A Dangerous Method

 We are taking a break from our normal forensic programming to bring you this guest post from Jesse, a review of the film "A Dangerous Method."  ---Clink

Another psychiatrist and I went with our spouses. We all hated it. There were at least three levels on which I considered the film, the first being whether it in fact is a good film, the second relating to what it shows about Freud, Jung, and the birth of psychoanalysis, and the third what it shows about a psychiatrist getting involved with his patient.

A Dangerous Method purports to show Jung, the protagonist, treating a young (and of course beautiful, played by Keira Knightly) Russian Jewish woman named Sabina Spielrein, who was brought to his clinic for treatment of her hysteria. It is quite obvious from the outset that he will fall in love with her, and we are not disappointed, but the predictability and lack of drama in the film are striking. Spielrein gets better and wants to become a physician and analyst herself, which she does (historically, her most famous analysand was Jean Piaget).

We see a little of Freud, stiff and priggish, but quite adamant on maintaining the scientific stature of psychoanalysis and opposed to Jung’s efforts to bring in parapsychology. It is hard to imagine a less sympathetic picture of Jung, and as one who knows relatively little about him I can just say that I hope this film’s portrayal is a strong dramatization: unfeeling, narcissistic, and breaking every rule that has been standard in our field since its inception.

Sabina has been abused by her father by being beaten, which she acknowledges led to sexual arousal. Her symptoms remit as she became able to talk about it. Of course the very worst thing for this woman would be to reproduce that trauma with her psychiatrist, but that is exactly what Jung repeatedly does. The director switches (again quite predictably) between scenes of Sabina being beaten by Jung prior to sex to scenes of Jung’s beautiful and virginally white-clad wife, loyal and forgiving, who tells Jung haltingly that she disappointed him by having given birth to a girl, but will do better next time.

Of course Sabina falls in love with him. You do understand that it is transference. But he soaks it up and wallows in it. For a patient who has been sexually abused and beaten by her father everything Jung does is the worst it could be.

No viewer has any sympathy for him. He is without feeling except for himself. No guilt. No regrets.

Now, if the film really taught us something about psychoanalysis! But it doesn’t. It uses the language but throws off profoundly important concepts with the ease of a ten year old telling you that E = mc2, and with equivalent understanding. Spielrein herself made some important contributions, and Jung was one of the most famous psychologists in the world, but how he got that distinction (rather than ostracism and shame) is anyone’s guess.

So the more you know about psychoanalysis and good drama the more you will hate this film. The more you understand that a patient having a sexual relationship (and even more a perverted one) with a psychiatrist causes profound and lasting damage, the more you will feel that a film that makes the relationship appear harmless is itself causing serious harm.

Freud Goes to Hoboken

Here's an op-ed piece from the New York Times about Freud's visit to the United States 100 years ago. It's an interesting historical perspective.

It's Your Mother's Fault

Moms and psychiatry have a long history.

Freudian psychoanalysts like to talk about moms. "Tell me about your mother." Oh, those Oedipal sexual longings....

Winnecott, who gave us the concepts of the "holding environment" and the "transitional object" talked of the "Good enough mother"-- an imperfect creature who could still raise normal children.

Melanie Klein gave us the good breast, a way for the infant to internalize dear mama.

Bruno Bettleheim gave us those Refrigerator Mothers who caused their children to be autistic while Theodore Lidz gave us Schizophrenogenic Mothers. Oy.

I could go on and on, if only Roy would let me. While we've moved beyond blaming mothers for autism (now we have vaccines to blame until we name the next culprit-- please don't let it be chocolate), we still believe that mothering is a key ingredient in who a person becomes. Good mothers have good kids, bad kids must have bad mothers. No matter how you dice it, we all believe in cause and effect, and we all can write the script backwards. An entitled, self-centered criminal must have had a mother who spoiled him and didn't set limits. I remember my own mother saying, "When you see a child hitting someone, you know someone is hitting that child at home." (My mother read Dr. Spock, she wasn't a scientist).

It's really easy to write the story backwards, and in fact, as psychiatrists, that's what we do. As a mother (have I mentioned that I have two teenagers?) it's not so easy to write the story forwards. If I do "X" my child will become this type of person and if I do "Y" my child will become that type of person. It doesn't work that way, trust me. If it did, we'd all read the instruction manual and have a perfect world.

