If you practice medicine or psychiatry in the year 2000, as you listen to patients, you are witness to a plethora of concerns in your patients concerning "alternative therapies." Naturopaths administer herbal medicines to my schizophrenic patients; depressed patients pay high fees to spiritualists who will help them communicate with their dead loved ones; manic patients "channel" spirits from distant ages; various psychosomatic ailments are "cured" by non?touch laying on of hands; and EMDR "cures" childhood traumas in a few sessions. The spiritual has penetrated the consulting room, but I find myself somewhat secure in my scientific training, even if it is the scientific study of emotions, behavior, mind?body interfaces and psychotherapy. It is in this rigorous discipline that I find guideposts and consensual validity that help me right myself and assist my patients.So imagine my surprise when I found myself haunted, plagued by ghosts, tormented by forces that I am still not sure I understand.
In 1993 I had been involved in resisting the abuses of managed care in psychiatry for three or four years. I had received the Distinguished Service Award from the Hartford Psychiatric Society for my opposition to MCC's takeover of a local HMO; I had been quoted in the Hartford newspapers as stating that managed care in psychiatry was the "rape of the mentally ill." I then became aware of a 35-year-old woman, hospitalized at a large general hospital, who had died after a postpartum psychosis. She had been treated by a colleague of mine and coincidentally was a friend of my next-door neighbors. I attended the hospital's Mortality and Morbidity conference. The patient was a prominent executive who became depressed after the birth of her first child. She was hospitalized for a short stay. During her hospitalization she was characterized by the nursing staff as quiet, and many nursing staff felt uneasy about her because she shared so little. Quickly the attending psychiatrist was besieged by three different reviewers demanding her discharge. These included the hospital reviewers, HMO reviewers, and out-of-town managed care physician reviewers. Each day the attending physician spoke to each of the three reviewers, answered the same question, "Is she suicidal?" and was threatened with the same refusal to authorize further days in the hospital. He discharged her after ten days against his better judgment. She was transferred to a partial hospital program, which she attended for a few days, and then she quietly drowned herself in her bathtub.
As I listened to the case, I felt a mixture of anger, disillusionment, helplessness, and disgust. I had just read Robert Lifton's book, The Nazi Doctors, and I felt it was unfolding before my eyes -- physicians concerned with other issues rather than patient care. My neighbors, who were unaware that I knew details of the case, lamented the loss of this fine colleague and mother and pondered the fate of her infant. Could the father raise the child alone? What would he tell his child of the mother's fate? My general knowledge was that postpartum psychosis was definitely a treatable illness, requiring careful monitoring, and support, and I was sure that if more time had been given to this patient, she would probably be alive today. After listening to the M&M conference, I believed this patient died because of managed care pressure to discharge her prematurely.
I imagined that the review physicians would have told the husband, "We have decided to take a risk with your wife because we wish to maximize profits for ourselves and our company. We will, with your permission, roll the dice, not take the maximum precautions, and gamble with your wife's life so we can minimize our financial risks and increase our bonuses based on cost savings. This is the policy you bought, so now live with it." It was at this point that I knew managed care died. No one would want anything but the safest course for their loved ones. Witness the case of the Firestone tires. They killed only 125 people, but who would buy these tires and take the risk? Even shipping them to third-world countries has proved difficult. I felt helpless in this overwhelming stampede by managed care. How do we educate the public to understand the risks involved? What was going through the minds of those review physicians who I felt were responsible for the death of this woman? I resolved to do my utmost to reverse this system.
Weeks later I awoke in a sweat. A woman who I had never known appeared in my dreams as the woman who drowned in the bathtub. She asked me to make sure she had not died in vain. I was mystified. The dream recurred every night for weeks and months, sometimes with her child, sometimes with her husband, but always with the command entreating me to not let her death be in vain. This went on for months and continues intermittently to this day.
In 1997 I read a front page article about a father whose 13-year-old daughter died from leukemia. His 15-year-old son became depressed and suicidal and was hospitalized. Over the father's objections, his son was discharged after five days. He pleaded with the hospital not to discharge his son as he felt the boy was extremely suicidal. On the day of discharge the boy hanged himself. Here were two children's deaths, one who received the most advanced treatment in the world for her leukemia, with no holds barred and no financial restraints, and the second with depression and the shoddiest of care.
More ghosts appeared, still the woman's. I waited for a couple of months. It seemed awkward, but after one of the harder decisions of my life, I called the father and asked if I could help. To my surprise he was very receptive. He said that nothing could bring back his son, but he did not want him to have died in vain. If it would help others in the future, he would cooperate in any way he could. He eventually filed a lawsuit that is pending today. I was able to facilitate finding a forensic psychiatrist for the family who could assist his case.
A few months later I attended the funeral of a neighbor's 15-year-old daughter, whom I had seen only a few days before. She had become depressed and was hospitalized for just a few days at a local hospital. It was decided, under pressure, that she was not suicidal, and she was discharged. I knew the parents well. Had they bought an insurance policy that stated they would gamble with their daughter's life so that an insurance company could post stronger quarterly reports?
In some of the many capacities physicians perform, I am also Chairman of a large Physician Health Committee which oversees licensure and assists physicians with problems. One case seemed particularly relevant. We received complaints from patients of a pediatric endocrinologist who had molested children 20 years ago. After confrontation he relinquished his license. Is sexual molestation worse than death? His injured patients were traumatized but alive. Are the physicians who discharged my neigbor's friend and the 15-year-old boy without guilt or responsibility? Have they rationalized their actions, believing that "We are preserving the system. That's what employers want. Rationing health care is necessary"? What if the surviving family members were to ask for their licenses? Would the experimentation on the population by the managed care experiment parallel the Tuskeegee experiment? Are patients and families due compensation? These questions are not answered and remain part of the current debate on managed care.
What of the Chairman of the Department of Psychiatry at a large community-based general hospital, who boasted that his was the "most managed care friendly system in the region," with low rates, short stays, managed?care friendly physicians, and reduced nurse?patient ratios. A state investigative unit concluded that the strangulation death of a 12-year-old patient resulted because of inadequate staffing, inadequate training of staff, and inappropriate response times. Did that chairman talk to the mother and apologize, explaining he was only trying to remain profitable. "only adapting to the system." One year later, at the same institution, a second death occurred when multiple drugs were dispensed in the hospital under improper supervision by staff physicians. The chairman was quickly removed from his job. Did he practice with "skill and safety?" Did he have his patient's health as his highest priority? Did he tell patients hospitalized there that "We are the low-ball provider in the state, and if a few of you die because of that, that is the risk involved?" What does he think of now? Does he have guilt and remorse? Is he still proud of being managed care friendly? Should he be allowed to continue to practice when the state cited his institution for improper care twice?
What of the reviewers of one large managed care organization who, acting on orders, mandated in 1994 that all patients who requested outpatient mental health care be "screened" first. Screening meant identifying yourself as a patient and presenting to a managed care office to be told by a physician that "You aree not as seriously ill as some patients and because there are only limited mental health resources, if you used services, think of all the more seriously ill people who would go without care." This physician was cited for "inappropriate behavior" by a county medical society (not his APA district branch) and continued to practice HMO medicine for another five to six years.
What of the medical directors of Magellan and United Health Care, who are permanent members of the Managed Care Committee of the APA? Under their direction mental health costs have significantly declined. Do they feel responsible? They blame employers. "They don't want to spend on mental health care. We push until we get a push back." None of the patients described here pushed back. The managed care directors continually tell me they are advocates for quality care. When discussing "phantom networks" and patients' inability to find a psychiatrist willing to see them, one recently stated that his dreams would be answered if every patient could see a psychiatrist within 72 hours of request. Are his dreams different from mine? His plans reimburse physicians at such a low rate that the majority of psychiatrists will not see these patients. This same physician was the medical director of a managed care company that routinely denied psychiatric treatment to a couple whose 19-year-old son was murdered. The father went through five sets of reviewers over a course of one year who all denied his requests for care. After one year the review process involved the medical director, who was generally hostile but finally approved a few outpatient visits. How many patients are so persistent? The father pursued the appeal process for over a year, knowing he was doing this only so that the next person might have an easier time. Did the father have dreams of his son? Did he want his son's short life to mean something for the mental health system in the future. Maybe the mind cannot fully contemplate its own death or the death of a child, who is experienced as part of the self, but it can understand the forces that attempt to extinguish us. Mmanaged care in psychiatry has significantly put our patients' health and lives at risk.
And what now? Are there still ghosts? I still have similar dreams, eight years later. As "managed care as we know it" dissolves under the weight of innumerable lawsuits and unprofitability, not by the increasing actions of responsible physicians who operate these systems, do we hold these physicians responsible? Should they be reported to their physician health committees? Should their licenses to practice medicine with skill and safety be reviewed? Are administrators who are responsible for the deaths of patients in their institutions to be held accountable? What will replace managed care? Will we return to a fee?for-service system? Will mental health patients be treated with respect and not criminalized and incarcerated? Will the forty psychiatric beds for adolescents that were closed reappear in my community? Will reasonable lengths of stays return? Will the cost of an hour of psychiatric care continue to be substantially less than my wife's appointment with a hairdresser? Will my dreams cease? Do I have to contact the husband and child of the woman who drowned herself and tell them that she was treated by an experiment in medicine that reduced costs but killed their wife and mother? Maybe then, and maybe when the patient with depression is treated like the patient with leukemia, and when the physicians who are responsible are held accountable, will my dreams cease.
