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psychotherapy

The Myth of Mental Illness: Thomas Szasz on Freedom and Psychotherapy

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 INTERVIEW WITH THOMAS SZASZ ON PSYHOTHERAPY.NET

Thomas Szasz on Freedom and Psychotherapy

by Randall C. Wyatt
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The foremost psychiatric critic of our times, Thomas Szasz, engages in an in-depth dialogue of his life’s work including freedom and liberty, the myth of mental illness, drug laws, the fragile state of psychotherapy, and his passion for humanistic values and social justice.
Randall C. Wyatt: I am going to ask you a wide variety of questions, given the diversity of your interests, and I want to make sure to also focus on your work as a psychotherapist. A little background first. You’ve been well-known for the phrase, “the myth of mental illness.” In less than 1000 words, what does it mean?
Thomas Szasz: The phrase “the myth of mental illness” means that mental illness qua illness does not exist. The scientific concept of illness refers to a bodily lesion, that is, to a material — structural or functional — abnormality of the body, as a machine. This is the classic, Virchowian, pathological definition of disease and it is still the definition of disease used by pathologists and physicians as scientific healers.

The brain is an organ — like the bones, liver, kidney, and so on — and of course can be diseased. That’s the domain of neurology. Since a mind is not a bodily organ, it cannot be diseased, except in a metaphorical sense — in the sense in which we also say that a joke is sick or the economy is sick. Those are metaphorical ways of saying that some behavior or condition is bad, disapproved, causing unhappiness, etc.

In other words, talking about “sick minds” is analogous to talking about “sick jokes” or “sick economies.”

In other words, talking about “sick minds” is analogous to talking about “sick jokes” or “sick economies.” In the case of mental illness, we are dealing with a metaphorical way of expressing the view that the speaker thinks there is something wrong about the behavior of the person to whom he attributes the “illness.”

In short, just as there were no witches, only women disapproved and called “witches,” so there are no mental diseases, only behaviors of which psychiatrists disapprove and call them “mental illnesses.” Let’s say a person has a fear of going out into the open. Psychiatrists call that “agoraphobia” and claim it is an illness. Or if a person has odd ideas or perceptions, psychiatrists say he has “delusions” or “hallucinations.” Or he uses illegal drugs or commits mass murder. These are all instances of behaviors, not diseases. Nearly everything I say about psychiatry follows from that.

RW: Let’s say that modern science, with all the advances in genetics and biochemistry, finds out that there are some behavioral correlates of biological deficits or imbalances, or genetic defects. Let’s say people who have hallucinations or are delusional have some biological deficits. What does that make of your ideas?
TS: Such a development would validate my views, not invalidate them, as my critics think. Obviously, I don’t deny the existence of brain diseases; on the contrary, my point is that if mental illnesses are brain diseases, we ought to call them brain diseases and treat them as brain diseases — and not call them mental illnesses and treat them as such. In the 19th century, madhouses were full of people who were “crazy”; more than half of them, as it turned out, had brain diseases — mainly neurosyphilis, or brain injuries, intoxications, or infections. Once that was understood, neurosyphilis ceased to be a mental illness and became a brain disease. The same thing happened with epilepsy.
RW: It’s interesting, because a lot of students of mine, and colleagues, who have read your work or heard of your ideas, think that when condition previously thought to be mental is to be a brain disease, as noted, your ideas become moot.
TS: That’s because they are not familiar with the history of psychiatry, don’t really understand what a metaphor is, and don’t want to see how and why psychiatric diagnoses are attached to people. Ted Kaczynski, the so-called Unabomber, was diagnosed as schizophrenic by government psychiatrists. If people want to believe that a “genetic defect” causes a person to commit such a series of brilliantly conceived crimes — but that when a person composes a great symphony, that’s due to his talent and free will — so be it.

Objective, medical diagnostic tests measure chemical and physical changes in tissues; they do not evaluate or judge ideas or behaviors. Before there were sophisticated diagnostic tests, physicians had a hard time distinguishing between real epilepsy — that is to say, neurological seizures — and what we call “hysterical seizures,” which is simply faking epilepsy, pretending to have a seizure. When epilepsy became understood as due to an increased excitability of some area of the brain, then it ceased to be psychopathology or mental illness, and became neuropathology or brain disease. It then becomes a part of neurology. Epilepsy still exists. Neurosyphilis, though very rare, still exists, and is not treated by psychiatrists; it is treated by specialists in infectious diseases, because it’s an infection of the brain.

The discovery that all mental diseases are brain diseases would mean the disappearance of psychiatry into neurology. But that would mean that a condition would be a “mental disease” only if it could be demonstrated, by objective tests, that a person has got it, or has not got it. You can prove — objectively, not by making a “clinical diagnosis” — that X has neurosyphilis or does not have it; but you cannot prove, objectively, that X has or does not have schizophrenia or “clinical depression” or post traumatic stress disorder. Like most nouns and verbs, the word “disease” will always be used both literally and metaphorically. As long as psychiatrists are unwilling to fix the literal meaning of mental illness to an objective standard, there will remain no way of distinguishing between literal and metaphorical “mental diseases.”