So this, I've decided, is the paradox of today's world, now that we are relieved of refrigerator mothers but not bad breasts: There are lots of things that society tells us we need to do for our children to grow them good. Mozart in the womb, and that's where it starts. No drugs, no tobacco, no caffeine, no artificial sweeteners, no alcohol: the perfect internal environment. And once they pop out, there are all sorts of do's and don'ts: what chemicals they inhale, what they watch (pg, pg-13, violence and sex and how long have you been sitting in front of that boob tube, junior?), how they behave, say please and thank you, not those violent video games and what are you watching on U-Tube? Montessori this, Rebounders that, chicken nuggets are good, chicken nuggets are bad, make sure they get enough sleep and not too much MySpace, quality time, licensed day care providers who build self-esteem, car seats and safety gates and all the right influences and none of the wrong. Talk to your kids, the TV says so, the billboards say so, talk to them about sex and drugs and God and country and the earlier the better (--see, I can go on and on).

Then they turn in to teenagers and they figure out that the word "controlling" is extremely pejorative in our culture. What's worse than a Controlling Mother? Even a bad breast doesn't sound so bad. Are you a controlling mother? What do you mean I have to eat vegetables? Or be home when? And that's the paradox.

In the world of teenagers and psychiatrists, it's hard to win as a mom.


You know you've been blogging a long time when....Roy followed me and added links in this post to past blog posts I've written-- I clicked on some of them and realized I don't even remember having written them. How does he? A man who needs a longer ToDo List!

Guest Blogger Ron Pies-- Religion & Psychotherapy: Two Armed Camps or Allies of the Soul?

Hey, I made a friend on Shrink Rap!

Dr. Ron Pies is a Professor of Psychiatry at both Tufts and S.U.N.Y. Upstate Medical University and I met him when he surfed over to read Don't Shrink Me. Ron is the author of The Ethics of the Sages (Rowman & Littlefield) and the upcoming book, Everything Has Two Handles: The Stoic’s Guide to Happiness (to be published in Spring, 2008 by University Press of America). Ron is a prolific writer and his work includes some fiction (we like that here). Finally, he's Editor-in-Chief of Psychiatric Times. I invited Dr. Pies to be a guest blogger, and here's what he sent:

Religion and Psychotherapy: Two Armed Camps Or Allies of the Soul?

Religion did not sit well with the early psychoanalysts. Although Freud’s views evolved over the many years he spent analyzing religion, he generally explained religion as a kind of neurotic “compromise”: focused as it is on an all-powerful “Father-God”, religion allows us to admit our vulnerability in the world, while also giving us a feeling of superiority and control. We become “God’s children”, develop all kinds of rituals and prayers designed to gain God’s good will, and thereby secure our place in the scheme of things. [I am oversimplifying greatly—for those interested in Freud’s views on religion, I recommend the web site of Prof. Jurgen Braungardt, a philosopher and psychotherapist]. For Freud and most of the early psychoanalysts, religion was a sort of childish problem to be, well, outgrown—often through the aid of psychoanalysis. Modern-day critiques of religion—witness the spate of books by Daniel Dennett (Breaking the Spell), Sam Harris (The End of Faith ) and many others—also focus on the supposed “irrational” or extremist elements of religious faith.

There is some truth to these critiques of religion, but in many ways, they obscure as much as they illuminate. For no matter how many theories we devise as to how religion arose, or what “neurotic” needs it may serve, we will never succeed in refuting the basic claims of most conventional religions; i.e., that there is a “Superior Being” of some sort; that this Being created and guides the universe; and that we are all governed by universal and “God-given” moral principles. There are simply no scientific experiments that could conceivably refute these claims—for no matter how many failed attempts to “detect” such a Superior Being, it is always possible that the very next experiment would succeed. And even if religion first arose out of some neurotic need to keep “Big Daddy” happy and on our side, this does not disprove the existence of a Father or Mother (or any other) God. (Imagine a primitive tribe that had a “neurotic need” to believe in tiny, sub-microscopic particles—this would hardly serve as evidence against the existence of atoms!).