Dr. Bozzuto is Assistant Clinical Professor Of Psychiatry, University Of Connecticut Department of Psychiatry
The author of this book is a psychotherapist and psychoanalyst who holds a Ph.D. in clinical psychology from Ohio State University and became a training and supervising analyst at the Southern California Psychoanalytic Institute. He was the founding president of the Institute of Contemporary Psychoanalysis and is now Professor of Psychoanalytic Studies, Emeritus, at the California Institute of Technology. Therefore, his book deserves to be taken seriously and he is clearly not one of that group of obtrusive crack-pots who lose no opportunity to take a shot at Sigmund Freud.Breger's book is a pleasant one to read; it is well organized, and he has an easy-going expository style, in contrast to the usual style of biographies produced by professional historians, of which he is not. Unfortunately, there is one major flaw in the book, and it happens to be the central premise of his entire study. According to Breger, Freud "invented" (p. 3) the Oedipus complex "which he instantly promoted to a universal law" (p. 3). Breger complains in his excellently written introduction that Freud's overblown theories and sweeping generalizations were fueled by Freud's desire for greatness, his attempt to be a powerful scientist-hero. There was never any convincing evidence for these ideas, says Breger; they arose primarily from Freud's needs and personal blind spots: "The version of Freud's own childhood that emerged from his self-analysis . . . that sexuality was at the root of his fears and symptoms -- and that he later extrapolated into psychoanalytic orthodoxy -- was an invention, a self-interpretation that served to cover up the unbearable losses and traumas of his own life" (p. 4). Throughout the book Breger depicts not only Freud but a number of his followers as suffering essentially from a post-traumatic stress disorder due to traumatic and unhappy childhoods. He demonstrates how Freud in sweeping generalizations attributed the Oedipus complex and sexual conflicts as etiological in all sorts of emotional illnesses and disorders. What Breger seems not to realize is that he is doing the same thing with his sweeping generalizations about the role of trauma in childhood as producing all sorts of emotional disorders. The continual attribution of the various personality characteristics and neuroses of individuals mentioned in the book, especially those of Freud, to traumatic experiences or deficit parenting in childhood becomes repetitive and should have been altered by an astute editor. It seems that Breger has the same failing as the one he attributes to Freud, except he concentrates on a different assumed etiologic agent. To me his orientation seems more Adlerian than Freudian, and one only wishes to know why he seems to need to reinterpret the entire corpus of Freud's work and attribute it unfailingly to various derogatory characteristics of Freud's personality.
If the reader can get by this fault, Breger's work is worth reading. He brings out the dark side of Freud in a persuasive manner and accomplishes a de-idealization of the man Freud which perhaps serves as a counterweight to the early idealizations of Freud by his original followers. In nunce, this book represents an honest effort to portray Freud as a flawed individual and to replace Freud's sex-based formulations with Breger's trauma-based formulations.
Breger's formulations are based on the same sort of speculative suggestions, bearing such phrases as "It is almost certain," "in all probability," or "It is a good guess," and so on. He claims that "As a very young child, Freud could do nothing about the painful realities that engulfed him; he almost certainly felt frightened, helpless, shunted aside, and overcome with longing for love and care" (p. 17). He concludes that "Freud created his oedipal theory because his traumatic losses aroused overwhelming emotions that were impossible to manage alone, in a self-analysis. By turning to the oedipal story, he created a comforting myth, one which allowed him to think that what most disturbed him was his adult-like sexual desire for his mother, and also promoted his weak father to a position of kingly power" (p. 19). He re-analyzes many of Freud's famous cases, invariably changing Freud's formulations, and makes it clear that in his opinion most of Freud's clinical work was simply wrong and based on Freud's neurotic difficulties arising out of Freud's deprived and frightening childhood. Freud's main interest in life, according to Breger, was to become famous by discovering a single theoretical principle. We are told, "He needed to produce 'cures' to prove his theories, and this overrode both the welfare of his patients and a careful assessment of the results of his treatment" (p. 121). These are harsh accusations indeed.
We are introduced to Breger's theory of the interpretation of dreams: Freud's "focus on wish fulfillment shifted attention away from one of the most important functions of dreaming -- attempting to master the disruptive emotions associated with traumatic and other threatening and distressing events" (p. 144). Breger concludes that Freud's "dread of giving in to his infantile yearnings was transformed, in his theories, into the image of a menacing sexual instinct" (p. 168).
Breger repeatedly and almost obsessively criticizes Freud for making speculative generalizations about his patients. He presents us with the following explanation of why Freud said, when he came to after he fainted in the presence of Jung, "How sweet it must be to die." Breger tells us that Freud's statement "expressed both his wish to be the passive recipient of love and care and the deathlike fear associated with the disappointment of this longing" (p. 229). No explanation is given as to how Breger arrived at this interpretation. We are also told that "Because Freud, intensely competitive and rivalrous with his former colleague, could not credit Adler with a theory of aggression, he needed to derive his theory from what had the appearance of 'biological-scientific' principles" (p. 267). Here Freud's postulation of the death instinct is attributed to Freud's allegedly unfortunate personality characteristics. There is no hint that perhaps Adler's theory was inadequate and superficial or that adopting it would have led to a major change in the focus of psychoanalytic treatment from the patient's sexual conflicts and fantasies to struggles for power with the parents, much more compatible to both Adler and Breger.
In summary, Breger's "new vision of Freud" (p. 376) is a highly debatable vision, and, remarkably, he attributes his findings to the same kind of procedure that Freud used to justify his findings of the ubiquity of sexual conflicts in the etiology of the neuroses. Breger writes, "I felt like a scientist who stumbles on a theory and finds that it reorders a mass of data into a new and more coherent form. As I did more and more research I kept coming across additional pieces of information that fit into the puzzle and enriched the account" (p. 377). This could have easily been written by Freud!
Dr. Chessick is Professor of Psychiatry and Behavioral Sciences, Northwestern University, and Senior Attending Psychiatrist, Evanston Hospital., and Training and Supervising Analyst, Chicago Center for Psychoanalytic StudyCorrespondence to: Richard Chessick, MD, PhD, 9400 Drake Ave., Evanston, IL. 60203-1106
A Memory from my Training:For some reason one of the most vivid memories from the time of my training in dynamic psychotherapy in London (1981-83) is the following. Every other Wednesday, after having lunch at the Tavistock Clinic "restaurant," or after skipping it, I would sneak away from the side entrance of the clinic, near the library and, after crossing one road, sight the Hampstead Clinic. I must say that every time I left the Tavi, this was always with some feeling of guilt. "What else are you looking for? Aren't you happy with us? You are in the cradle of psychoanalysis. Is what you're given not enough? How greedy of you!" I experienced the pervasive Kleinian atmosphere at the Tavi in a highly schizo-paranoid way, and this anxiety about my greediness might therefore be regarded as the result of an identification with the aggressor (Sorry, this is an Anna Freud favorite!).
When, three minutes after leaving the Tavi, I entered the Hampstead front door, a sense of awe took the place of my guilt. I was getting into Freud's home (almost so) and hopefully about to meet his daughter! That was really a sacred temple. Moreover my analyst, whom I had to leave in Milan to go to the Tavi, was enthusiastic about Anna Freud, which made my transference feelings to him and Anna even more oedipally charged. You will imagine the intensity of my emotion then, the day Anne Hayman, in recognition of my assiduous and faithful attendance to the Clinic's Wednesdays for the last months, asked me if I would like to be introduced to Ms Freud. Adrenaline is a poor word to describe my accelerated heartbeat and the upsurge of heat coming from the depth of my body and filling my cheeks, face, and ears, my wobbling gait toward Anna, and my almost complete inability to articulate a dignified speech.
I will spare you the dialogue that followed which, in any event, meant really little compared to the physical experience I was going through. This intensified even further when we shook hands, and I confusedly felt I was actually touching what for a few seconds was to me nothing else but Freud's incarnation. I would not write this, which may sound disrespectful of Anna, had it not been my sheer experience, for which I cannot be held responsible. Even though that day was one of the last times Anna Freud took part in a Wednesday open meeting (she was to die only a few months later), she proved to be thoroughly lucid in her careful discussion and extremely bright in the comments she made at the end of the research report presented by two American colleagues.
Brief Psychotherapy and Long Psychoanalysis:
Why mention all this? What has it got to do with brief psychotherapy (Short-Term Dynamic Psychotherapy on the American side of the ocean)?
