FURTHER NOTES on the HISTORY OF PSYCHOTHERAPY
Adam Blatner, M.D.

June 4, 2012 

Other webpages in this series include the following:   Beginning and Overview to the History of Psychotherapy       Part 2: The Middle Period.    Part 3: The 60s-80s     Part 4:  the 90s and Beyond.

Psychotherapy has been early on a fusion of medicine and psychology, with a smattering of cultural criticism. There had been some contemplation of the workings of the mind in psychology, and that included a variety of themes, from the nature of religion and parapsychology (e.g., the work of William James) to more psycho-physical research on perception, illusions, and conditioning (European psychology, Pavlov, etc.). Freud introduced an introspective element mixed with other roots—hypnosis, the theory of the hysterias (Charcot), and perhaps some indirect influence from  Janet on dissociation. The idea that psychology might be useful in treatment of illness had precursors in the use of hypnosis in medicine.

Later, psychotherapy came to include anything innovators could think of that help raise consciousness, dissolve folly, counter ignorance, raise morale, and bring people forth into more mental freedom and happiness. This then drew on all sorts of fields—shifting theories of spirituality, philosophy, communications studies, social psychology, politics, economics, art, play, creativity, and so forth.

Thinking About “Mental Illness”

It was clear that mental illness, whatever its source could be intensified or compounded by stress or trauma. For a while the idea reigned that mental illnesses were largely caused by emotional stresses. Note to begin with, though, that everything humans do is permeated by attitudes and habits that tend to add somewhat to the level of stress—this is the product of ignorance and belief in mistaken ideas. Humanity is still burdened by its own very incomplete evolution. Though we have made many advances over times we look back on as being less civilized and cultured, there is no doubt that in a few centuries people then will look back on us today as being mired in ignorance and folly, for all our clever technical advances.

Anyway, the theory that the major mental illnesses were caused by intense stress didn’t fit the medical history of most people who had become mentally ill. To remind you, there were four or five major sub-types:
  - autism and atypical development, “schizophrenia” in childhood
  - dementia praecox—“precocious” insanity—now thought of as schizophrenia with its onset in adolescence or early adulthood
  - manic-depressive or “bipolar” illness
  - “dementia paralytica” or insanity with its onset in mid-life, most of which is due to tertiary syphilis, an ongoing degeneration of the nervous system due to infection with a spirochetal bacteria, a sexually-transmitted disease (STD)   (This was quite common a century ago, but curable now with penicillin, and now rare.)
  - dementias of old age—and, rarely, with an onset in middle age—not understood well

Now, note that if you’re sick with a stroke or a broken arm or whatever, ill-treatment and blame and other psychosocial stresses can make the overall recovery more difficult. In that sense, folly, ignorance, superstition, and ill-treatment by family or the health care community can make whatever condition occurs worse, can take a bad experience and make it deeply traumatic. In rape there is a sub-condition called “second wounding” in which the victim is assaulted verbally by police or family and blamed for immodesty or partially causing this crime. The point here is that major mental illness is an emotional catastrophe—often for the family of the patient as well—and can be worsened or helped by the way it’s dealt with. In that sense, a certain kind of wisely applied psychotherapy or counseling is generally useful.

A century ago there was still a tendency to think reductionistically, meaning that if we can fix little things, maybe we can apply that to understanding and fixing far more complex things. It works with fixing clocks, but it doesn’t work in systems that are far more complex, such as minds, because more complex systems have multiple reverberating circuits and amplifying or suppressing feedback systems. The point is that major psychoses are NOT simply minor neuroses writ large. The are something else again. But back then, folks didn’t know—and still don’t, really—what major mental illnesses are about. (Although the anti-psychotic medicines discovered in the mid-20th century and further drugs developed since then suppress most of the symptoms of major mental illness in most cases—not always—and was considered a “third psychiatric revolution”— we still don’t know what actually causes these diseases!)

Three Levels of “Mental Illness”

I mentioned the problems of folly and ignorance. These, mixed with the simple reality that life is difficult, amplify stress. I imagine a spectrum that ranges from simple difficulty to stress to what I call “affliction” to trauma to breakdown—the last overlapping with major mental illness. The point to note is that the last category, “breakdown,” may involve several elements. People with a susceptibility to the psychoses or major mental illnesses mentioned above tend to “crack” more easily when there are significant levels of stress or affliction. So, back to the problem. My latest thinking is as follows:

Much of outpatient and private practice psychotherapy and counseling is devoted to people struggling with the natural consequences of ignorance compounded by pride, misunderstandings that are socially accepted as “common sense,” taking some things too seriously, making too many overgeneralizations, and so forth. These are compounded by misleading beliefs, superstitions, wariness about seeking help and another kind of wariness about giving into weakness, plus a thousand ways that people bully and manipulate each other. All of these mistakes make for stress.