RW: Psychiatrists, of course, don’t want to be pushed out of the picture. They want to hold on to schizophrenia as long as they can, and now depression and gambling, and drug abuse, and so on, are proposed as biological or genetically determined. Everything is thought to have a genetic marker, perhaps even normality. What do you make of this?
TS: I hardly know what to say about this silliness. Unless a person understands the history of psychiatry and something about semantics, it’s very difficult to deal with this. Diagnoses are NOT diseases. Period.

Psychiatrists have had some very famous diseases for which they have never apologized, the two most obvious ones being masturbation and homosexuality.

Psychiatrists have had some very famous diseases for which they have never apologized, the two most obvious ones being masturbation and homosexuality. People with these so-called “diseases” were tortured by psychiatrists — for hundreds of years. Children were tortured by antimasturbation treatments. Homosexuals were incarcerated and tortured by psychiatrists. Now all that is conveniently forgotten, while psychiatrists — prostitutes of the dominant ethic — invent new diseases, like the ones you mentioned. The war on drugs is the current psychiatric-judicial pogrom. And so is the war on children called “hyperactive,” poisoned in schools with the illegal street drug called “speed,” which, when called “Ritalin,” is a miracle cure for them.

Let me mention another, closely related characteristic of psychiatry, as distinct from the rest of medicine. Only in psychiatry are there “patients” who don’t want to be patients. This is crucial because my critique of psychiatry is two-pronged. One of my criticisms is conceptual: that is, that mental illness is not a real illness. The other one is political: that is, that mental illness is a piece of justificatory rhetoric, legitimizing civil commitment and the insanity defense.

Dermatologists, ophthalmologists, gynecologists, don’t have any patients who don’t want to be their patients. But the psychiatrists’ patients are paradigmatically involuntarily.

Dermatologists, ophthalmologists, gynecologists, don’t have any patients who don’t want to be their patients. But the psychiatrists’ patients are paradigmatically involuntarily.

Originally, all mental patients were involuntary, state hospital patients. That concept, that phenomenon, still forms the nucleus of psychiatry. And that is what is basically wrong with psychiatry. In my view, involuntary hospitalization and the insanity defense ought to be abolished, exactly as slavery was abolished, or the disfranchisement of women was abolished, or the persecution of homosexuals was abolished. Only then could we begin to examine so-called “mental illnesses” as forms of behavior, like other behaviors.

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Judgement day

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imagesCAISXD6SWhy is it so easy for us to judge? Wikipedia states:

A cognitive bias is a pattern of deviation in judgment, whereby inferences about other people and situations may be drawn in an illogical fashion.[1] Individuals create their own “subjective social reality” from their perception of the input.[2] An individual’s construction of social reality, not the objective input, may dictate their behaviour in the social world.[3] Thus, cognitive biases may sometimes lead to perceptual distortion, inaccurate judgment, illogical interpretation, or what is broadly called irrationality.[4][5][6]

Some cognitive biases are presumably adaptive. Cognitive biases may lead to more effective actions in a given context.[7] Furthermore, cognitive biases enable faster decisions when timeliness is more valuable than accuracy, as illustrated in heuristics.[8] Other cognitive biases are a “by-product” of human processing limitations,[9] resulting from a lack of appropriate mental mechanisms (bounded rationality), or simply from a limited capacity for information processing.[10]

Written on wikipedia, it looks so straightforward. So logical. But understanding it is not the same as living With it. Seeing that People judge others for several reasons, helps, but it still hurts to BE judged. In normal circumstances we judge everything all the time, but what about judgment in the Health service? What irks me is how the People who`ve read page after page about cognitive biases and heuristics, still fall into the judgement trap without realizing it. Not that I don`t do, myself. We all do, no matter how we try not to. But still, shouldn`t it be more panic rooms available, more safety nets to protect us from human fallibility? Let us take an example: Someone is diagnosed With  schizophrenia. Suddenly the Person is not just a Person. He or she is the “Person With Schizophrenia”. Suddenly everything the person does will be interpreted in the light of that diagnosis. If things don`t work out, it might because they have a serious mental illness, if it does, it must be because they have some special resources. Expectation are based on what we know about schizophrenia as a groups. Most Health Professionals are taught to always keep their eyes open, so that we don`t fall into judgment traps. But we still do and often there is no rope to haul us back up. We need constant reminders so that we don`t fall into those traps too often. And when we do, we need to see it. Because judgement is the opposite of seeing. Without others to correct us, everything is dark.

Judgment comes from experience

Epistemic Trust, Psychopathology and the Great Psychotherapy Debate

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Over the past decades, meta-analyses have found almost no clinically meaningful differences in efficacy between the various evidence-based psychotherapies. This has led to the formulation of the so-called “Dodo bird verdict”, based on the Alice in Wonderland story, which argues that “all [psychotherapies] have won and all must have prizes”.

Consequently, major figures in the field have questioned the notion that theory-specific techniques or interventions, such as addressing dysfunctional cognitions in cognitive-behavioral therapy, or the relationship between past and present in psychodynamic therapy, are mainly responsible for therapeutic outcome. They argue that, instead, factors that are common to effective treatments – providing the patient with hope and with a comprehensive theory that explains the patient’s complaints – would typically explain a greater proportion of the therapeutic outcome. This would be particularly the case if the therapist is able to establish a warm and empathic therapeutic relationship with the patient. Hence, the “Dodo bird” still looms unresolved over the field of psychotherapy.