At the Tavi I was on David Malan's Psychotherapy Unit, specializing in brief psychotherapy and doing outcome research studies under his direction. This contrasted with the remarkably long-term Kleinian atmosphere which we breathed all around. Analyses with Kleinian analysts tended to last longer than analyses with Freudian or more Independent analysts. Historically, a gradual increase in the length of treatments started with Freud himself and characterized the first fifty years of the development of psychoanalysis. The early treatments by Freud were, however, brief, and by crossing that road to see Anna Freud I was in a way returning to where it all started and symbolically uniting what had been divided. Why, in fact, call analysts Freudian, Kleinian, or ...? Apart from the obvious cacophony of Winnicottian, Sullivanian, or Frommian, and the tongue problems posed by Ferenczian (of which he was aware, considering his 1933 "confusion of tongues" paper), do these definitions say anything relevant to what analyst and analysand actually do? About the way they relate with each other? Or is it just a way to divert our attention from all this, ennobling our ignorance with a respected label? Finally, why do we use different names for long-term psychoanalysis and short-term psychotherapy? Is treatment length per s� a meaningful index? If it is, what does it measure?
These and other thoughts and question marks populated my mind at the time of my training, and they still do.
The Malan-Davanloo Connection: Chemistry and Surgery :
At the Tavi, it goes without saying, I attended Malan's Brief Psychotherapy Workshop every Friday afternoon. We discussed sessions and viewed tapes within the group, and Malan emphasized the "Davanloo technique." This name sounded rather exotic at the time, and hearing Malan say that Davanloo was Persian, lived and taught at Montreal General Hospital, and was a genius of STDP, infused his image with a mysterious, fascinating halo. The British, as a heritage of their colonial empire, tend to turn up their noses to most of the other cultures, but Malan is a leading and highly respected clinician, and since he saw revolutionary elements in Davanloo's approach, it was impossible to ignore them. It must be said, in total honesty, that Malan's hammering on this made us trainees feel uncomfortable, first because it seemed to detract from the "Tavistock tradition," and second because learning this revolutionary method turned out to be horribly difficult.
Once I met Malan in the fourth floor corridor, and he handed me manuscripts of four articles he was writing for Davanloo on the subject of "Intensive Short-Term Dynamic Psychotherapy" (IS-TDP). That represented the best that was available to make theoretical sense of what Davanloo was capable of doing in his spectacular videotapes of defense-dissolving interaction with the patients. Considering that Malan graduated in chemistry before becoming a Doctor Medicinae at Oxford and that Davanloo's career in general surgery preceded his devoting himself to psychiatry, one may well conclude metaphorically that Malan was able to identify the molecules and to describe the chemical process behind Davanloo's deeply incisive interventions and remarkably cutting stance. The two of them made up a very special and highly specialized team and a unique example of co-operation between two outstanding researchers. Davanloo's volume Unlocking the Unconscious (John Wiley and Sons, 1991) describing the principles of IS-TDP was made possible by their conjoint efforts. Both Malan and Davanloo proved to be the midwives of STDP therapists, since legions of trainees attended Malan's Brief Psychotherapy Workshop over the years, and many others attended Davanloo's symposia and the "Immersion Courses" he held in Canada, the United States, and Europe.
Family Trees:
Even though Freud and the other early analysts published some accounts of notable brief cases, the goal of brevity as such was never in their dreams. The historical birth of STDP dates back to the 1940s and took place on the American side of the ocean, when Alexander and French made systematic efforts to make psychoanalysis "briefer and more effective," providing patients with a corrective emotional experience. Leigh McCullough (Changing Character. Basic Books,1997, p.8) observed that,
Unfortunately Alexander and French were strongly criticized by the analytic establishment because there was active manipulation of the transference. In practice, however, the transference is inadvertently "manipulated" by whatever therapists do, and no less so when neutrality or passivity are maintained in the analytic technique. The point is that we must acknowledge and specify [...what we do...] so that the effects can be experimentally examined.
Another major source of STDP research endeavors sprang up in the Boston area. A tragic fire occurred at the Coconut Grove Restaurant in Boston in 1942. Many customers were killed either from the fire or while trying to escape, since they found the doors locked. The survivors of this fire, whose friends and loved ones died beside them, were rushed to Massachusetts General Hospital, where Eric Lindemann and his staff provided treatment. Lindemann observed that these survivor victims improved more rapidly than his long-term patients and surmised that the crisis raised anxiety levels, resulting in their defenses being more responsive to intervention. Two of Lindemann's residents were Peter Sifneos and Habib Davanloo, who developed their respective STDP models, both of which have a notable anxiety-raising component.
On the European side of the ocean, in the early 1950s Michael Balint experimented with brief forms of therapy. He was personally acquainted with Alexander but ignored his work and did his own investigations from the beginning. He founded the Brief Psychotherapy Workshop at the Tavistock Clinic, consisting of a group of selected and gifted clinicians, one of whom was Malan. Their initial idea was to circumscribe a conflict area on which to concentrate dynamic work, and Balint coined the term "focus." I was told by Malan that the therapies supervised within the BPW were never really focal since interpretations actually addressed all the meaningful material and not only the parts of it connecting to the focal conflict. The term "focal," applied to brief therapy, became widespread and was mistakenly thought to be almost equivalent to "brief." This term also appears in the title of Balint's posthumous book, written with his wife Enid and his disciple Peter Ornstein (Focal Psychotherapy: An Example of Applied Psychoanalysis, Tavistock, 1972). Basically, I regard "focal" as a reassuring concept, in that brevity makes it easier to accept focality, and the latter seemingly explains brevity. This view is, however, simplistic because even a dynamically simple case with a single and highly meaningful focus, is not guaranteed to be effectively dealt with in a short time. In other cases using an effective approach a relatively short time may allow for the resolution of dynamically more complex, thus "multi-focal," disturbances. Since there are other factors involved, the term "focal" as a label for brief psychotherapy, is as misleading as it would be to use "couch" or "free-association" as a label for psychoanalysis. To quote Balint himself, "I used to think that the essence of analysis was five times a week on the couch, free association, etc., but now I realise that the essence of analysis lies in the attitude of the therapist" (Malan, personal communication).
With the help of Marco Bacciagaluppi, the President of OPIFER, I tried to sketch a family tree of present-day STDP therapists (figure 1). On the second line there are a few of Freud's analysees plus Federn, who was never analysed by him but was his devoted disciple. Federn analysed Weiss, who analysed Italo Svevo, the famous Italian writer and the author of La Coscienza di Zeno (Zeno's Conscience). Weiss then emigrated to the United States, because of the fascist anti-Semitic legislation in Italy (1938), and co-authored Psychoanalytic Therapy (1946), with Alexander, French and others (1946), hence his link to STDP. What is meant here by "last generation STDP therapists" is that they trained with Malan, Davanloo, or both even though they were not (at least not all of them) analysed by either Malan or Davanloo.
A Transitional Phase :
In the mid 1960s David Malan started his own Brief Psychotherapy Workshop for trainees at the Tavistock Clinic. This was quite different from Balint's, since the original one was entirely for experienced therapists. Malan postulated the unavoidable connection among selection criteria, therapeutic technique used, and the quality of results obtained. His elucidation of the dynamic process and of change factors in dynamic psychotherapy and psychoanalysis is invaluable. His well-known books contain a rich harvest of clinical material, providing evidence on which the "science of psychodynamics" is based. In this respect they represent an ideal continuation of the book by Alexander and French. Malan was actually able to disprove the "hypothesis of superficiality" according to which brief psychotherapy is a superficial treatment, applicable to superficially ill patients, and bringing about superficial results. He spelled out that, "The aim of every moment of every session is to put the patient in touch with as much of his true feelings as he can bear" (Individual Psychotherapy and the Science of Psychodynamics. Oxford, 1979, p.74). This simple statement actually has two major practical consequences: Firstly, a therapist should be able to detect what "as much [...] as he/she can bear means when applied to a specific moment of the interaction with a specific patient, and, secondly, it would be good to have effective ways to regulate the intensity of emotional experiencing as indicated. Thus Alexander's original intuition of how crucial is the actual experiencing, was strengthened by Malan's clinical research, but what was still lacking was an adequate clinical methodology effective enough to facilitate and handle intense emotions in the patient and also in the therapist. This is certainly the main reason why Davanloo's advent was immediately felt by Malan to be the "missing link," eventually making it possible to connect together the therapeutic and the theoretical sides of psychoanalysis.
Two remarkable research studies evaluating the relevance of emotional experiencing to therapeutic outcome were carried out in New York at the Beth Israel Research Program. The correlation between three types of intervention by the therapist and the frequency with which they were followed by an emotional response by the patient was investigated (McCullough, L., Winston, A., et al., ...., The relationship of patient-therapist interaction to outcome in brief psychotherapy, Psychotherapy 28:525-533). Research results indicate that transference interpretations followed by an emotional response bear a significant correlation to improvement at termination, whereas an intervention followed by a defensive response correlates negatively to outcome. In another study (Winston A., Pollack, J., et al., Efficacy of brief adaptational psychotherapy, Journal of Personality Disorders, 4, 244-250, 1990), 32 patients with personality disorder were randomly assigned to Davanloo's IS-TDP or Brief Adaptational Psychotherapy (BAP), a more cognitive approach developed at Beth Israel. Significant improvement took place in both groups as compared to controls.