On the aforementioned spectrum, stress blurs into a new category that I call “affliction,” to describe not only things being difficult, and compounded by misunderstandings but another layer: interpersonal manipulation, bullying, sadism, intimidation, threats, meanness, selfishness, judgmental-ness, mocking, name-calling—some of which has been part of the standard repertoire of parents, teachers and drill sergeants. This is more than mere stress. It adds the mind-pickling confusion as to what’s going on. Do those who are afflicted deserve the abuse they’re receiving? Should they reproach themselves and drive themselves harder, suck it up and tell themselves this is what growing up and reality is about, you’ve got to be tough, or should they be indignant or resentful? If the latter, how much should they show it? Two points here: First, this more-than-simple stress is very prevalent! Second, the compounding that is ambiguous generates neurotic patterns, because the situation is a subtle double-bind.

A double bind involves a compounded dilemma: First, you’re stressed, humiliated and told that the pain is good for you. That’s bad enough, but furthermore, the situation is such that if you protest you only make the situation worse. The people defining the situation, the teachers, parents, a dominating spouse, the drill sergeant, affirm that they are okay and you are just being weak or wilful. You’re not sure. Further compounding the situation is the perception or reality that you cannot leave the situation in which there is this mixed message. In more subtle ways, these situations are pervasive. The consequences for leaving a job in which the employee feels overworked are too heavy.

Hans Selye, a researcher on stress, noted that the most severe stresses are situations in which one feels that one must make a choice—the consequences are significant—and yet the bases for making that choice are entirely ambiguous.

Trauma

Okay, so much for affliction. This whole complex can be escalated one more step: In trauma, the degree of pain is intense, overwhelming. Something—anything—must be done to relieve the pain. It can be the psychological pain of fear, shame, humiliation, and overwhelming rage—that can be scary, too—or some mixture of these. This is often compounded by disorientation: Who is friend and who is enemy is confusing—referring to the observations of Selye noted above. Other negative emotions can add to this, such as disgust. The peculiar illusion that one should force oneself to take action in the face of fear or shame adds further stress.

Other elements that add to trauma include:
  - the shame of being overwhelmed, of not being able to “take it” anymore
  - disorientation as to who are friends and who are enemies
  - feelings of betrayal at ill treatment or abandonment by those considered friends or protectors
  - guilt over enjoying any part of the feelings or one’s response to the situation (and why there’s any enjoyment is a complex property of the way the mind works that requires a lot of explanation that would distract from what we’re saying here)
  - relief from shifting into coping patterns that get deep reinforcement to the extent they’re effective—surrender to the will of others, becoming mindless and passive, rage-ful and destructive, closed off and semi-catatonic, self-condemning and depressed, paranoid and reactive,  etc.
  - tendencies for these reactions and perceptions to become embedded in the nervous system, strongly reinforced by strong emotions, vivid images
  - often associated with hyper-vigilance, sleeplessness, semi-hallucinatory hyper-reactions, trigger memories, and other symptoms.

Trauma can involve even a few of these elements, or several not so prominently—but the key is that when triggered, one flips into a complex of perceptions and reactions that are almost automatic. They can be healed, more consciousness brought in, etc. but it takes a goodly amount  of time and sensitive and well developed effort to turn it around. Interestingly, falling out of control adds to shame—it’s not clear what one can will and what cannot be willed.

Now, all this is complicated by innate sensitivity and intelligence—the two are sometimes but not at all always associated. Highly sensitive people might up the stress from difficulty to quasi-affliction, and more likely, experience strong affliction as mildly traumatic. But even a relatively resilient and even insensitve person, if the trauma is intense enough, will suffer from PTSD.

Once some of the elements of what in World War I was called war shock, and in WW2 called traumatic neurosis, and in Vietnam was called PTSD—same conditions—became recognized, it also became clear that what my people who had been called “borderline” were suffering from was also PTSD. These symptoms are often masked by other qualities, including drug abuse, which leads them to compound their predicament and confuse the diagnostic process. But behind these were also situations in which the identified patient had suffered from significant sexual, physical, and emotional abuse. 