We have recently proposed a new, evolutionarily informed approach to the “Dodo bird” controversy that also has important implications for understanding psychopathology more generally.

Mentalizing and attachment: Evolutionary advantages

Our starting point is contemporary evolutionary theories concerning social cognition. Evolutionary theory suggests that as the human mind needed to respond to ever more challenging, complex, and competitive conditions, norms for social behavior and understanding could not be “fixed” by genetics or constitution. These norms had to be optimized through a prolonged period of development within a close circle of people – people who we would term attachment figures. Attachment figures not only provided young children with the basis for feelings of security and exploration (Bowlby, 1973; Main, Kaplan, & Cassidy, 1985), but also provided a training ground for the ability to mentalize – the capacity to understand ourselves and others in terms of intentional mental states (Fonagy & Luyten, in press).

Mentalizing provided an evolutionary advantage because it allowed these early humans to adapt better to their physical environment, by facilitating social collaboration and well-functioning kinship groups, but also by supporting competition for survival when different social groups were at odds. Hence, mentalizing is a key element of our species’ uniquely developed level of social cognition.

The link between attachment and mentalizing is clear. Attachment contexts provide the ideal conditions for fostering mentalizing. Secure attachment relationships, where attachment figures are interested in the child’s mind and the child is safe to explore the mind of the attachment figure (Fonagy, Lorenzini, Campbell, & Luyten, 2014), allow the infant to explore other subjectivities, including that of his/her caregiver. Finding him/herself accurately represented in the mind of the caregiver as a thinking and feeling intentional being ensures that the infant’s own capacities for mentalizing will develop well (Fonagy, Gergely, Jurist, & Target, 2002).

Epistemic trust and the transmission of culture

Recent elaborations of thinking on mentalizing have taken the argument one step further to point to another important function of attachment relationships. This is the development of epistemic trust, that is, trust in the authenticity and personal relevance of interpersonally transmitted knowledge. Epistemic trust enables social learning in an ever-changing social and cultural context and allows individuals to benefit from their (social) environment (Fonagy & Allison, 2014; Fonagy, Luyten, & Allison, 2014; Fonagy and Luyten, in press).

Gergely and Csibra’s theory of natural pedagogy (Csibra & Gergely, 2009) helps to clarify the key issues here. Human beings are faced with a major learnability problem: they are born into a world that is populated with objects, attributes, and customs whose function or use is epistemically opaque (that is, not obvious from their appearance). Humans are thus evolved to both teach and learn new and relevant cultural information rapidly.

Human communication is specifically adapted to allow the transmission of epistemically opaque information: the communication of such knowledge is enabled by an epistemically trusting relationship. Epistemic trust allows the recipient of the information being conveyed to relax their natural, epistemic vigilance – a vigilance that is self-protective and naturally occurring because, after all, it is not in our interest to believe everything indiscriminately. The relaxation of epistemic vigilance allows us to accept that what we are being told matters to us.

These views do not diminish the importance of attachment, but put theories concerning the role of attachment in a very different perspective. Recent research suggests that the long-term relationship between attachment in infancy and attachment status in adolescence and into adulthood is complex. It seems likely that there is a fluctuating relationship between attachment, genes, and the social environment across the life course (Ellis et al., 2011; Fearon et al., 2014).

In terms of psychopathology, we suggest that the most significant implication of the developmental triad of attachment, mentalization, and epistemic trust lies in the consequences of a breakdown in epistemic trust. What we are suggesting here is that many, if not all, types of psychopathology might be characterized by temporary or permanent disruption of epistemic trust and the social learning process it enables.

An infant whose channels for learning about the social world have been disrupted – in other words, whose social experiences with caregivers have caused a breakdown in epistemic trust – is left in a quandary of uncertainty and permanent epistemic vigilance. Everybody seeks social knowledge, but when such reassurance and input is sought, the content of this communication may be rejected, its meaning confused, or it may be misinterpreted as having hostile intent.

In that sense, many forms of mental disorder might be considered manifestations of failings in social communication arising from epistemic mistrust, hypervigilance, or outright epistemic freezing, a complete inability to trust others as a source of knowledge about the world, which may be characteristic of many individuals with marked trauma and personality problems. An individual who was traumatized in childhood, for instance, has little reason to trust others and will reject information that is inconsistent with their pre-existing beliefs. As therapists, we may consider such people “hard to reach”, yet they are simply showing an adaptation to a social environment where information from attachment figures was likely to be misleading.

The “p factor”: Epistemic mistrust as a common factor in psychopathology?

A serious challenge for our thinking about psychopathology arises from the fact that when we consider many individuals’ psychiatric history over their life course, it rarely follows the discrete, symptom-defined, and diagnosis-led categories that extant cross-sectional research uses when conceptualizing specific disorders.

This lack of specificity may relate to compelling evidence presented by Caspi et al. (2013) suggesting that there is, in fact, a “general psychopathology factor” in the structure of psychiatric disorders. Caspi and colleagues’ findings suggest that a hierarchical three-level structure explains the relationships among psychiatric disorders:

  • A general psychopathology factor (labelled the “p factor” as a conceptual parallel to the “g factor”, the well-established dimension by which general intelligence is understood);
  • Clusters of symptoms (internalizing, externalizing, and psychosis); and
  • Individual disorders, for example, schizophrenia, generalized anxiety disorder, and depression.