But there is a deeper and—from my perspective as a psychiatrist—more important sense in which the critics of religion have missed the proverbial boat. This involves their failure to distinguish what I would call pathological religiosity from the religious impulse. Think about it this way. Mr. A. is convinced not only that his religion is valid, but that it is the only “true faith”, and that everybody else is a “heretic”. Mr. A. is completely impervious to any attempts to challenge his beliefs, rituals, or religious practices. Any attempt to do so sends Mr. A. into fits of frothing rage, and violent fantasies of “avenging the slur against the One True Faith.” Furthermore, when Mr. A. violates his own religious commandments, he is thrown into deep bouts of self-hatred and depression.

Sound familiar? Mr. A’s relationship to his religion encapsulates, in my view, a certain type of fanaticism that has become all too familiar in our age. (Fanaticism, by the way, can exist in folks of any faith, or no faith at all—it is a psychological type, not a religious label). Mr. A’s religiosity is clearly at odds with most traditional goals of psychotherapy; namely, reducing excessive guilt and anger, broadening the individual’s perspective on life, and increasing the patient’s “cognitive flexibility”. Mr. A. would be one tough customer in psychotherapy!

Now consider Ms. B. She describes herself as “not a religiously observant” individual, but one who does attend religious services “when I’m feeling a little lost or alone.” Ms. B. is not sure she believes in an all-knowing, all-powerful God; however, she says that, “I feel like there is something out there greater than us—some kind of order or intelligence in the universe that I feel drawn to very strongly.” Ms. B. has undertaken psychotherapy in order to “help me figure out who I am, and where I’m headed—like, is there a purpose to life beyond just working and getting by?”

Ms. B.’s relationship to faith is clearly very different in tone and content from that of Mr. A. Indeed, Ms. B would find little difficulty relating to many traditional psychotherapists, all other things being equal. In fact, one type of psychotherapy, called Existential Therapy, would be nicely suited to the kind of exploration Ms. B. is seeking. She represents what I call the religious impulse—a yearning for something larger than ourselves, often manifest as a sense of awe, mystery, or ineffable bliss. (The word “religion” is probably derived from the Latin, ligare, meaning to “bind” or “connect”—as in feeling “connected” to some larger community, set of laws, or spiritual purpose). I believe Freud would be quite wrong in regarding Ms. B’s religious impulse as “neurotic” in any way. Her sense of wonder and awe is certainly not a feeling I would ever want to “outgrow.” On the contrary, Ms. B’s powerful attraction to some transcendent “order or intelligence” in the universe is quite like the feeling expressed by Albert Einstein—arguably the greatest scientist since Isaac Newton. Einstein said
"Try and penetrate with our limited means the secrets of nature, and you will find that, behind all the discernible concatenations, there remains something subtle, intangible and inexplicable. Veneration for this force beyond anything that we can comprehend is my religion. To that extent I am, in point of fact, religious.”¹

Not only should psychotherapy be tolerant of this mature kind of religious impulse, its goals should be compatible with those of such a seeker. This is not to say that psychotherapy should be intolerant of more conventional or orthodox forms of faith; it is just to say that, in so far as the religious impulse veers over into pathological religiosity, its difficulties with traditional psychotherapy will multiply.

In my book, The Ethics of the Sages, I try to show how several different religious faiths hold views compatible with those of cognitive-behavioral therapy (CBT). For example, in the Jewish tradition, we are instructed, “…do not consider yourself wicked.”

[Pirke Avot 2:18]. The rabbis believed that, while we could certainly judge our individual acts as “wicked”, we should not entirely condemn our very being. (Hence, the modern-day expression, “Hate the sin, not the sinner.”). All this is quite compatible with a type of CBT developed by Dr. Albert Ellis, known as Rational Emotive Behavioral Therapy (REBT). Ellis (who died just recently) argued that, “If human beings have any intrinsic worth or value, they have it by virtue of their mere existence, their being, rather than because of anything they do to “earn” it...You are “good” or “deserving” just because you are…” ²

Similarly, in another portion of the Talmud [Pirkei Avot 2:21], we are told, “...it is not up to you to complete the task, but you are not free to desist from it...” This teaching is part of a powerful "anti-perfectionism" in Judaism. It tells us, in effect, “Don’t condemn yourself if you don’t finish everything successfully—but don’t just give up on it, either.” This is quite consonant with the position taken by Ellis and Harper: “People who lead a lazy, passive existence...are almost always (consciously or unconsciously) defending themselves against some irrational fear, especially the great fear of failure. Viewing failure with horror, they avoid certain activities that they would really like to engage in...” (A Guide to Rational Living, p. 174).