The Problem of What is Really "Illness"

Back to the three levels of “mental illness.” Should stress be part of the sick role? Isn't some stress part of what everyone must experience as part of development and adaptation?  I think so, but I also think that someday there may be a significant lessening of the less necessary elements that lead to affliction. Most of what is treated by psychotherapists is a mixture of affliction and stress, which comes out mainly as variations of anxiety and depression. There’s another outlet that involves getting rageful at others or getting drunk or abusing other drugs, and these folks generally come when either they’ve “hit bottom,” made a mess of their lives, or when ordered to by the courts.

Most of all these patients have a further complicating factor: They want relief, but they don’t want to re-evaluate their own attitudes, beliefs, or consider the possibility that there are significant things they don’t know or things about which they have really wrong understandings. This lack of humility is most important. They want to feel better, but don’t want to discover how  what they are thinking or doing makes things worse. So getting over this not insignificant hurdle is often difficult.

The culture feeds into this: It doesn’t teach people that we are all in need of continued growth and maturity throughout our adulthood! Rather, the illusion is that you should have learned all you need to know by early adulthood, if not earlier, and if you try, you can learn it all. This is a giant lie, but it’s a pretty pervasive notion. So it’s an assault on one’s secretly fragile but outwardly strong (but brittle) self esteem to be confronted by the need to re-evaluate basic attitudes.

Really, it should be no more problematic than recognizing that of course a computer needs to get updated in its basic power, capacity, and other features, and also needs a built-in anti-virus program to preserve its integrity. No occasion for shame, just the way computers are nowadays. The mind needs to be treated not so much as a precious location for self-esteem, but rather as a toolbox that needs upgrading and renewal. Thus, culture makes it hard to really do psychotherapy.

Psychotherapy Into and Out of Psychiatry

The theme being developed is that psychotherapy---the art of bringing people forth from lesser and into greater mental health and resilience---emerged as ambiguously part of medicine (Freud), became mainstream in psychiatry in the mid-20th century, and then continued on. Psychoanalysis itself declined, but hundreds of other types of therapy proliferated and spilled out beyond the sick role into the human potential movement, coaching, personal development workshops, spiritual guidance, thousands of self-help books, anti-bullying programs in school, sensitivity training for managers in business, and a general field still forming known as Social and Emotional Learning (SEL). The basic tools of psychotherapy and the idea of being psychologically-minded, of upgrading our personal and interpersonal skills, is slowly moving into the mainstream, though at present I estimate its penetration at something around only 10%---if that much. Viewed from the points noted above, there are several general fields interacting. Some people seem to be more susceptible to overload and more, to taking their mind in psychotic directions. This might merit being treated within the medical model, and the patients assuming the sick role.

But then there are many people now seeing psychiatrists for medications to reduce their emotional reactivity to affliction or stress. Just because medicine reduces this vulnerability to distress, that doesn’t mean that the problem is basically medical or organic. It might equally be true—and often is true—that the person is running software—sets of attitudes and behaviors — that are ultimately self-defeating. Unless these thought patterns are changed—by psychotherapy—they either stay stuck or later fall back into these negative cycles of behavior. Often other people’s reactions to that behavior add to the stress, and sometimes working with the whole family or group is helpful, because they all play off each other.

The Rise of Psychotherapy

In a sense shielded or protected by the aura of the growing respectability of medicine—the profession itself riding on a wave of advances including anesthesia, antisepsis, antibiotics, and other nutritional advances, and their being incorporated into other advances in surgery and other kinds of treatment, psychotherapy as a treatment for mental illness spilled over to the idea that therapy or counseling could also alleviate the milder “disorders” caused by mainly stress and “affliction.” And indeed, it can, if a good treatment alliance is set up. That is to say, the client begins to want to change and is willing to begin to examine himself and participate actively in changing thoughts and reaction patterns. It’s really more a process of unlearning and re-learning, and the learning is more experiential, learning by doing—not book learning.

From this, psychotherapy caught on as a form of personal growth and clarification in an era of change. I want to note that the idea that personal counseling—in the sick role as a client, or more recently the healthy role as a client getting personal coaching—all operates within a larger culturally shifting frame. What it means to be an adapted individual in modern society all is affected by the cultural attitudes that have arisen about politics, religion, art, work, recreation, and so forth. These in turn have been influenced by changes beginning in the 19th century such as the rise of the middle class, international migrations, the continuing fragmentation of religion and loss of its political influence, and so forth. Personal questions of identity intensified as freedom expanded.

Advances in science took on a mythic power, and along with it, other seemingly scientific endeavors such as psychotherapy. In the first half of the 20th century there were yet few or doubts about what might be considered the downside of science, the possibility of unintended consequences, the idea that some wisdom might not depend on the kinds of thinking supported by science, and questions as to the unvarnished positive results of progress.