A higher p factor score is associated with increased severity of impairment, more developmental adversity, and greater biological risk. The p factor concept convincingly explains why, so far, it has proved so difficult to identify isolated causes, consequences, or biomarkers and to develop specific, tailored treatments for individual psychiatric disorders.

The p factor is thus far a statistical construct. We propose that the p factor may be a proxy for impairments in epistemic trust: An individual with a high p factor score is one who, because of developmental adversity (whether biological or social), is in a state of epistemic hypervigilance and epistemic mistrust. If this is true, it may have major consequences for psychosocial interventions. It would mean, for instance, that people with relatively low p factor scores might be most responsive to psychosocial interventions.

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A depressed patient with a low p factor score may, for instance, recover with the help of brief cognitive-behavioral therapy or psychodynamic therapy, perhaps even when delivered via an e-platform. These patients may be relatively “easy to reach” in terms of treatment because they are open to social learning in the form of therapeutic intervention. In contrast, a depressed patient with a high p factor score, who is suffering from high levels of comorbidity, longer-term difficulties, and greater impairment, is likely to show intense treatment resistance because of their high levels of epistemic mistrust, or outright epistemic freezing. We consider it likely that such patients will require more long-term therapy to first stimulate epistemic trust and openness.

Epistemic trust as the key to effective psychotherapies

In proposing that epistemic mistrust might underpin the p factor that underlies long-term impairment, we thus also consider that (the relearning of) epistemic trust may be at the heart of all effective psychotherapeutic interventions. Put simply, we suggest that effective interventions specialize in generating epistemic trust in individuals who struggle to relax their epistemic vigilance in more ordinary social situations. Patients with BPD, for example, are typically experienced as “rigid” and “hard to reach”, and the difficulties involved in stimulating epistemic trust have historically blighted attempts to intervene effectively with these individuals.

“Psychotherapy” in its many forms thus may simply be a specialized variant of an activity that has been part the repertoire of communicative behavior for a very long time – turning to others in times of need to make sense of what is happening to us. It is the seeking out of perspective and the reassurance of another’s social knowledge. But for it to be meaningful there needs to be a workable level of epistemic trust.

The psychotherapeutic communication systems

Based on the above considerations, we propose that there are three distinct processes of communication that cumulatively make psychotherapy effective:

Communication System 1: The teaching and learning of content

The different therapeutic schools belong to this system. They may be effective primarily because they involve the therapist conveying to the patient a model for understanding the mind that the patient can understand as involving a convincing recognition and identification of his/her own state. This may in itself lower the patient’s epistemic vigilance.

Communication System 2: The re-emergence of robust mentalizing

When the patient is once again open to social communication in contexts that had previously been blighted by epistemic hypervigilance, he/she shows increased interest in the therapist’s mind and the therapist’s use of thoughts and feelings, which stimulates and strengthens the patient’s capacity for mentalizing. Improvements in mentalizing or social cognition may thus be a common factor across different interventions.

Communication System 3: The re-emergence of social learning

The relaxation of the patient’s hypervigilance via the first two systems of communication enables the patient to become open to social learning. This allows the patient to apply his/her new mentalizing and communicative capabilities to wider social learning, outside the consulting room. This final part of the process depends upon the patient having a sufficiently benign social environment to allow him/her to gain the necessary experiences to validate and bolster improved his/her mentalizing, and to continue to facilitate relaxation of epistemic mistrust, in the wider social world.

Conclusion

What this view suggests is that the effectiveness of psychotherapies, regardless of their “brand names”, should be investigated at the three levels of communication. Furthermore, it redirects our attention to the social environment, and to interventions that may directly target environmental factors that could contribute to the origin and maintenance of psychopathology, but could also have the potential to support recovery and the individual’s capacity to benefit from benign aspects of the environment.

Editor’s note: Drs. Fonagy and Allison recently published an article titled “The Role of Mentalizing and Epistemic Trust in the Therapeutic Relationship” in Psychotherapy. Read below for their further thoughts on epistemic trust in psychotherapy.

If you’re a member of the Society for the Advancement of Psychotherapy  you can access the Psychotherapy article via our App or login to your APA member page.

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Cite This ArticleFonagy, P., Luyten, P., Campbell, C., & Allison, L. (2014, December). Epistemic trust, psychopathology and the great psychotherapy debate. [Web Article]. Retrieved from http://www.societyforpsychotherapy.org/epistemic-trust-psychopathology-and-the-great-psychotherapy-debate

References

Bowlby, J. (1973). Attachment and loss, Vol. 2: Separation: Anxiety and anger. London, UK: Hogarth Press and Institute of Psycho-Analysis.