The Last Generation of STDPers :
The confirmation of the positive correlation between emotional experiencing in response to therapist's intervention and outcome gave further thrust to the clinical investigation of the ways to actually facilitate this experiencing and make it more easily attainable. This was repeatedly confirmed using video technology and mutual supervision and proved to be a crucial factor accelerating dynamic processes within the patient-therapist relationship. A number of former trainees of Davanloo and of Malan contributed their own creativity and their personal research endeavors, laying equal emphasis on the psychodynamic and the experiential aspects. Diana Fosha (The Transforming Power of Affect, Basic Books, 2000) proposed to call this approach "Experiential Short-Term Dynamic Psychotherapy" or E-STDP.
I have described some aspects of the historical evolution of STDP, and it is not possible to go into the theoretical or operational framework of E-STDP more deeply. E-STDP especially draws on Malan's work for the emphasis given to the deepening of feelings in the therapeutic rapport and on Davanloo regarding the handling of defenses and the quality and intensity of human feelings. A number of colleagues who, like myself, received training from one or both of them base their clinical work and research endeavors along these main guidelines. A new association of psychotherapists, the International Experiential STDP Association, (IESA, www.stdp.net) was recently founded in New York. E-STDP is basically a relational psychotherapy firmly rooted in the patient-therapist relationship, seen as a genuine, personal, and respectful human interchange. It is psychodynamic -- that is, it uses the basic dynamic theory of conflict and transference phenomena, -- and it is experiential, promoting and valuing the actual physical (through the body) and mental (related mental representations, thoughts and fantasies) experience of feelings, affects, emotions, impulses and desires. A first international conference centered around E-STDP was held in Milano, Italy, on May 10-12, 2001, with the conjoint efforts of IESA, OPIFER (Italian Psychoanalytic Association and Federation), and the Niguarda Mental Health Department.
Dr. Osimo is Associate Professor of Short-Term Dynamic Psychotherapy at Universit� Statale di Milano,Italy, President of IESA: International Experiential STDP Association, and Treasurer of OPIFER: Organizzazione di Psicoanalisti Italiani, Federazione e Registro.Correspondence to: Dr. F. Osimo, Via P. da Volpedo, 12, 20149 Milano, Italy
The importance of language cannot be overestimated in the practice of psychiatry. It is our stethoscope, our thermometer, our MRI. Language, including body language and non-verbal communication, is our primary method of assessing improvement, change, and, on a psychodynamic level, meanings in the therapeutic relationship. We must accept that words have meaning, sound and a flow that is unique to every individual.In dealing with more severe forms of psychiatric illness, we have become accustomed to use psychotropic medications that can reduce the intensity of the symptomatology. Many recent books and articles emphasize the controversial qualities of these agents and their use and may even sensationalize their effects and precautions. I am a strong supporter of the intelligent use of psychotropics. My issue is with the our excessive reliance on medications as the only way of approaching severe pathology. The art of entering the patient's world, so common and necessary in doing empathic psychotherapy with neurotic or personality disordered patients, is a valuable way of understanding and treating the world of psychotic pathology as well. Understanding the autistic meanings of words, symbols, delusions, hallucinations, and referential ideas in conjunction with patient motivation and a trusting therapeutic alliance clears the road for deep change of defensive structures and realignment of psychic functioning. It is also an avenue for deeper exploration of actual or perceived trauma and adaptation mechanisms. None of this need be seen as antagonistic to neurobiological views of schizophrenia or affective disorders. The art of processing and storing perception, is refined and evolved through therapy, learning, experiencing, and realizing, as it promotes recompensation. Awareness can always be deepened, and the struggle for a harmonious psychological balance with the environment is constant and enduring.
As a linguistic expedition into the mind of a schizophrenic, which ultimately resulted in a successful outcome, I want to present a case I treated starting in the second week of my residency in July 1975. Barraged with learning to differentiate TD from EPS, FOI from LOA, and where on the sheet to write admission diet orders, I met Dana, a 30-year-old Caucasian female admitted during the night after she was picked up for "bizarre behavior" in the ladies' room at Port Authority Bus Terminal where she lived. Before going to interview her, I was cautioned by the ward chief to approach her slowly and observe a classic but now rare sign. I walked into the room and saw a seemingly attractive woman, old before her time, her long brown hair messily hanging over an amorphous gown, slowly turning around in place, her absent stare not fixing on any point in the room. Introducing myself, I asked if she would be willing to speak with me. She continued to turn and responded, "Can't talk, but will try... the voices are talking to.... Don't know why they are talking to like that. Not normal, am not normal." I thought, "Oh my God, maybe I can still land that pediatric residency. What the hell is this crazy field I got into." The rare sign of course, was the posturing, and in addition she showed waxy flexibility. I asked her to come over to the table, have a seat, and talk to me, and she walked over backwards. She never walked forwards. Her speech entirely lacked "I" or "me." She was clearly hallucinating and was guarded about what turned out to be a complex delusional system. There was no drug or alcohol abuse history, no medical pathology and a past history of one admission elsewhere about two years before with no ostensible follow-up. In spite of this seemingly fragmented and almost hopeless level of psychosis, I was very moved by the fact that she could see all this as "not normal." This shred of intact reality testing was the basis of the treatment done over the next ten years. She was started on low doses of perphenazine and integrated into ward activities. Nobody told me at the time that I shouldn't try to understand delusional thinking so I went ahead with trying to figure out why Dana decompensated. I decided to work on the delusional ideas first to see if these could be connected to the posturing. The rotating related to "fighting the voices" which were sent by the government to control all thoughts. By constantly facing all directions "vigilance would be a protection." Walking backwards aimed to confuse them into going away. The government, it seemed, had made her into a robot as a punishment for having caused the war in Vietnam. In trying to make sense out of this symbolic material, I needed to define the terms and parameters and see how they related to her life history. In Dana's delusion, the government represented an incomprehensible force that makes things happen, influencing people to do things, and dehumanizing them. A robot was a depersonalized human substitute that could imitate but never be a human because it lacked feelings. Due to the external controls, the robot also lacked choice. The war in Vietnam symbolized a world war, one that ultimately destroyed all countries. The delusion could be reworded as follows: Dana had been made into a feelingless human substitute, devoid of choice by some incomprehensible powerful governing force as a punishment for creating a world war that destroyed the nations of the world. I am not a Freudian analyst and would perhaps now seek out the effects of this on her life today, but at the time, I wanted to connect the belief system with trauma in childhood.
Dana was born in New York to working-class Irish parents, devoutly Catholic. She was an only child and could recall no extended family and no socialization outside the home with neighbors or schoolmates. Her parents fought a lot, physically and verbally, because her father drank excessively and womanized. They were strictly religiously observant, so no divorce or separation was possible. She recalled fearing for her mother's life and felt she needed to be around for whatever protection she might provide. Though she tried to intervene in the fights, she was rebuked with "You stay out of this! Don't you get into this! Everything was fine until you were born! You can't fix what you destroyed!" It should be mentioned that Dana, prior to her decompensation, worked for an airline as a reservation agent and as such, had been able to travel throughout the world. My attempt to understand the delusion lead me to infer that in her family she was made to have felt responsible for causing the whole world to fight and that as a result, the governing force, her parents, had ostracized her from the world. Therefore Dana was not truly human. For a five-year-old, your home and family is your world; for a ten-year-old, your neighborhood and school and friends are your world; for a twenty-five-year-old travel agent, the world becomes your world. The conflict is constant; the battlefield expands. Though her affect up to this point had been completely flat, her eyes showed some evidence of tears. We explored the reality of this idea, that whether the birth of a child could truly create such problems. She was able to note that there had to have been deep problems from before that could not have been her fault. Within two days she stopped posturing, began to walk forwards, albeit slowly and somewhat machine-like, and started to integrate "I" and "me" into her conversation. I was omnipotent! She continued to improve. The perphenazine was lowered to 4 mg a day. She was accepted by a residence, and a discharge date was set up. Against the ward chief's wishes, I wanted her as an intensive patient and took her on. My first supervisor, though an analyst with an interest in the symbols of dream interpretation, felt that she could not be treated in an interpretive way. I was to see to it that she took her meds, bathed, paid her rent, and got a date from time to time. It didn't matter. I was unstoppable! I was going for the gold, the ultimate interpretation.
The next delusional system we encountered was her belief that Hitler was secretly living in the White House. Once again I needed to figure out the language. Hitler symbolized the embodiment of tyrannical evil, though not in her mind connected with the world war spoken of earlier. No specific relation to Nazis, persecution, genocide, or Germany could be elicited, only that he was supremely evil. The White House was of course the central seat of government. Evilness lurked in the powers that run the nation! On one level I thought that this could be interpreted as more symbolic referents to her parents, but I off target. The belief remained unchanged, and the affect still was the same. So, more history. What emerged was that when she had just finished high school and turned eighteen, her mother died from unknown causes, possibly suicide; Dana wasn't sure. Her father had for some time been involved with a lover and, soon after the mother's death, moved the woman into their home. This made Dana completely redundant, and since she was eighteen, he threw her out. "Life has to begin again! She's dead and now you're out of here too!"
Dana moved from apartment to apartment of high school friends in exchange for cleaning, baby-sitting, and dog walking. Later she lived in a room and supported herself cleaning houses. She took a course in making reservations for airlines and got a job making phone bookings for an airline. All the while, she felt rage at her father for throwing her out, being non-supportive and unavailable to her. This took the form of fantasies of "him getting his" and his being afflicted with misfortune. As it happened, she learned later that he had in fact died from alcoholic liver disease, but she was not contacted at the time.