Science and, by extension, early forms of psychotherapy, were mythic because they arose from a mixture of psychology and medicine, fed into by the European discoveries of the mysteries of hypnosis and the strange spread of two condition we rarely see any more, neurasthenia and hysteria, more flagrant, dramatic expressions of sickness, psychosomatic illness, that now are viewed as depression, anxiety, borderline personality disorder and variations of post-traumatic disorders.

I'm suggesting that much of psychotherapy is really an experiential method for unlearning folly and re-learning wiser forms of adaptation. I add that this notion still hasn’t caught on, and that few therapists think of it that way.

Rise and Fall of Psychoanalysis

There have been several reasons why psychoanalysis caught on. First, it was the first form of systematized introspection, critical thinking.  There had been a lot of it in previous centuries, but it was scattered around among philosophers and other intellectuals. Until Freud, psychotherapy as applied psychology had never before been organized into a system, “bottled” (so to speak). Nor was there a general sense that there might be a way people could help each other as a form of mid-life education. Even Freud didn’t go so far as to realize that re-evaluation of one’s own thinking (i.e., meta-cognition) might  be the best treatment for mild symptoms of neuroses. He developed an elaborate theory of mind that included some pretty counter-intuitive ideas.

Although Freud was wary that his nascent approach to treatment might be applicable to the treatment of more severe mental problems, he nevertheless undertook a few cases. He needed the money and who knew what good might come of this new approach? In writing ups such cases, Freud thus made it ambiguous what psychoanalysis could and could not do.

Meanwhile, in America, there was a widespread dissatisfaction among professionals about the care of the mentally ill. They just didn’t know what else to do! Perhaps this new talk therapy might work. It was certainly less brutal or invasive than the other approaches being developed (e.g., insulin coma therapy, electro-shock therapy, lobotomy). So psychoanalysis was incorporated into the nascent field of psychiatry. (There weren’t yet any residency training programs in the 1920s.) In spite of the fact that  Freud didn’t like America nor Americans, didn’t like their optimism, his method began to be incorporated into American medicine just as the country was most vigorously feeling its thrust of progress, in the flush of its expansion.

In the 1930s, with the influx of many psychoanalysts from central Europe, psychiatry changed a bit. There was a band-wagon process of people claiming to offer more hope for mental illness. Interestingly, Freud had warned against psychoanalysis being co-opted by the Medical Profession—he knew it transcended the medical model and applied to all fields, anthropology, sociology, history, everyday life, art, etc. It was a way to bring psychological-minded-ness to the way modern people thought. But nevertheless, for many reasons, the rising professionalization of psychiatry did just what Freud warned against.

Over the next thirty years psychoanalysis rose to a position not only of dominance, but hegemony. That is to say that as a college student in the early 1950s, although I knew a little of Jung and Adler, I thought their schools or followers had gone extinct. (I have been surprised and pleased that these strands still have much to offer and Jung’s work is in fact rising to a new level of prominence, because it alone speaks to the psychedelic or entheogenic experience.)

Nearing the end of the 1960s psychoanalysis began a precipitous decline in its influence, for a number of reasons. First, it had become so full of its own suppositions that then became dogma, and the process itself was so lengthy and expensive and cost-ineffective; it tried to work for people with major mental illnesses and didn’t, in spite of this and that case history of recovery—but people recover occasionally from major mental illnesses without psychological intervention—this positive response hadn’t been appreciated. It wasn’t always downhill.

And then there’s competition—the rise of other explanatory systems that played off of psychoanalysis in a dialectic fashion.
   - not scientific enough, try behaviorism
  - too long term, try shorter term approaches
  - too silent and blank mirror, try inter-subjectivity, more personal engagement
  - too reductionistic to childhood problems, try more adult, humanistic, existential
  - too up in the head, add attention to body tensions
  - too passive, try having the patient be more active
  - too verbal, include non-verbal approaches such as art, dance, music
 and so forth.

Distilling “Baby from Bathwater”

When thousands of creative, intelligent, thoughtful people are involved in thinking about, reflecting on, and becoming creative in an endeavor, it is not all folly. Because it is far from perfect, it is tempting to discard the whole social movement as a misleading cult, but that reflects the tendency of the small minded to dismiss that which they cannot understand. A pickpocket at a convention of saints would only see their pockets. But the field was problematical—and indeed, all fields are problematical. It is a childish small mind that wants parents to be perfect and professions to be perfect—law, politics, education, religion—all are in fact suffused with problems and controversies, and medicine is also part of this, and psychotherapy. Our whole culture, indeed, is very much a work in progress and it is only the prideful or those who want there to be an answer already—are we there yet?—the impatient—who feel that if we really were good we’d be successful. The desire to blame that which is not perfect is one of the underlying streams—and that brings us back to baby and bathwater.

