical because they are matching each other with the same behavior. He also suggested that a drinker could be in a contest with a “symbolic other”, such as a bottle of alcohol. The alcoholic doing battle with the bottle. This is also symmetrical. And the bottle typically wins the contest. The drinker commits an epistemological error in assuming they can beat the bottle (or the other drinker). As the contest escalates (progressive directional split) the addictive process gets out of control. I take some license with Bateson’s notion of complementary schzmogenesis by applying it to the relationship between a cult leader (messiah, guru) and his followers, which he did not do. My thinking about this is that each “complements” the other in a progressive manner. The more the cult leader needs his followers and the more he acts like a messiah, the more they require him to be a messiah and the more they become part of the fantasy or delusion. They are each addicted to the other in a progressive split fashion. As I mentioned in my earlier posts, as Jim Jones, Shoko Asahara, and Donald Trump became more delusional, their followers also became more delusional.

I did not list the 12 steps, and instead referred to the 6 principles that Nan Robertson lists in her book, “Getting Better”, because I am developing a theory of addiction which goes beyond alcoholism or other drug addiction. The 12 Step programs are extremely effective for AA, NA, AlAnon, but may not appeal to those recovering from other addictions, such as former cult followers. Also, since God is mentioned six times in the 12 Steps, some recovering alcoholics/ drug addicts may not subscribe to a belief in God. Hence, the reference to “higher power” or “power greater than ourselves”, which opens the 12 steps to anyone , including non-religious people. The psychological potency of admitting that one does not have control of their addiction, is a willingness to break the cycle of schizmogenic dependency and epistemological error of pride or assumed ego control.

Can we somehow change an entire cultic group? Not likely, though the catastrophe of Jim Jones taking more than 100 people with him to death did end the People’s Temple as an organization. And there have been a number of other apocalyptic or millenarian cults which have dissolved once leaders have been deposed, imprisoned, or killed. In order to interrupt the symmetrical schizmogenesis, some sort of intervention needs to break the cycle of addiction between the leader and followers. It is also possible for the cult followers to continue to follow the symbol of a cult leader/ messiah/guru even are he or she is gone. The current hard-corps followers of former president Trump are still in an addictive pattern, as he is with them. The addictive process has been interrupted but not yet dissolved. Meanwhile, the best way to bring about a serious interruption with any cultic group is to work with individuals who are already questioning their attachment the the leader and group or those already disaffected. Particularly if the administrative leaders in an organization become disaffected and begin to leave, there is more likelihood of many others leaving.

This relates to the next item: what are the best ways to transform an individual who is addicted within a cult? I suggest that the individual must first be able to become aware of the epistemological error of believing that salvation or a new millennium is forthcoming if they maintain their attachment to the cult leader and the doctrines of the cult. If they are able to correct this error and retain their independent will and decision making, they will likely need to have some alternative and healthy replacement of a belief system and identity social group to the cult system and group. One of the hallmarks of AA groups is that they replace unhealthy attachments with attachments to AA members who can identify with and support those who are addicted and help them avoid relapsing. The same might be operable with the equivalent of reprogramming groups for former cultic followers. There have been some recent reports that people who had become swept up in the QAnon conspiracy cult have become disenchanted with the group because the prophesy of Trump winning his presidential bid and bringing about the changes promised by the delusional ideology, did not happen. This has also been an outcome of a number of other messianic or apocalyptic movements of the past, when prophesies have proven false.

In a recent National Public Radio interview, Audie Cornish interviewed Dannagal Young, a professor of communications at the University of Delaware, who said: ” If you think about somebody who is either addicted to heroin or you think about someone who has fallen into a cult, or you think about someone who has fallen into QAnon, they are all creating boundaries that divide them from their families. They’re all engaging in dysfunctional behaviors and holding dysfunctional attitudes that make their participation in regular life more difficult. And they all tend to need a similar kind of psychological pipeline and outreach to bring them back.” (January 15, 2021). My thinking about this is that the boundaries that Young refers to must be crossed by family members, friends, other helpers, and hands must be offered to pull the addicted members out of the addicted trap. This is easier said than done , as anyone who has been tasked with this effort can testify. Also, regarding the QAnon phenomenon, the social media platforms which likely exacerbated the growth of the conspiracies, were not interrupted soon enough to quell the addictive process. Earlier intervention – deplatforming – may have broken the cycle before the outcome of an insurrection on the Capitol.