Caspi, A., Houts, R. M., Belsky, D. W., Goldman-Mellor, S. J., Harrington, H., Israel, S., . . . Moffitt, T. E. (2013). The p factor: One general psychopathology factor in the structure of psychiatric disorders? Clinical Psychological Science, 2, 119-137. doi: 10.1177/2167702613497473

Csibra, G., & Gergely, G. (2009). Natural pedagogy. Trends in Cognitive Sciences, 13, 148-153. doi: 10.1016/j.tics.2009.01.005

Ellis, B. J., Boyce, W. T., Belsky, J., Bakermans-Kranenburg, M. J., & van Ijzendoorn, M. H. (2011). Differential susceptibility to the environment: An evolutionary–neurodevelopmental theory. Development and Psychopathology, 23, 7-28. doi: 10.1017/S0954579410000611

Fearon, P., Shmueli-Goetz, Y., Viding, E., Fonagy, P., & Plomin, R. (2014). Genetic and environmental influences on adolescent attachment. Journal of Child Psychology and Psychiatry, 55, 1033-1041. doi: 10.1111/jcpp.12171

Fonagy, P., & Allison, E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy, 51, 372-380. doi: 10.1037/a0036505

Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York, NY: Other Press.

Fonagy, P., Lorenzini, N., Campbell, C., & Luyten, P. (2014). Why are we interested in attachments? In P. Holmes & S. Farnfield (Eds.), The Routledge handbook of attachment: Theory (pp. 31-48). Hove, UK: Routledge.

Fonagy, P., & Luyten, P. (in press). A multilevel perspective on the development of borderline personality disorder. In D. Cicchetti (Ed.), Development and psychopathology (3rd ed.). New York, NY: John Wiley & Sons.

Fonagy, P., Luyten, P., & Allison, E. (2014). Epistemic petrification and the restoration of epistemic trust: A new conceptualization of borderline personality disorder and its psychosocial treatment. Manuscript submitted for publication.

Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of the Society for Research in Child Development, 50, 66-104. doi: 10.2307/3333827

Protected: The sound of ice freezing

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Help for the helper

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Inspiration comes from a variety of sources

We have many great therapists in Norway, and through courses and education I sometimes meet some of them. It`s usually very inspiring, since they knit their theories together with their work in exciting tapestries. Last year we were on a lecture by a sden1156ltherapist called Per Isdal. He tried to help violent men, and told us about burn-out or compassion fatigue in that regard.

Yesterday we had a meeting were one of the lead psychiatrist at our clinic, talked about the same theme, and we had to fill out a questionnaire that asked about felt tiredness, stress and satisfaction with our work. Luckily I was in the “no risk” group, which I think comes from the meaning I derive from my work. I truly feel that I can help, and nothing is better than seeing my clients blossoming. To see them walking forwards through strive, and to be there when its extra rough, is an honor, and I try to remember that every time I`m afraid, have too much to do, or just think about everything that is wrong with the world. I also think that going to lectures and reading relevant books, has helped support my sanity and ability to help.

Help for the helper

I`ve read many good books this year, and one of them is “Help for the helper”. It is packed with quality advice and knowledge, and is also easy to read. P. Isdal recommended it himself, so I immediately ordered it and prioritized reading it. The ideas from the book were reawakened today, after reading “treating complex PTSD`by Courtis and Ford. I came to a part about sensorimotor psychotherapy, and it reminded me on features from “help for the helper”. I then remembered one of the sessions where I applied the theory, and wanted to share it with you. Some have said it would be good if I shared more from my clinical practice, and I want to do that, at the same time as I keep the privacy of my client and duty of confidentiality. 

My office.
 
We all have needs
 
We have thousand needs that we need to navigate around like a surfer who has to keep his balance in the waves.  Trauma-patients who dissociate find this harder than most: They can be immersed in something so intensely, that they forget to eat, be social or even sleep. When this happens a lot, the body and mind`s needs create a state of constant tension.
Most people know that balance is important; If we only eat sugar, we need salt. If we never saw white, we wouldn`t understand black. This principle of balance also has a name: Homeostasis. Homeostasis regulates a lot of the body`s needs, and also kicks in when people develop addictions and is generally alarmed when we start to wander too far away from the golden “middle way”.
When we struggle for balance
 
But what if this fine-tuned system could not work, since you had to keep needs separated to survive? For children who`re abused or neglected, it is indeed often necessary to ignore certain needs because having them is associated with danger. If neglect and abuse has been severe, they might split feelings, needs and actions apart from each other, and the machinery that once went smoothly, starts to misbehave. Many of them don`t register what happens with their bodies at all, especially after sexual abuse. It`s better to  float above the body and it`s feelings, than to experience and face the abuse. The only problem is: Some part of the body remembers anyway, and those parts also have needs.
Working with abuse is a lot about listening to signals from the body again, and that means that we have to explore memories and feelings that might awaken fright or terror.
How I used the book to help both myself and my clientsTo help my patients explore their own needs, I have to use myself: What happens inside me? What can I notice from their words and body-language? For example: When they talk, without  emotions about how they could not escape from a violent father, and at the same time raise their hand a little, I might say: “I see you`re raising your hand. What do you want to do with that hand? Can you complete the movement”? If they do, they might discover that they wanted to raise their hand, to protect themselves. By directing attention to this movement, and asking them if they could just do what they want, they might actually do just that and then feel better afterwards. Instead of frozen terror, energy and control starts to thaw up.shame
An example of an emotional reaction I often see with clients, is shame. It can for example come when they finally manage to say something that scared them to say. Their initiat reaction will often be looking down. They “shrink” together as if to protect themselves, and don`t meet my eyes. This is understandable, since their innocent gaze was met with hatred or ridicule before. Shame is many clients middle name, and I wish I could have been there when the mis-labeling happened.
Unfortunately, I can`t go back in time, but I can do everything I can to help them live the life they never had.
So there they sit, weighted down by shame and fear. I look at them, seeing the little child that never got what it needed. And so, softly I ask: Do you dare to look at me now? Painfully slow they turn their heads toward me.
Changing yesterday by being in the now
 