There are many such fruitful intersections between psychotherapy and various religious traditions. The values of psychotherapy—and let us be clear, there are such values—may never coincide completely with those of traditional religion; but neither do psychotherapists and the religiously faithful need to be adversaries. Though they proceed from different premises and may seek different goals, psychotherapy and religion may yet be “allies of the soul.”

Albert Einstein, Response to atheist, Alfred Kerr (1927), quoted in The Diary of a Cosmopolitan (1971)

Ellis A, Harper RA: A Guide to Rational Living; No. Hollywood, Wilshire Book Co., 1971, p. 89

Because It Feels Good

See other Savage Chicken cartoons here

The Psychology Of Altruism

I saw a story in our local newspaper recently that summarized the results of a Johns Hopkins survey of people who volunteer for research projects. The projects they were looking at were Phase I clinical drug trials, in other words studies that are done using drugs on humans (as opposed to animal) subjects for the first time.

It led to the obvious question: Who the heck would do something like that?

Now, I knew a couple people who volunteered for studies when I was an intern. They were both rather adventurous, young, and somewhat in need of money. Looking back on it I could say that they were trusting people who believed that the researchers wouldn't do anything to seriously put them in harm's way and that they were also fully armed with the youthful denial of any possibility of death, disability or adverse consequences to many things they did.

Some of the subjects in the survey reported that they essentially became professional guinea pigs, even travelling from state to state to make a relatively lucrative living (lying to the investigator in the meantime about their extracurricular research activities). However, about half the volunteers were employed at the institutions where the research was being done. They reported that volunteering made them feel good that they were helping people.

That got me thinking about altruism in general. We have many examples of altruists in our society: parents, volunteer firefighters, soldiers, people who sign organ donor cards or send money to charitable organizations. What leads people to give up something when there is no immediate benefit to the giver? Or worse yet, when there are always people ready to take the benefit without ever making a sacrifice in return?

There are religious motivations for altruism, but this being a psychiatry blog I thought it would be more relevant to look at the psychology and evolutionary biology of altruistic behavior. (Don't worry, I'll keep it short to avoid being snooze-worthy.)

In The Ego And The Mechanisms Of Defense Anna Freud described the concept of "atruistic surrender". I'm admittedly nowhere near being an analyst, so if any reader out there has a better handle on this than I do feel free to enlighten me. As best as I can figure it out, altruistic surrender takes place when a patient's unconscious conflicts are triggered by superego suppression of impulses. To manage the resultant anxiety the patient projects the forbidden impulse onto someone else, identifies with that person, then works to help that person satisfy the impulse. For example: someone feels the urge to eat lots of gourmet food but this impulse triggers an unconscious conflict. The impulse is attributed externally: "I am not hungry. They are hungry," and the person throws herself into feeding the hungry or cooking extravagant meals for friends and family.

Whew. This must be why analytic training takes years.

The evolutionary perspective is much more simple-minded (lucky for me). A behavior survives for one of a few reasons: it's good for your relatives, it helps you have more kids or it improves your standing in the community. The weird thing about altruism is that it doesn't seem to do any of those things, yet you see the behavior in non-human species as well as insects. And if altruism didn't do something to enhance survival then all altruists would be extinct by now. What gives?

This is where I get to refer to an economist---probably the only time we've mentioned economists on the blog even though the few I've known have been pretty terrific people. Robert Aumann and Thomas Schelling developed game theory in order to understand economic cooperation and conflict, but they ended up enlightening human behavior. They used mathematical models to prove that given enough time and enough opportunities for strangers to interact the altruists come out ahead economically the majority of the time. Later researchers showed that the "cheaters" (people who don't sacrifice) eventually get punished by the group by being denied opportunities to interact---no one wants to do business with them.

And finally, now that we have this gee-whiz cool fMRI technique you can pretty much count on the fact that someone somewhere has taken a picture of an altruistic brain in action. One study showed that increased activity in the posterior superior temporal sulcus strongly predicted a person's likelihood for altruistic behavior. (And now that I've volunteered my time to write this summary I can practically feel my posterior superior temporal sulcus glowing.)