The high school she attended, a strict parochial school, had inculcated a teaching (which I am told is no longer taught but which was at that time prevalent), namely that from God's viewpoint, fantasizing an act was no different from actually doing it on an external level. So much for psychodynamics! Catholic friends of mine corroborated that they too had been taught this concept. Since the intensity of any feeling is experienced through the associated fantasy, it appeared that the feelings themselves were being stifled. Dana was, justifiably in my opinion, furious at her father, but her fantasy, to her, was the wish that caused his demise. In her delusion then, the White House represented not the parents but the government of her own life, her psyche, and Hitler represented the evilness of her anger killing her father in fantasy and, therefore, in truth. Though she could see how his drinking in fact caused his death rather than her anger, it was not apparent to her that a fantasy is merely a metaphorical way of experiencing the intensity of a feeling, and not the same as an action.
To concretize this concept, I devised a chart, written on a notecard for her to keep, which we called "The Circle of Feelings." It was completely improvised and may seem rudimentary by therapeutic standards of today, but it clarified otherwise difficult and confusing words. It begins with the idea of a cause, specific to every person, based on ones tastes, ones beliefs, or ones background. What makes you happy might well differ from what makes me happy. We get turned on, ecstatic, furious, or soothed by specific stimuli related to our own emotional hierarchy. This cause leads to the feeling itself, whose major characteristic is that it cannot be controlled except by controlling the cause, accomplished on the internal and external level. Someone steps on your toe on the bus and creates the feelings of pain and anger. The pain does not begin to subside until the person gets off your foot. The anger, based largely on that person's clumsiness, could be dissipated by the person apologizing (external) or by your noticing that he is blind and could not help it (internal), or by simply deciding after a time that there is no point to remaining angry (internal). The feeling would then lead to a responsive action. This is completely controllable, based on one's resources (Am I able to do this action?) and consequences (What would happen if I did this action? What would likely happen if I did not do it?). We would like to tell the man who is stepping on our toe to get the heck off. Can we? Would he understand and respond appropriately? What would be the consequences? If he were, for example, Mike Tyson and in a very bad mood, the benefit of keeping silent would far outweigh the consequences of telling him to get the heck off our toe. Finally, we judge the consequences. Did I do well? Did I accomplish satisfactorily what I wanted to? These judgements become in and of themselves causes of new feelings that then start the cycle again. It is noteworthy that this judgement should best be directed at the choice of behavior, which is always changeable. However, judgement is usually directed at the validity of the feeling itself, which one cannot control. We try to extinguish, suppress, or eclipse a feeling when the associated behavior is the real source of fear. I cannot be angry at my father because disrespecting him would be unacceptable to my moral beliefs. The anger exists and cannot be pushed away. How you handle anger -- by direct confrontation, by redirecting your energy, by choosing to remain quiet, or by proving your value by believing in yourself -- is within your control and, therefore, can be reasonably judged. Additionally, between the feeling itself and the resultant behavior, is the notion of a fantasy. In the "Circle of Feelings" fantasies play two roles: They are substantive ways of measuring the intensity of a feeling, and they "rehearse" the concomitant behavior as a way of arriving at the optimal solution. Schwartz's third law of psychiatry states "A fantasy is a fantasy because it is a fantasy. If it were a reality, it could not be called a fantasy." A fantasy need engender no fear.
My aims were to generate more trust in the basic logic of her thought content and, second, to urge her to bring the delusional material to the sessions so we could examine and analyze the underlying feelings. I also felt it might be beneficial to give her a "souvenir" of our discussion to refer to and to keep in her wallet. We often referred to the "Circle of Feelings," and it has been helpful for other confused or regressed patients. As Dana became more comfortable with these truths, the presence of Hitler in the White House subsided.
As the therapy continued over the ensuing months, the focus gradually shifted to "life issues" and less interpretation of schizophrenic delusional ideas. Questions of improving communication with her boyfriend, how to negotiate for a raise at work, and how to deal with demanding or obnoxious clients became more common than symbolic interpretation of autistic ideas. Occasional delusions did emerge in the form of strong word puns. The 1976 presidential election, as an example, caused her fear that she could not vote without a driver's license since the candidates were a Ford and a Carter. In 1977 the news focused much attention on congressional approval for the funding of the B-1 tactical bomber. Dana had by that time gotten more confident in her airline ticket sales job, had met a new boyfriend, and had become friendly with people from work and from her residence. She seemed happy, but one day she announced to me that the government was experimenting with the B-1 not just for defense but as the mediator of all future foreign policy for the rest of eternity. Here the government referred to the self, the psyche. B-1 meant being one (person), being whole, complete. Foreign policy denotes the way that one's government (i.e. self) interacts with other governments (i.e. people), and eternity means forever, for the rest of ones life. Thus translated, "being whole is more than simply a defense, but becomes a means of successful interpersonal socialization for the rest of your life." The concept was completely congruent with her external experience and accurately described, albeit in a symbolic fashion, a universal truth. Despite the interpretation, she had a lot of difficulty seeing her fantasy as a projection of her internal issues and tended to maintain her view of certain government activities. Related statements at the time included the idea that Egypt built the "As one" dam to stop "denial," and that Henry was "kissing her."
The whole notion of the undercover inner workings of secret politics and clandestine activities in government is a source of mystery to most people, from Nixon's Watergate enemy hit list, through Oliver North and the Iran-Contra affair, through the KGB, the CIA, the Secret Service. These mysteries are the meat of delusional ideas, and while we can attempt to relate it to internal emotional churning, it is not possible to "prove" that on a governmental level it does not exist. One could even create a pun suggesting that "governmental" is a way to "cover mental" issues. I conceptualized a kind of boundary line onto which is placed a see-through mirror. On the far side, we place the government, the world, and international politics. On the near side is the self, the feelings, the psyche. There could be reflections of world events from the outside in, but since world events can be so inexplicable, perhaps we could stay with the explicable, understandable, internal events. These internal realities may be then projected out, but for them to remain on the near side of the line would be much more beneficial. Admittedly, I liked my metaphor of the line and mirror, but it got only smiling, passive acceptance from Dana.
Since I was not going to get her to cross the line to the internal self, I decided to approach the level of understanding by crossing to the outside. It was time to study history, in this case (of course knowing me) medieval history. I devised the following "historical" analogy. A tiny nation was surrounded by two powerful, warlike countries that constantly bombarded each other and the tiny nation. To protect itself from this ongoing attack, its government built a huge wall, completely sealed off, thick and impenetrable, to guarantee the safety of its citizens. No hostile forces could invade; nobody could even see inside. Of necessity, the inhabitants could not see or go outside either. After a time the neighboring governments were overthrown and replaced by more benevolent rulers, but these changes were of course unknown to the walled-in tiny nation. No more bombs were falling. No more banging on the wall. Was this a trick, or had peace finally been declared? People began to peek between the bricks and saw no soldiers outside, and the neighbors peeked in but caused no damage. The neighboring nations perhaps could even be of help by providing resources or technical support. Gradually, the walls, which were no longer necessary, were dismantled, and free exchange was implemented. Dana responded, "Gosh that sounds a lot like my life, don't you think?"
An extended period of respite followed with discussions about leisure time, work, and social life. Her affect was full range, and her relatedness was on a level that belied the pathology we had explored. This was interrupted by a slight increase in paranoid thinking and double meanings, largely government-connected, like "The government makes Indian reservations to fly them away." For the first time she told me that, in fact, I was an agent of the government. I! Part of the forces of possession and oppression! I was shocked, even a bit insulted, given all the effort and time I had put into the treatment, with every intention of freeing up, rather than oppressing her life. I told her that I was absolutely sure I was in no way linked-up with the government, and that I wanted to know what evidence would make her think such a thing. She attempted to calm me and said that unbeknownst to me the government was working through me and could program me to say certain words that had special control issues, but that I, of course, had no awareness of all this. Figuring that this related to certain authoritarian expressions or words I might have used, I asked what these magical words were.
Her response was one word, "which." "The voices on the street always told me I was a witch and so whenever you use that word, I know that the government is talking through you." I asked if either usage of the word was an issue, either spelling, and was told "That's how the government works. Any way you use that word, it is their way of attacking me, humiliating me." Apparently, this did not occur with other words incorporating "which" such as, "switch," "twitch," or "sandwich." Needless to say, I did not want to be part of the "bad guys," even unknowingly, and I had trouble figuring out what this was all about: Negative transference? A way of moving away in therapy? A form of testing? I discussed it with a psychoanalyst friend who suggested that she was testing my own strength to tolerate her crazy ideas and that the best way to proceed would be to try to eliminate "whiching" from my sessions. I disagreed with the tolerating part, since I had tolerated much stranger ideas in the past. My own neurotic needs to please did, however, gel with the idea of talking without using the word. To speak without the noun "witch," as in "on a broom," was easy, but "which" to introduce an explanatory phrase happened to be very much a part of my speech pattern. I found my ... self ... speaking ... slowly ... with ... hesitation ... to plan ...every upcoming ... phase. All spontaneity was lost. Every sentence was a challenge fraught with the fear of accidentally using "which."