In addition to using their body-signals as a compass that shows me where they are and need to go, I also use my personal reactions to enlighten me about their feelings. I might sit there, and suddenly realize that I`m gritting my teeth. My reaction to this can be telling them about it. “Do you know what just happened? I suddenly find I`m sitting here with my teeth clenced”. A client can then look at me in surprise and say: “I do too!”
By being observant on what happens inside me, I actually help them realize what happens with them. It can be subtle things: That I suddenly breathe slower, or that I need to push my chair back, or maybe that I feel uncomfortable. When I get unusual reactions like, I ask myself like Rotschild recommends: What is going on right now? Maybe I have picked up on something they are feeling?
Working and thinking about this has been as surprising for me as it for them. It shows how easily we are influenced by others.
We are mirrors
 
Did you know that women who live together, start to menstruate at the same time? That people who live together start to talk the same way, and even change their gestures? Since we have mirror Neurons in our brain that actually repeats movements of others, we actually make it more likely THAT we move or do other things like the people we observed.
 8badc05312854ed310fbba54cb6ee6caWhen we see someone play the piano, some of the same nerve-cells for moving the fingers are activated in our brain as in theirs. When I subconsciously register that my client feel scared, I will “mirror” this and start FEELING scared myself, and often too a degree where my heart starts to speed up or my breathing starts to change. Monkeys who never showed fear toward some object, might actually feel fear for the same object later if they see another monkey react that way.
 
We are social in every way, and I must use my reaction to understand and feel what my patients do. When we both realize what`s happening, we can use the information to take a step back and do something different. We can slow down the fear before it spirals out of control, or we can realize anger is marching forwards, and calm down before we start to shout at each other. By repeating patterns like this, again and again, we lay the first stones of new knowledge that give clients more freedom to act in similar situations. Awareness means possibilities and flexibility, something that often lacks when “things just happen”. The extra bonus is that this also benefits the helper. By realizing where feelings come from, we lessen the risk of compassion fatigue and are more able to stay in the “now” ourselves. 

I never promised you a rose garden

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a6b5cfbe87b90adc58888458745ded5f I love reading, and the last months I have read some good “based on a true story” books that really gave me some wonderful insights into the human mind. I want to write a bit about the wonderful book I never promised you a rose garden, because it really captivated me. It wasn`t just  the fact that it was well written, but it gave such an acute feeling of being there with the main protagonist, that it almost felt like watching 3D-movie. The book has also been shown as a movie, which I have not seen, but I can assure you that the book is really worth it, even if the film wasn`t (generally books give you something that easily might lack in movies, the persons thoughts, ideas and way of seeing the world. You must use your own imagination more).

Here is some information about the author:
Joanne Greenberg (Helen Green is the alias she uses for the book)

“I wrote [I Never Promised You a Rose Garden] as a way of describing mental illness without the romanticisation that it underwent in the sixties and seventies when people were taking LSD to simulate what they thought was a liberating experience. During those days, people often confused creativity with insanity. There is no creativity in madness; madness is the opposite of creativity, although people may be creative in spite of being mentally ill.”
– Joanne Greenberg

I Never Promised You a Rose Garden is a fictionalized depiction of Joanne Greenberg’s treatment experience at Chestnut Lodge Hospital in Rockville, Maryland, during which she was in psychoanalytic treatment with Frieda Fromm-Reichmann. The book takes place in the late 1940s and early 1950s, at a time when Harry Stack Sullivan, Frieda Fromm-Reichmann, and Clara Thompson were establishing the basis for the interpersonal school of psychiatry and psychoanalysis, focusing specifically, though by no means exclusively, on the treatment of schizophrenia.

It is useful to keep in mind that Sullivan and Fromm-Reichmann were by this time renowned for their work with severely regressed patients, some diagnosed as schizophrenic and others who were not so easy to categorize, using nothing in their treatment scheme except psychoanalytically oriented psychotherapy. Though the use of medicating drugs was in its infancy in those days and most psychiatrists were using electroshock therapy, sleep therapy, and other bizarre forms of treatment, both Sullivan and Fromm-Reichmann resisted these practices and treated their patients, as they themselves would have like to be treated were they suffering from a similar state of collapse and confusion–as though what they really needed was someone to talk to.