There has been a proliferation of true insights mixed with misunderstandings in all fields. As knowledge expands it tends to veer off into over-generalizations,  over-simplifications, ignorance that pretends to know, and many other wrong turns. Also mixed in is the proverbial “ baby” in that bathwater, some valid or truly useful approaches and ideas. Often what is needed is a continual process of distillation, discrimination, filtering out what is useful. In addition, what is useful may need to be revised, reframed, polished up, made more user-friendly—and such refinements are by no means trivial.
    (The fellow (or woman!) who invented the wheel deserves credit, but the one who realized that you need four of ‘em to really work well—ah, s/he was a genius!)

 Also what is more true for one generation may be less  true for subsequent generations. So the process of discernment, distillation, revision, these are always with us—and as I say, they apply to politics and education and (dare I say?) religion as well as psychiatry.

Lifelong Learning, Discernment, Wisdom

A problem for humanity in general and for the purposes of our talk today, psychiatry as only one case, is that folly operates at all levels. Much of what accounts for suffering is due to simple folly, that mixture of ignorance, misunderstanding, pridefulness, and the compounding of these element. There are innumerable examples of this that operate in the human mind, in family life, in the professions who care for people. The culture as a whole, for all its vaunted progress, is still mired in a process that is only beginning to emerge from savagery.

Seven year-old children will feel their superiority over four-year-old kindergarten babies. Twelve year old kids begin to get the illusion that what they know is so much more than what they knew at seven that they know enough. Grown-ups feel so much more knowledgeable than kids, and elders more than younger adults. This illusion of relative knowledge can be so deceptive, and it feeds into and is in turn fed by the unconscious desire to feel proud.

The cultivation of humility in the right form is an important part of wisdom and we don’t teach it well. It’s become overly associated with mere memorization of data, as celebrated and rewarded by the 64 thousand dollar question type quiz shows. That humility involves a lifelong process of growing discernment—that idea is already too sophisticated to the masses. It’s classified as politically elitist by younger people who themselves want to be seen as worthy of authority. That everyone, even elders, have much to learn, is simply the way it is, and has become ever more so as the quantity and complexity of what there is to be known has expanded geometrically.

Science and Spirituality / Meaning

This whole story progresses within a larger story, one we don’t have any consensus for as to its happy ending—or maybe as some might suggest, accepting as wise the probability of an unhappy ending. It’s operating within a greater intuition of life as meaningful or meaningless, progress as true or as illusion, the status of the grand narratives of traditional religion—true or illusory—and the continuing back and forth of conservativism and liberalism within all elements of society.

It operates within a context of controversy over whether culture is evolving or not, and whether consciousness itself can evolve. I will confess I am biased towards the ideas that consciousness can evolve, and from this culture and species—but not everyone shares this bias. So I dare not present all these ideas as a done deal. It’s an ongoing controversy, and people select the gradual amassing of information to bolster their deeply felt beliefs. Much of what we call the world of the mind operates in support of what we want to believe—this in a way is Freud’s point, and Nietzsche’s and others.

Summary

The history of psychotherapy should be recognized as a more systematic way to explore critically the assumptions people bring into their personal and family lives. It overlaps with a critical examination of cultural assumptions in general. It further overlaps with a cultural trend towards re-evaluation of culture, assumptions, rules, boundaries, ethics, epistemology (how do we know what we know), metaphysics (what is real), and other branches of philosophy. While such questions are addressed here and there in academia, the real issues play out in a host of everyday socio-political controversies. It’s by no means just academic.

Part of all these controversies have rarely included the idea that the proponents of this or that doctrine might be thoroughly infested with illusions or driven by bias in favor of their economic or social status. That people create elaborate manifestoes to rationalize deeper and less worth motives has not yet come to the surface—but it very much needs to!

What if the perspectives of depth psychology and methods of psychotherapy are applied in ordinary social discourse. I don’t mean Freud’s earlier methods of psychoanalysis—they are way too inefficient and vulnerable to a number of distortions. Rather, the point is that in dialogue, opening up all sides to examining themselves and their own biases, and moving in the direction of peacemaking rather than trying to prove oneself as “right” (as if anyone cared)—that this new mode of discourse might end up in everyone raising their consciousness a little.
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References

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