Within a few weeks of this, I was feeling increasingly upset with the entire process, and I told her so. She asked me what I meant and why I was doing that. I explained that if I were a government tool giving secret messages, she would leave treatment and we would lose all the gains we had made. She assured me that there was nothing to worry about, that I had said the word "which" hundreds of times over the years and that she had never walked out or left treatment. After so much time, she assured me that I certainly had nothing to fear. True as that was, I still thought that now that I knew about this, I could no longer trust that reassurance, and that she would not tolerate a government agent being her therapist. I came to realize that I had developed a fixed belief, completely impervious to the most reasonable, gentle experiential convincing, that was causing my entire communication process to become stiff, rigid and inexpressive. I had developed a paranoid delusional response with verbally catatonic features. Dana saw my dilemma and commented that "Now you have a deeper understanding of what it's like for me." I surely did. I could see my process as a massive defense against the potential loss of goals, purpose, validity, and alliance. I could not trust the fact that, even with her promise not to walk out, the fact that she had never done so up to then, and that great strides had been made, she would not abandon our journey.
So I maintained my route of compulsive avoidance, practiced intensely, and improved at speaking proficiently without using the word "which." I taught myself to substitute words like "that" or "whatever" or break the sentence into shorter sentences. I also observed that she could speak fluently without using the word. The outlook improved for both of us. One day Dana told me about two men who liked her, but she was not sure which one she liked more. In the same session she mentioned an interest in visiting one of two islands in the Caribbean on vacation, but she could not decide which one to travel to. I realized that the only place where there can be no substitute for "which" is when a choice is made between two objects. I asked her to talk about what it meant for her to make choices. Dana said it was the worst thing imaginable, that she hated to make choices. Choosing was tantamount to selecting one and rejecting the other, feeding one and starving the other, nurturing one and killing the other. It was always better to do both options since you would be creating pain and death for one of the choices. She felt this dilemma since her childhood, and it was always a source of anxiety, based on her apparent need to establish an alliance with one or the other parent. What kind of person could inflict such a degree of pain so easily? A witch. The entire delusion was referable to the trouble caused by making a choice, with the concomitant rejection of certain options.
This was the climactic point of therapy. The rage that Dana had felt through virtually all of her life had combined with her fear of any form of fantasy, based on the learned doctrine of mortal sin. This combination made it necessary to suppress the conflict out of consciousness. Any semblance of choice risked opening the gates to an emotional turmoil she felt was unmanageable and uncontrollable. By displacing the entire conflict into an out-of-reach government place, she attempted to do away with her fears of being an evil murderess. She was, however, stuck with her ever-present rage fantasy, likening herself to a witch. The government can be interpreted on many levels. Obviously, it represented her psyche. It also represented a projected father, an embodiment of humiliation, that addressed her despised self, the portion of the internal image that can never be good enough and made her unable to be a part of the world. The government also was an idealization of the guilt she felt at having the power to choose an attitude, as a choice-making witch. On a larger level it represented the whole worldview, the inexplicable lack of control over her existence, with the strong ambivalence of needing the control, yet relinquishing it, and yet resenting no longer having it. The result was a figurative and literal inability to move, causing a belief system that exuded grandiosity and at the same time horror, through persecutory delusional ideas. The balancing act of my trying to communicate without using the word "which" was a reflection of her balancing act between the desired loss of homicidal potential and the inevitable feelings of rage she had always suffered.
Dana did well in therapy, never exceeding the low dose of perphenazine, eventually working as the assistant to the director of a well-known museum. I did well in therapy too. I developed some strong personal insight into what may have been a tiny piece of paranoid-catatonic process. More importantly, I came to a tremendous respect for human creativity, even in the context of schizophrenic thought disorder. One of my supervisors, who was more sensitive than others to my explorations, told me that I would never have this sort of therapeutic encounter again. I was furious! I had found the cure for schizophrenia, and the world was full of jaded old "shrinks" who knew everything and did nothing! Years later my supervisor's statement proved right, at least in part, and I came to an understanding of what she meant. First, Dana truly hated being schizophrenic. Her illness had ceased to function as a defense against an unaccepting and humiliating world, becoming in and of itself a source of humiliation and rage.
Many other patients remain less comfortable with returning to the external reality of the actual world and manage to balance their lives in a way she no longer would do. Secondly, and far more apparent to me now, is that the effort I made throughout the treatment to reframe and understand her delusional system may have meant more to her than the specific meaning of my interpretations. The active interest and participation of a stranger, for the purpose of making sense out of one's emotional chaos, are powerful messages for the lost soul. The idea of a strong entity becoming available to our presence and willing to help us is a central concept in religion, education, and therapy. Saints, teachers, and therapists all extend lifelines to worlds unattainable to us without them, and they help us to achieve those solutions with dignity and awareness. It is likely that the lifeline I extended to Dana did not require that degree of interpretation, and I could have maintained the effect without the vast expenditure of emotional and intellectual energy.
While treating Dana, I started analytic training. Students at school and colleagues at work all had strong opinions about what I should have done, what would have been more effective, more stimulating, or less self-effacing for me. Many of the approaches I had used were pure improvisation. The whole direction was uncharted territory for me.
At a distance of twenty-five years from the treatment, I admit that the interpretations were at times sophomoric, perhaps heavy-handed, maybe too limiting. There are those who oppose using psychodynamic interpretations to comprehend schizophrenic symbols or those who would reframe them in other ways. In fact, my own dynamic framework is far less retrospective now than it was prior to my formal training. Perhaps my youthful grandiosity made me too headstrong about the validity of my efforts. However, I was able to avoid the whole cookbook, complacent therapeutic approach all too common today. This case cannot be used as a model of how treatment should be done. Rather, I use it as an example of the importance of seeking meaning, of communicating, of penetrating into what someone really is talking about, trying to help a person at that level. Not long ago, a group of medical students asked me how does one "do therapy." I wanted to avoid a dismissive answer like, "It takes years to learn," or "It cannot be done on an inpatient unit." I thought about their question and gave them three basic rules: First, seek out the intrinsic strength of the individual as the main bulwark against the pathology. Second, think carefully how you yourself would want to be spoken to. Offer what you can deliver, and never promise or threaten what you cannot or will not do. Third, be aware that there is always more to learn about a patient, and keep digging.
A few months ago, I was talking with a woman from Minnesota about a fascinating project with which she was involved. She and a group of investors had put together a "health center." After programming Harrison's textbook of medicine and the equivalent textbooks of pediatrics, gynecology, pharmacology, psychiatry, and therapeutics into a large computer, they set it up so that people (for a small fee) could input their symptoms into this computer, day or night. They would be given a diagnosis, a treatment plan replete with prescriptions, possible side effects, and a series of return appointments to report their progress. The woman excitedly told me that this would effectively eliminate the need for doctors altogether, thus saving tremendous cost and time and putting tons of money into the investor's pockets. This idea appalls me and frightens me. The business of medicine and psychiatry has all but killed psychodynamic therapy and has crippled cognitive and behavioral models. This plan would eliminate all individual treatment in favor of a few group psycho-educational sessions to bolster the need for lifetime medication, prescribed by a primary care "gatekeeper." It is not a long jump to the next step of eliminating us psychiatrists completely. Ironically, the administrators and the captains of industry comfortably place blame for their takeover of our work on the need to control our excessive greed! Too many of us are burned-out and cynical about the inevitability of this phenomenon. Among the things that humans do better than machines are thinking, feeling, and caring. As a psychiatric community, we can offer understanding, pain-reducing medications, and the redirection of destructive perceptions or impulses. People surely have impairments of neural pathways and chemical imbalances, but they also need the support, the communication, the belief, and the reality of empathic warmth to reconstruct their lives. Let us never sacrifice either direction in our work.
Scott Schwartz, MD, is a Fellow and Trustee of the American Academy of Psychoanalysis, Assistant Professor at the New York Medical College Department of Psychiatry, and Attending Psychiatrist at Metropolitan Hospital Center, New York.Correspondence to: Dr. Scott Schwartz, 829 Park Avenue, Apt. 10B, New York, NY 1021
This is a long and thorough anthropological study by a professor of anthropology at the University of California, San Diego. The target audience of such a book is the generally educated public who may be interested in medical affairs and in problems in the mental health field. Psychiatrists and psychoanalysts reading this book will find little that is new in it, but they will find that Luhrmann has done an excellent job in describing the current status of psychiatry and psychoanalysis. That status can only be described as a disaster, and more of a disaster for the mentally ill than for the practitioners in the mental health field.There is no need for me to review what Luhrmann experienced in her studies of various psychiatric hospitals, psychiatric treatment programs, and psychiatric residents in training, as it is all quite familiar to those of us who are in the field. The book has a somewhat polemical and at times repetitive tone because it is frankly aimed at making the public aware of the calamity that managed care has imposed upon the mentally ill in our country. When I tell my European colleagues about this situation they are aghast and convinced that we Americans are insane. At the same time they worry that the general Americanization of the world that is going on today will be spreading away from our shores and encompassing and ruining medical practice in the rest of the world including their own countries.