The topic which received the most reaction was one being experienced by a number of parents with young children: possible addiction to various screens – phones, computers, television. This issue includes both time spent and types of content. The ramifications of this topic are beyond what I am covering in the post, but the potential for current and future addictions to our collective communication devices does follow the pattern of what I have suggested for addictions to various drugs, as well as the type of complementary schizmogenesis which occurs between a cult leader and cultic followers. Screen time alone for children can affect not just their mental and emotional life, but even their eye health. Some current studies are indicating that children need to be spending more time outside and away from media platforms indoors to protect their eyes from later weaknesses. The monitoring issue for parents is not just managing time spent, but types of content. This can also be a challenge for adults. During the current Covid 19 pandemic, more people are spending more time indoors and on various electronic devices, which contain content varying from relatively healthy educational material to levels of entertainment to downright harmful material. As I mentioned earlier, the QAnon conspiracy, with it’s essentially false and delusional material, gained a large following among people who were spending all their waking hours engaging with various online sties addicted to the conspiracy theory. Addiction to stimulation from electronic devices, may be somewhat similar to a gambling addiction. There is a need for stimulation, sometimes out of boredom, though not always. There is an expected reward. The reward can be positive enough to warrant seeking further reward, or it can be negative enough to want to seek a more positive reward. Either way, the addiction process may have begun. If there are any predispositional vulnerabilities, such as serious dependency needs or biopsychosocial weaknesses, the reward provided by the involved activity may become schizmogenic and interventions may become necessary. And , again, the earlier the interventions the better.

I welcome any comments or questions you might have about my responses.

Proposing an Addiction Recovery Theory

Building on the ideas explored in my previous post about the addicition process, schizmogenesis, and epistemological errors, I am proposing a possible way to think about recovery from the addiction process from a systems perspective. If we can acknowledge that there are different types of addiction, yet a similar dynamic pattern in the process, we might be able to identify a similar pattern in a recovery process. I suggest a possible framework which helps us think about breaking a schizmogenic process. The first step for interrupting the process is some type of intervention, followed by some type of deprogramming or detoxification, then proceeding to the beginning of a recovery journey. Using the three examples of types of addiction mentioned in my previous post, alcohol and other drug addiction, cultic addiction, and the arms race, each will require some type of intervention to interrupt the progressive addicting split before beginning the correction of an epistemological error. An intervention can take the form of a group of family and friends confronting a drug addict with the reality of their destructive path, a family , friends or even other authorities intervening to remove a cult follower from a cult setting, or a diplomatic settlement which creates a mechanism for de-escalating a competitive arms race. The next step would be some form of detoxifying (from drug addiction), deprogramming (from cultic addiction), de-escalation (diplomatic intervention). If an intervention has succeeded, and the process of detoxifying/deprogramming has begun, the beginning of recovery will include some type of re-programming or changed epistemology or mind set – possibly a reshaped or transformed self. Recovery is not a static point of achievement. The recovery journey or process is one of ongoing maintenance. Whatever the conditions of predispositional vulnerability and epistemological errors in thinking set up the initial addiction process may continue to present an ongoing threat for relapse or re-addiction.

The obvious critical first step in breaking the addiction process is some type of intervention. The earlier the process can be interrupted the more likely there will be a successful intervention. Detoxifying or de-programming cannot occur until there is a successful intervention. There are plenty of examples of failures to intervene with alcoholic addiction or other drug addiction and the person addicted dies. Likewise with cult leaders and followers. There were plenty of warnings about the deadly path Jim Jones was on when he rallied some of his most devoted followers in the People’s Temple to sell everything, cut off all family ties in the U. S. and follow him to Guyana. He eventually became so delusional that he believed, and convinced his followers, that by killing themselves they would gain heavenly graces in an afterlife. The complementary schizmogenesis combined with the epistemological error led to the death of 913 in Jonestown, plus 4 in nearby Georgetown, and 5 in congressman Leo Ryan’s group which had travelled to Jonestown to intervene (obviously too late). So the timing of the intervention is critical.

We are currently (during this recent week) in a serious crisis in the U.S. as a result of a U.S. president who has cultivated a cultic following during his four years in office and though there have been various attempts at interventions to interrupt the complementary schizmogenesis between him and his followers, none of them were robust enough to stop the eventual riot which he incited on January 6th, 2021. The riot was both destructive and deadly to others and property and deadly for some followers. The apocalyptic characterization from several strands the Trumpian cultists resembles that of Jim Jones and the Peoples Temple followers, and other apocalyptic movements, such as Aum Shinrikyo in Japan. Robert Jay Lifton recounts the events of March 20, 1995 when sarin gas was released in a Tokyo subway, in his book, “Destroying the World To Save It” (2000): “On March 20,1995, Aum Shinrikyo, a fanatical Japanese religious cult, released sarin, a deadly nerve gas on five subway trains during Tokyo’s early morning rush hour. Eleven were killed and up to five thousand injured.”(p.3). Lifton compares the psychological makeup of Jim Jones and Shoko Asahara, the guru of Aum Shinrikyo:

“Like Asahara (and many others who show paranoid tendencies), he [Jones] became more grandiose the greater his anxiety and inner conflict. He also resembled Asahara in his increasing tendency toward megalomania and in episodes that were close to or actually psychotic. As with gurus in general, a pattern of decompensation and breakdown was greatly accentuated by faltering control over his disciples. Jones and Asahara, to fend off threats to their guruism, escalated their demand on their disciples, ultimately insisting that they be ready to die for their guru – in Jones’ case, through acceptance of a doctrine of revolutionary suicide as an ultimate expression of loyalty.” (p.284-285). This scenario played out in Washington, D.C. last week, with president Trump inciting his disciples to insurrection by storming the Capitol building. This has resulted in immediate repercussions with an unprecedented second impeachment of a U.S. president and immediate arrests of many of Trump’s disciples. In all three cases – Jones, Asahara, Trump – the significant intervention was too late to save lives, but the complementary schizmogenesis was interrupted. Asahara and his top disciples went to prison, Jones and most followers went to their death, and Trump and his followers are facing legal ramifications. A state institution intervened in all three cases.

The way in which an intervention may occur with someone who is addicted to drugs will differ according to variables such as age, class, gender, psychosocial context, relationship patterns, and timing. As mentioned above, the earlier the intervention the better. With regard to alcoholic addiction, we are perhaps most familiar with family and friends who confront an alcoholic in the form of a group support system, yet the founders of A.A. did not have such a support group intervention. Bill Willson (Bill W.) and Bob Smith (Dr. Bob) had each other. Each of them had multiple fits and starts with alcohol, but found that no external or personal attempts to break the addictive cycle worked. Bill W. was staying in a hotel in Akron, Ohio, in 1935. He called a friend, Henrietta Seiberling, to ask if she could put him in touch with another drunk to preserve his own shaky sobriety. She happened to be a close friend with Dr. Bob Smith, who she had wanted to help with his alcohol addiction. She arranged for them to meet at her house and they spent six hours sharing their life stories and struggles with alcohol addiction. This founders’ story is told in multiple A.A. and other publications. Nan Robertson’s account in “Getting Better: Inside Alcoholic Anonymous” (1988) is particularly engaging, since she was a pulitzer winning writer with the New York Times and she recounts her own alcoholism story as well. She makes an insightful and critical comment about why A.A. is particularly effective: “There could not have been just one founder of A.A. There had to be two, because the process is one person telling his story to another, as honestly as he knows how.”(p.34). Robertson quotes a comment Dr. Bob made in a letter, in which he explains why none of his previous reading, or encounters with professionals or others were as effective as possible interventions as his exchange with Bill Wilson: “‘Of far more importance was the fact that he was the first living human with whom I had ever talked , who knew what he was talking about in regard to alcoholism from actual experience. In other words he talked my language.'” (p.35). So the intervention for Bill W. and Dr. Bob was each other. Robertson says, “The essence of A.A. is conversation, dialogue, one alcoholic talking with another in a meeting or or over a cup of coffee elsewhere. The problem with the active alcoholic is that his life is a monologue- he connects with his addicted self, and that is all. Ninety percent of the recovery process is through peers talking with one another.”(p.126).

The recovery process from any addiction will move from an intervention to some type of detoxifying or deprogramming or reframing. For A.A., once an alcoholic had ceased drinking and his or her body is detoxified, the typical 12 Step Program provides a framework and support system for the ongoing process of recovery. I am not going to discuss the various interpretations and arguments around the 12 steps, such as what the meaning of “higher power” might be. Robertson says, “an A.A. pamphlet points out ‘ Newcomers are rarely helped by ponderous sermonizing about the Twelve Steps, or by complicated interpretations. The Twelve Steps speak plainly for themselves, and all newcomers are, of course , free to use them as they choose’. Members refer to the Twelve Steps not as musts or rules but a kind of road map to an enjoyable sober life.”(p.132) Robertson has boiled down the Twelve Steps to six principles, which I find address a fundamental approach to a recovery process:

  1. We admit we are licked and cannot get well on our own.
  2. We get honest with ourselves.
  3. We talk it out with somebody else.
  4. We try to make amends to people we have harmed.
  5. We pray to whatever greater power we think there is, even as an experiment, or to think of our A.A. group as our “Higher Power’.
  6. We try to give of ourselves for our own sake and without stint to other alcoholics, with no thought of reward. (p. 132).

The first three principles can break the symmetrical schizmogenesis of the alcoholic’s pride believing he can win the battle over the bottle (epistemological error). These three as well as the next three help ensure an ongoing scaffolding for recovery.

Recovery from drug addiction, cult addiction and the arms race, requires consistent maintenance, once an intervention and detoxifying/deprograming/reprograming process occurs. Commitments to reform need to be reiterated and reinforced by both internal (personal) and external (social, relational, economic, political, legal) mechanisms.