So now when someone asks you why you volunteered for that activity that everyone else in the neighborhood is hiding in the attic to avoid, you can say: "Because given X number of trials involving Y individuals there's approximately Z percentage likelihood that I'll come out ahead by doing it." Or you can keep it simple: because it feels good.

Freud set back Psychiatry 100 years

[Rant posted by Roy]

Okay, it was his birthday last week and all, but I think Sigmund Freud single-handedly stalled the progress of psychiatry for nearly a century.

Look at some of the thought leaders in psychiatry in the early 2oth century. Kraepelin. Bleuler. Alzheimer. It was around 1905 when it was found that syphilis could cause a type of psychotic illness, called general paresis of the insane. Most "psychiatrists" were actually neurologists then, and the field was decidedly heading in the what's-wrong-with-their-brain direction. Fifty years later, the first antipsychotic drug was introduced. What happened in those first 50 years, and in the 50 years since?

The locus of pathology switched from the brain to the mind, from the individual neuron to the individual person. We were just starting to realize that psychiatric illness could occur through no fault of one's own (okay, maybe unprotected sex, but you see where I'm going), and then Dr. Freud comes along and we start looking at the mother or the father or Uncle Pete as the source.

And the treatment? Lie on a couch and talk. About whatever comes to mind. Four times per week. For seven years.

The result? Worsening of stigma. Marginalization of Psychiatry from Medicine. Diversion of research interest and resources from the cell to the self. The "psychiatric reduction" and non-parity in health insurance coverage. (The "psychiatric reduction" was Medicare's discriminatory practice of requiring outpatients with psychiatric illnesses to pay 50% out-of-pocket, while all other illnesses cost you 20%. This sham is still on the books today, despite bipartisan efforts to end this anachronism.) Tom Cruise.

So now, with the Decade of the Brain a recent memory, we have now entered the Century of the Genome. We are discovering more and more about how the brain cell is put together, which protein does what, and what goes wrong when the blueprint goes awry. About time.

The damage is fading. People are getting more comfortable to talking about having an illness, less worried about folks wondering about the "dirty little secrets" which have tripped them up.

Don't get me wrong. We learned some things in the process about human psychosocial development... about transference... about id. After all, understanding psychiatric illness cannot be boiled down to neurons and receptors any more than diabetes can be boiled down to insulin and sugar. But we have had a long and winding detour. Time to blow out the candles and get this party started.

Pill Line

[Posted by ClinkShrink]

Happy Birthday, Siggie!

I found a pertinent Freud quote in honor of the day, particularly relevant to correctional work:

The first human who hurled an insult instead of a stone was the founder of civilization.

And now for something completely different....

Imagine working in a hospital where the patients change rooms every night and your unit gets 350 new admissions every day. Imagine dispensing medication to hundreds of inmates who come to your pharmacy twice a day to pick up their psych meds. I think of medication times (or "pill line" in correctional idiom) as a kind of March of the Penguins for prisoners. When people wonder why inmates don't always get their medications, I can tell you that some inmates decide they just don't want to face the daily migration. Sometimes they don't want to get up out of bed, or they don't want to take the chance of missing commissary or they have a visit scheduled. Maybe they are afraid of being ridiculed by other inmates. Maybe it's raining out and they don't want to cross the recreation yard. Maybe they are afraid of having confrontations with other inmates during the hour-long wait in line. More likely, the medications work so gradually and the effects are so subtle that they think treatment simply "isn't worth the hassle".

When I read about the effort required to persuade patients to take Lithium my first thought was, "That's so true!". But in addition to dealing with medication side effects, I also have to convince them that going down to get the medication is worth it. Fortunately, I have some research on my side. In the early days of lithium research the first research subjects were prisoners with a history of violence. Lithium was found to cut the rate of infractions in half. This is a strong selling point for my patients---"take your medicine because it's a good way to stay out of trouble."

Happy Birthday, Dr. Freud

Sigmund Freud was born at 6:30 p.m. on the sixth of May, 1856, at 117 Schlossergass, Freiberg, in Moravia, and died on the twenty third of September, 1939, at 20 Maresfield Gardens, London. That Schlossergasse has since been renamed Freudova ulice in his honor.
-- Ernest Jones, the opening to his three volume biography The Life and Works of Sigmund Freud