It should be noted that they apparently enjoyed extraordinary success in their work, if “success” is indeed the right word, by the measure that many of their patients–like Joanne Greenberg herself–eventually left hospital for good, never to return. Today, when there is so much currency about the presumed causes of schizophrenia and other psychotic disorders–that they are genetically determined, for example, and that it is irresponsible to deprive such patients of the drugs that are now available to them–one wonders if it would be possible–indeed, if it would even be permitted–for people like Sullivan and Fromm-Reichmann to work with patients the way they did 50 years ago. Whatever the cause of schizophrenia might be–and nobody, despite what some claim, actually knows what it is–the treatment still depends on people like Frieda Fromm-Reichmann who are willing to sit with them hour after hour, day after day, and year after year for however long it may take to see them through their ordeal. As a young girl, Joanne Greenberg suffered from an ordeal of her own which her family only gradually began to realize was getting worse. At the age of 16 she was taken to Chestnut Lodge Sanitarium in Rockville, Maryland, where Frieda Fromm-Reichmann became her therapist. Her treatment experience lasted from 1948 to 1951. Ms. Greenberg remained in outpatient psychoanalysis with Dr. Fromm-Reichmann until 1955, by which time she was attending college. Their relationship not only served as a vehicle for Joanne Greenberg’s remarkable recovery, but was also the source of a friendship that continued until Frieda Fromm-Reichmann’s death in 1957. In fact, Joanne Greenberg, her mother, and Frieda Fromm-Reichmann had intended to collaborate on a book revolving around Joanne’s treatment experience, but Frieda died before the plan could be executed. A few years later, Joanne decided to publish a book about her experience on her own, an account that many believe demonstrates a measure of courage, literary power, and immediacy that is unparalleled in the literature on this rarefied and near-impenetrable subject.

As every psychoanalyst knows, the success of any treatment experience is never the result of one person, but the consequence of a collaboration between the two principals: a clinician who possesses the sensitivity and unflappability to contain whatever manner of experience a patient is capable of, and a patient who possesses the courage, grace, and determination to face whatever demons her history has dealt her. Clearly, Joanne Greenberg’s account of her trial is the story of two such individuals, and her courage to write such a book is an inspiration to us all, patients and clinicians alike.

In her presentation, Ms. Greenberg spoke informally about her relationship with Frieda Fromm-Reichmann for the first time before a public audience. She used the occasion as an opportunity to revisit her experience at Chestnut Lodge and to share it with those who are endeavoring to work with people who may be suffering a similar ordeal.

The author, Mr. Greenberg, really have a wonderful way of describing her inner life, that makes it all so alive. Sometimes I had to stop and just soak in the words, feeling the pleasure through my spine as I read through them again. There isn`t many books that give me that feeling, but some of the descriptions were so poetic and at the same songs_of_schizophrenia_by_xalineatime intelligent, that I was really moved. The interesting thing is how the work with the therapist is so closely woven together with her experiences. This adds extra spice to the story, there are so many wonderful metaphor, chilling, because you know they were so much more for her when she lived in the schizophrenic confusion. It was real pain, and the blood on the walls were her way of describing it.

If you are somewhat interested in the psychology of the mind, this will NOT be a disappointment!

http://www.goodreads.com/book/show/45220.I_Never_Promised_You_a_Rose_Garden

http://www.sparknotes.com/lit/rosegarden/

 

My work as a psychologist

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Freud with his couch

Therapy has for most people been associated with something mystical. Before I started with psychology myself, I also had my mental images of it, and knew about the standard Freudian couch where you simply said whatever you wanted. I`ve heard about Freud, and knew you probably had to talk about your childhood, but had no idea how a typical therapist or patient looked like.

For people who haven`t been in therapy, it is often still a mystery. A lot of my friend have asked me, isn`t it hard to hear about so many horrible things, every day? But it’s basically what we all do, every day, anyway. We see films, listen to our friends, read books and watch news about what`s going on. Of course, we don´t have the “obligation” to do something about that, so people might feel that it`s different, but I promise you, a therapist is not more than a personal trainer cheering the clients on. We always stand by our patients sides when something needs to be done or untangled.

Even if I am a therapist, I still love to go to therapy or supervision myself. I don`t respond to the words, but simply to the fact that I talk with a human being about myself. It’s good to have someone there, who just say “it truly sounds like you had a rough time”.

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What do you talk about in therapy?

This might still be a bit vague. You might think: Well, that`s fine: But what do you exactly DO in those 45 minutes? To make it more concrete, I will try to write a bit more of what therapists do in therapy. Since we can`t talk about patients, I must underline that I don`t describe any patients of mine.

Of course there will be variations in how we work and approach problems, but I always have some basics that underlie everything I do: Respect, curiosity and an attitude of “everything is possible”. I truly believe that, no matter how far someone has fallen, with motivation and hard work, nothing can´t be done.

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People come to therapy for all kinds of reasons

A typical morning for me is getting to work, looking through my calendar and appointments or maybe attending a meeting if its monday or Wednesday. Normally I have about four sessions every day, with people who have a variety of diagnosis. If we have our first meeting, I have to go through some standard questions, but mostly I try to get a description of the problem as they see it. Sometime I also give them some surveys that should be filled out before the next session, but personally I prefer to not use too much time on those, as I find talking to people and hearing their story more important.

people have a variety of problems
people have a variety of problems

In addition, people might get a bit annoyed if everything is about answering questions on papers. I also explain why they have to answer them: So that we can choose a treatment that fits people who generally score the same on those surveys. And of course, if they have a diagnosis where medications is necessary, I can`t ignore that. For very depressed, bipolar people, AD/HD or people with psychosis, conversations might not be what we focus on in the beginning. Sometimes I contact a doctor so that we can secure basics like sleep. For some people, collecting energy will be the first thing we do. It’s can be saying no to people who drain energy, working with attitudes about how perfect everything must be, or simply making a schedule where they put in healthy food, physical activities and “alone-time”. Some people worry a lot, and then the goal might be to set up experiments where those worries are put to the test. For example, people with panic attacks, might worry about fainting in public, and after a while they start to avoid situations that they feel are dangerous. An example that I actually saw on television, was a woman afraid of hurting kids if she had a knife in her hand.