This and my previous post on the addiction process are frameworks for further theory development. I encourage readers to comment in this site or to contact me with any questions you might have. I intend to continue developing the theory and my thinking will be informed by your feedback.

Cybernetics of the Self and Addictions

I am revisiting Gregory Bateson’s article, “The Cybernetics of Self: A Theory of Alcoholism” in “Steps to an Ecology of Mind”(1972) now because I am thinking about the meaning of addictions. I have studied various aspects of addiction, to include approaches to healing and recovery. For this post, however, I am interested in the dynamics of an addiction process – from alcoholism to the arms race to cultism. This is what Bateson explores in his cybernetics of self essay.

I will not discuss all of Bateson’s propositions in this post as they encompass a vast theoretical terrain. But there are at least two central ideas which help us understand the dynamics of the addiction process: epistemological errors and schizmogenesis. Let’s take schizmogenesis first. While this term can be somewhat off-putting, we can think of it as progressive directional change in a system. Bateson suggests two types of schizmogenesis or directional change: complementary and symmetrical. Complementary would be when one party, say a man in a Latin American culture, behaves in a ‘machismo’ manner – or an exaggerated masculinity. This may then trigger a women to behave in an exaggerated feminine manner. Each party may exaggerate their different roles in reaction to the other. The addiction is to the split or directional dynamics of difference. Each party (male and female) are addicted to the exaggerated behavior of the other. Another example might be the relationship between a cult leader and his/her followers. They rely on each other to provide identity needs. The more needy the followers of a particular cult or religion, the more paternalistic the messiah or cult leader may behave. They are addicted in a complementary way to each other.There are plenty of examples from Melanesian Cargo Cults to Jim Jones and his followers while in San Francisco then to Guyana and mass suicide, and to include the current occupant of the U.S. White House and his cultic followers who have over-identified with him. He must have them and they must have him.

Symmetrical schizmogenesis would be a competition between two parties in a boasting or chest beating manner and might even include the international arms race, as Bateson suggests. As one escalates, so must the other. The addiction is in the systemic progressive split – a possible runaway system. The prime example, however, the one Bateson studies in depth, is the competition between the alcoholic and the “bottle”. The “bottle” is a symbolic “other” that the alcoholic is geared to challenge with “self-control”. The pride of the alcoholic sets him/her up for believing they can use self control over the addicting power of the “bottle” or alcohol. The addiction is not in the bottle or alcohol (the agent) or in the alcoholic person: it is in the relationship between them. Likewise with other symmetrical relationships and complementary relationships. Addiction is a dynamic process.

The epistemological error is in the pride of the alcoholic and the assumption of self control and in the case of cult followers, the over-identification with the cult leader and the relinquishing of one’s autonomy. With regard to the arms race the error is in assuming that more arms than one’s competitive nation will provide more safety or security. These epistemological errors can lead to systemic runaways and in each case may result in death (alcoholic death, cultic death, nuclear death).

While I have followed Bateson’s lead in exploring addiction as a dynamic systemic process, I am aware that there are likely different types of addiction and not all addictive behavior is necessarily negative. William Glasser wrote “Positive Addiction” in 1976 and focused on two particular positive addictions: long distance running and Transcendental Meditation. The suggestion from Glasser is that one may be able to replace a negative addiction, such as to alcohol or other drugs, with a positive one, which might be generative rather than degenerative. While this may be possible, too much of anything could be dangerous, including running or TM. So addiction as a process will likely need ongoing management and avoidance of a systemic runaway, which epistemological errors may ignite.

In consideration of different types of addiction, we might think alcohol and other drug addiction to be distinct from that of the one cultic followers and leaders have. The process is the same, though the agents are distinct. I propose that both types include a type of schizmogenesis and an epistemological error. And both may also include a predispositional vulnerability, which I proposed in my systems analysis of schizophrenia. In the case of an alcoholic there is likely a genetic predispositional vulnerability (biochemical?), which combined with psychosocial context and epistemological errors, sets up the addictive process. In the case of cult leaders and followers, the predispositional vulnerability may be strictly in the psychosocial realm. The followers of Jim Jones were mostly poor and socially deprived and in need of perceived salvation. Jim Jones progressively believed himself to be their savior. Each had their vulnerability.

Bateson investigates what has made the A.A. twelve steps program and the A.A. philosophy and group support the most effective antidote to alcoholism and other drug addictions. I will discuss in my next post the way that the A.A. approach interacts with the dynamic processes of addiction, schizmogenesis and epistemology.

Back to Schizophrenia 4

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

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

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

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

Back to Schizophrenia Part III

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Back to Schizophrenia Part II

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

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

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

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

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

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

Back to Schizophrenia

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

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

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

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

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

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

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

Cornett summarizes his interpretation of Interpersonal Psychotherapy:

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

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

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

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

Insider: Irvin D. Yalom

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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