The book begins with an introduction that leaves the author open to some question regarding her capacity to bring about her investigative field work, but as the book moves on it becomes apparent that she certainly has done a respectable job; as for her motivations in doing such a study, this is not relevant to the results of the study in this case. She states that since 1989 she did four years of field work "including more than sixteen months of full-time intensive immersion" (p. 9) involving local hospitals, attending lectures, visiting at length with residents, and sitting in on medical meetings. She spent time at various kinds of private hospitals and traveled around the country "speaking with hospital administrators, psychiatry residency program directors, and young psychiatrists" (p. 9). She shadowed residents during their days of work, watched patients interviewed, and received twice-a-week psychotherapy "with a senior psychoanalyst for more than three years" (p. 10). She does not explain why she received this psychotherapy, and she also tells us "I have followed eight individual patients for psychotherapy under the supervision of a senior psychoanalyst" (p. 10), which makes one wonder how this came about and raises concern about the ethics involved.
In the first two hundred or so pages of the book Lurhmann tries to paint a balanced picture of psychiatric training as it was when she started her research over ten years ago, when residents were given instruction in both psychodynamics and psychopharmacology. As time passed it became clear that under the influence of managed care there was going to be no time for psychodynamics and no time to spend trying to understand patients; psychopharmacology became the predominant treatment. So psychiatrists increasingly spend their time prescribing medication, doing extensive paper work, and arguing with managed care to get authorization for treatment and payment. There is a general demoralization in the profession. At one extreme there are the biological psychiatrists and at the other extreme the psychoanalysts, an unfortunate split since it is increasingly clear that a combination of biological understanding and treatment, along with psychoanalysis or psychodynamic psychotherapy, is the optimal approach to people with mental illness.
Her description of the annual American Psychiatric Association meetings is impressive, She points out the "air of carnival" (p. 55) and it is clear that the gigantic multinational pharmaceutical industry has now totally dominated the field of psychiatry. Psychoanalysis is increasingly shoved onto the periphery, and of course this position is used by managed care as an excuse to deny payment for such treatment. Training in psychodynamic and depth psychotherapy has largely been eliminated and rightly so, since it is almost impossible for young psychiatrists starting out to find patients who are able to pay for this by themselves. The net result is a calamitous medical malpractice situation in which the psychiatrist is held responsible and yet manipulated into situations where clearly inferior treatment is provided. This is especially true of hospital psychiatry, as documented at great length by Luhrmann. Luhrmann reviews some of the extreme positions of psychoanalysts in the middle of the twentieth century, such as the attempt to explain manic-depressive disorder on the basis of family dynamics, and so on. The deep psychoanalytic interpretations of peptic ulcer that I learned in the 1950's now look rather strange next to the discovery that this disorder is caused by bacteria. So, describing the meeting of the American Psychoanalytic Association, she tells us that a young analytic candidate described it as "watching dinosaurs deliberate over their own extinction" (p. 183).
Because the power of the pharmaceutical corporations and the insurance corporations with managed care is "pushing the psychodynamic approach out of psychiatry with a nearly irresistible force" (p. 203), many individuals needing long-term treatment are deprived of a chance to have at least a passable existence during their short span on this earth. So ...
The real crisis for psychodynamic psychiatry has been not the new psychiatric science but managed care. . .. It isn't that psychiatrists think that psychotherapy isn't important . . . but the more time they spend on the phone with insurance agents negotiating for a six-day admission to be extended to nine days because a patient is still suicidal, the more admissions interviews they need to do, the more discharge summaries they need to type, the less the ways of thought and experience of psychodynamic psychiatry fit in. (p. 238)
Luhrmann concludes, "Then, at the end of my field work, I saw the balance tilt irrevocably" (p. 238), and she is told by one of the residents that "They've decided to ax the psychoanaltyic journals from the library" (p. 239). The disaster that managed care has caused to the mental hospitals is described in detail, with the firing of staff, the demoralization of those who remain, and the change in orientation toward patients from humans with problems to biological things that have to be patched back together and sent out to the environment that precipitated their illness in the first place. A lot of anxiety occurs because some of these patients still seem to be suicidal, and it is very difficult to be the psychiatrist caught in the middle. Most of the analysts in these hospital settings have either left or have been fired, and I am sure the readers of Academy Forum are aware that the chairmen of departments of psychiatry today are all administrators and pharmacologists, whereas fifty years ago they were mostly psychoanalysts.
So, as Luhrmann quotes an eminent psychiatrist, we are "seeing our profession in the beauty of its great sunset" (p. 252). In the whole area of psychiatry and psychoanalysis, as well as in the rest of the medical field, we are enduring the demise of the doctor-patient relationship. Those who wish to practice psychoanalysis have to accept a very substantial financial drop in their income. Given the exigencies of modern life in corporate America, few of us are in a position to accept such a drop, and the result is a migration toward once or twice a week therapy for patients who at least can afford to pay for their therapy on a much less frequent basis. The great age of the flowering and expansion of psychoanalysis is over; the enormous gains in understanding the human mind and how it functions from the depth psychodynamic exploration of patients in four and five times a week treatment is a matter of history except in the hands of those few who are willing to make the sacrifices entailed to continue this exciting and worthwhile journey. The side effect of this loss of the psychoanalytic orientation is a loss of empathy and compassion for suffering human beings, what Heidegger referred to in the age of technicity as "enframing," a viewing of people as objects to be manipulated, controlled, medicated, with the implication that they are also objects that may be liquidated and erased.
By writing this book Luhrmann apparently hopes that somehow she can influence the American public to put a check on this disaster, but I think in that hope she is underestimating the power of the insurance and pharmaceutical industries. The reader merely has to examine the amounts of money that are given to political campaigns and lobbying efforts by these giant corporations and the total control of the media by their conglomerates to see how the situation has progressed to a state of what Marx called mystification or "ideology," in which the predominant economic powers of a country inculcate what they wish to be known as "truths" in the mind of the public and enable those who challenge these "truths" to be labeled as "bad" or "mad."
In summary, Luhrmann has done a great service by this anthropologic study. She is a clear although rather verbose writer and one can only hope that her book catches on. Let us not forget that it has to compete in the bookstore with the enormously popular appeal of the fantastic twists and turns of the imaginative "better than reality" Harry Potter works and the well-written and long chilling horror that is the fictional reality of Steven King's novels.
Dr. Chessick is Professor of Psychiatry and Behavioral Sciences, Northwestern University, and Senior Attending Psychiatrist, Evanston Hospital., and Training and Supervising Analyst, Chicago Center for Psychoanalytic StudyCorrespondence to: Richard Chessick, MD, PhD, 9400 Drake Ave., Evanston, IL. 60203-1106
There is a version of what used to begin or end many psychoanalytic papers in the past, the unequivocal statement that Sigmund Freud was a genius and that "he got there first." Besides his many other formidable gifts, his genius was expressed in leaping from few data to an organizing principle of sweeping depth and extraordinary explanatory power. This aspect of his work has resulted in many of his conclusions remaining valid, while others have been more or less discarded. I am well aware that he himself swept many of his ideas under the rug in favor of later propositions of his own construction. The uncertainty of several of the more hallowed principles allows me to refer to them as fictions. They may be true some of the time. It is highly unlikely that they are true all of the time, but it is useful to at least think of them as if they are always true. Hence, the term of "fictions" in the service of analysis. I do not refer here to such concepts as Thanatos, which has been more or less disregarded by contemporary psychoanalysis. Rather, I will emphasize certain clinical concepts which are still stressed, although I question the all or none aspect of their validity.Psychoanalysis is not a science in the usually accepted definition. This point has been endlessly debated, often terminating in the cheerfully optimistic statement that psychoanalysis is a hermeneutic science, even if it does not meet the rigid criteria of a natural science. This area of contention does not interest me. I leave the matter to the Poppers and Gruenbaums of the world and to some Freudians who continue to debate this contentious area.
Even if certain basic theories of psychoanalysis are not universally true and can never be proved to be so, they may be eminently useful in clinical work. We need not apologize for this view, even if it is short of what we might like. Even in physics, the "hard science" to which we are often unfavorably held to in comparison, the situation bears some similarity. The theories of Newton and Maxwell, once regarded as universal truths, have long since been shown to fall short of the mark. Nonetheless, they remain of remarkable utility for contemporary functional scientific work because they are true in the huge majority of situations.
Here are a few examples of clinical situations in which it is extremely useful to listen as if certain truths always hold, even if we cannot, or do not choose to, view them as universals. In working with dreams we still follow the Freudian tenet that we must not settle for the manifest content but rather must listen to associations that will bring us to the latent content, where the "real" meaning lies. Also, we were taught that a dream always represents the fulfillment of an unconscious wish. It has become clear to me that in the dream work process, in which latent meanings are changed into the manifest, recalled content, we are dealing with a very uneven process. There are times when the manifest content has been altered only to a small degree, if at all, and other situations in which much work of displacement, condensation, and so forth requires analysis before a meaningful understanding can be reached. There do appear to be dreams in which a wish is not of paramount interest. There clearly are dreams in which great attention must be paid to the relatively undisturbed manifest content. This approach will often lead us to at least a partial interpretation of the dream, if not to the idealized "complete interpretation" so desired by students in our field. It is certainly useful to "think" in idealized terms, even if we know that the reality will often be otherwise. Here we have an example, more often stated than observed, where we must not force the patient's clinical material to fit the Procrustean bed of theory. We must be prepared to shift our attention to more reasonable views when the idealized picture does not exist in a given clinical situation, although our initial attention often focuses on the theoretical model.