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Using eye movements to reduce fear

After a while, she stopped using knives, and even made sure to lock them in. She also developed a fear where she worried she might accidentally kill someone while driving. After a while she simply stopped driving, because she didn`t want to take any risks. The therapy for her was rather concrete: She had to expose herself to what she feared, like being in the area where kids could be WHILE she carried a knife, and drive a car where people could potentially be hurt, without turning back to check if she had run over people.

I work mostly with traumatized people and people with personality disorders. I usually follow a model where I first focus on collecting energy, before we work with specific traumas that give them flashbacks, nightmares and disrupt them in their daily lives. I use EMDR for this work, which is basically using eye movements while thinking about traumatic memories. I ask them to bring forward a memory that scares them, and to think about the worst part of it. Then they keep that picture in their mind’s eye, while following specific movements I do with my fingers. I monitor their discomfort on a scale from 1-10, where 10 is the worst discomfort they have ever felt, and 0 is completely calm, and keep doing the finger movement until they feel calm. I will write more about EMDR later, but it the main point is that afterwards, it`s easier to live with what happened. People have described it as “earlier I felt the past was as real now as then and now it feels like it`s finally behind me”.

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How to say goodbye

The last “phase” is to talk about ending therapy. We go through the work we have done, and talk about how it will be to say goodbye. This is important, because separations is something a lot struggle with. I must make sure that people don’t feel abandoned, that they can take with them some part of what they learnt in their hearts. I have also talked to a therapist once, and when I feel especially low, I still hear her voice saying: “Take care of yourself, dear”. I say this to my clients: If you take some of what you have learnt here with you, I am happy. I also say that they can contact me later, if they need to. It’s just a way of saying that goodbye is just “Now you can continue on your own. I wish I could walk every step of the journey with you, and in my heart, I will”.

A lot of my jobs is actually just being there. Far too many think they aren`t good enough. It doesn`t matter how many times they have been told or have read that they have worth, it still FEELS like they haven`t. Sometimes its all about stating the obvious; I see how kind-hearted they are (most people are really wonderful), how hard they try, how much suffering they had to go through, and remind them off this, when they think they are terrible people. Therapy is about never leaving, and making sure that they never give up.

I truly care about my clients. When they manage to do something good for themselves, I cheer them on and feel real joy for them. When they change, it feels like magic. It gives me hope, because no matter how bad the past has been, there is nothing that can`t be achieved.

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The sound of ice freezing

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PTSD, the black, sterile letters from the screen are screaming. The clock is 13.30, and a dark something has been sliding between our feet, where it slipped past us silently. Light and dark has always been in conflict with each other, so much that the other colors were miffed by coating of the void left after the fight. It’s impossible to win a war that never had the possibility of victory in its programming, impossible to learn something good from something that’s wrong.

Hours pass by relentlessly, and 8 days has gone since I sat in a meeting-room, learning yet again how wrong everything can go, how madness lurks behind every corner of safety. It’s the bomb exploding when you really tried to step at the right places, the unspeakable acts of people who should be your protectors. Trauma strikes before and after you take a breath, it’s real dangers in its unpredictability, in the soft caress of your skin before a slap, the sudden death where life was moments before. When our mind can’t make sense of it, it leaves you grasping for meaning in something that’s just chaos.

Every one of us have their stories, rarely we go through life without feeling pins pricking our skin. Most of it heal and hide the marks, but some wounds bleed again or the needles strike you at another piece of skin. In my work I’ve encountered different kind and types of wounds. Some still bleed their hurt, some of them are on the brink of reopening and some healed the wrong way, and must be healed one more time. People bear them in different ways and on different parts of their bodies, some visible, some under layers of clothes and some covered by make-up. My job is about this healing process, always searching for hidden ones, making sure their healing properly and keeping them free from infections that threaten the organism. It’s even more important for me to be sterile, so that I make sure that I offer a safe haven to open and plaster the wounds.

Life has been stable in its instability the last two weeks. I keep longing for something lost, and having a hard time resisting whispering thoughts trying to tell me there’s hope.

It’s not long since his arms where there, resting over my shoulder. It’s not long since the beats of his heart reached the ear I placed on his chest. It’s not so long since I felt safe there, and I had the feeling that no matter what happened around me, I would be fine, if I just could lay still and hear the thumping sounds of life running through him. To let go of that safety is pain, it’s trusting that I will do the same thing again, with somebody else. Sometimes it’s hard to believe: How do you replace love that you gave everything for? How do you find the energy and will to use it once again? It’s not that I think somebody else is the only was to happiness, more that I know how good it can be to really love someone and being loved in return. I have so much to give and I hope somebody out there will awake the possibility of me releasing it again.

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