A second area concerns the matter of transference. So many comments of the patient may refer to disguised feelings about the analyst, but they certainly do not necessarily have this value. Nonetheless, it is always useful to consider that possibility and to interpret it if other material is suggestive. Just as it is foolhardy to force a transference interpretation on all presented content and affects, it is careless not to think of such a case as a distinct possibility. The situation may represent a truth or a fiction, but we are usually better served if we consider transference to exist at all times. That is precisely what I refer to as a useful fiction, begging the question on each occasion as to whether we are dealing with an absolute truth.
The last example I would like to present is more equivocal. It concerns free association. If associative material is continually presented in this fashion, I do believe that one can follow the material in that mode of working. However, patient's productions are never presented in that way without significant gaps. In spite of the inability to prove the case, the use of free association represents an enormously significant aspect of psychoanalytic practice. We must always maintain the stance that it is an ongoing truth, even if, on reflection, we know that there are frequent and significant gaps in the process, gaps which we cannot elucidate. This is a useful fiction, even if there is a space of a day or more between sessions.
In essence, then, I feel it is more prudent to think of such clinical ideas as representing universal truths, even if we come to the conclusion that they may be fictions in a given clinical situation. The alternative, as we well know, is to let too many opportunities pass by outside of our awareness. It always seems better to follow our clinical precepts first, and then be prepared to alter them, as necessary.
Harold R. Galef, M.D., is Clinical Associate Professor of Psychiatry, Albert Einstein College of Medicine, New York, NY; Faculty, Westchester Center for the Study of Psychoanalysis and Pschotherapy, White Plains, NY.Correspondence to: Dr. Harold R. Galef, 15 Roosevelt Place, Scarsdale, NY 10583
Why is Harry Potter so popular among children? The very existence of the series is itself a kind of magic story. Harry Potter books are written by J.K. Rowling. She herself is in her 50s, Scottish, and a single mother. She did not expect to abruptly become one of the world's most popular authors. Rowling began the first book on scraps of paper, sitting in a caf�.Rowling writes fantasy. Harry Potter, an oppressed little boy, discovers he has great powers. The stories are, in a sense, collections of modernized and sophisticated fairy tales. The question is why today's sophisticated children love Harry so. Bettelheim comments in The Uses of Enchantment: The Meaning and Importance of Fairy Tales: "The fairy tale ...conforms to the way a child ...experiences the world.... He can gain ... better solace from a fairy tale than he can from ... comfort ... based on adult reasoning.... A child trusts what the fairy story tells ... its world view accords with his own."
Children explore both pleasurable and frightening scenarios from the safety of fairy tales. Fraiberg concurs in The Magic Years: "... a magic world is an unstable world ... a spooky world.... As the child gropes his way toward reason ... he must wrestle with the dangerous creatures of his imagination and the real and imagined dangers of the outer world."
Fairy tales involve more than magic. Familiar figures, from the outside world, guest star garbed in any number of guises. Characters, both villains and heroes, are rewarded or punished for their actions. Reward or punishment is often determined by how well or badly a character copes with the unexpected. As Freud wrote in "Creative Writers and Daydreaming" (1908, SE, Vol. 9, pp. 141-154), literature and fantasy are tangibly intertwined.
Children like reading Rowling just for this reason. She spins fantasies about coping. The Harry Potter series concerns dualistic feelings of being despised and being admired. Harry experiences the pain of being a despised minority among the Muggles - the ordinary people. And he experiences celebrity. In Rowling's books, Muggles constitute the ordinary world.
A Muggle is a person who has no flare for the magic of life. He has neither curiosity, nor sense of surprise, nor of beauty in any sensory modality. Muggles never experience any sensations of serendipity or epiphany. They are boring, normal English people. Harry starts out experiencing terrible deprivation among the Muggles. The world he escapes to, though, is filled with wonder. There are wondrous animals, unicorns, dragons, griffins. Harry finds himself in a puckish world full of Pucks, as if dropping into Shakespeare's A Midsummer Night's Dream. It is a world, however, where Harry and his friends must learn to confront human evil, jealousy, envy, revenge.
Nothing in the wizard-world is ordinary. The wizards are the lucky few who possess inspiration, creativity. This gives them power. They find "miraculous solutions" to frightening problems - a common fantasy. The wizards turn bad situations into good. In school, Harry has to deal with a problem many children wish to have - without knowing the consequences - of being a celebrity. Harry has to bear the consequences of being admired, as well as being feared and despised.
A fascinating thing is how Rowling's books are a combination of Grimm fairy tales and the Hauff fairy tales, in which violent and horrible things happen to children. Harry Potter's struggle between evil and good, light and darkness, is also a reminder of Zoroastrian mythology, e.g. The Magic Flute, with the Queen of Night. Zoroastrian battles are always fought between forces of dark and light. Even in Harry's wizard school there are two parties. There are good and evil forces. The evil want nothing more than to kill Harry. The good, in the personage of the giant Hagrid and the teacher Dumbledore, saves him.
Who is young Harry? He is the hero of all myth, legends, fairy tales. In the first volume, Harry Potter and the Sorcerer's Stone, it is clear that he doesn't know his parents. He is maltreated by strangers. The secret that he is of famous royal descent is kept from him. Harry's self-discovery follows the pattern of Freud's family romance. His self-discovery partly follows a m�lange of folk legends: orphaned Oedipus, the Nibelungen Ring's Siegfried, the Norwegian Edda cycle, the English King Arthur. Harry likewise resembles Moses, who is miraculously found floating down the Nile by a princess.
Harry has something else in common with figures from legend. After being struck on the forehead by a wizard, Harry is marked, like any number of stigmatized saints - notably Joan of Arc - immortals, the exiled Cain, and the Golem. The Golem, a creature from Jewish folk legend, actually bears a mark signifying truth, emes, on its forehead.
How else is Harry a figure from folk legend? Harry starts out by being enslaved and tortured by the Muggles. His sufferings may remind readers of themes of enslavement and torture, the labors of Hercules, of Jason searching for the Golden Fleece, or of biblical-scale victimization, Jacob working for Laban, Joseph the dreamer being victimized by his own Muggle brothers. Harry himself is modest, like any good hero. He doesn't fight evil to gain fame, but because it's the right thing to do. He seizes opportunities as they arise.
Harry has much in common with earlier heroes from children's literature: the four siblings from C.S. Lewis' Narnia chronicles, who have no clue they are kings and queens of Narnia, until they are transported via a wardrobe from a British country house, during World War II. Harry may remind readers of Mark Twain's little boys in The Prince and the Pauper, who swap birthrights with disastrous consequences. He resembles Charles Dickens' heroes David Copperfield, horribly exiled to a life of pasting labels on wine bottles among the proletariat, and Oliver Twist, surviving among the thieves though he has a rich grandfather. Harry resembles Frank Baum's Dorothy, marooned in the Land of Oz - in Hebrew the word Oz means courage - coping with good and evil witches. Harry is like Kipling's Mowgli from the Jungle Book, a parentless child who learns the language of animals.
Like its predecessors, Rowling's books are parables about mental mechanisms for defense, adaptation and integration. I asked one little girl why she is fascinated with Harry Potter. She said, "Something unexpected happens all the time." Rowling's characters cope with happenings, whether expected or unexpected. Harry copes with being disliked by the Muggles, even with being disliked in the ideal world of the Hogwart wizard school by teachers like Snape or by his schoolmates Malfoy and Crabbe.
What else does Harry cope with? It is his tenacity, his endurance, his life instinct, his patience, his ingenuity, which so appeal to children. First, Harry confronts his state of being different. A child always feels different from grown-ups. Every child has to cope with his differences from the Muggle or grown-up world. Harry Potter shows us how to endure immense difficulties imposed on him by Muggles. He is cold and doesn't get food. He is locked in the dark in a closet. Yet despite his fright at being closed in, Harry overcomes any number of claustrophobic situations, even his early fear of being annihilated. He deals with what Fraiberg calls "anticipatory anxiety."
Secondly, Harry shows how one can overcome difficulties with wit and skill more than with strength. Harry is himself a weak boy. He is as innocent and helpless as a human being can be. Children often feel helpless, cheated, frustrated. Consigned to his little cubbyhole when there was a big party, Harry coped. Even when his own birthday went uncelebrated, Harry gathered enough self-solace to protect himself from pain.
These narratives appeal to girls as much as boys. Both male and female characters represent good and evil forces, virtues and vices, intellectual strength - particularly personified by the schoolgirl Hermione - of loyalty, friendship. Hermione represents brilliance, consistency, reliability. Harry's female teacher McGonagall represents brightness and kindness; she is the closest thing in the books to a good mother.
Rowling's avoidance of superficiality is equally appealing. The books contradict the clich�d, modern-Hollywood ideal that bright and beautiful go together. Harry's fatherly Professor Dumbledore and ever-present Hagrid demonstrate how physical beauty and spiritual greatness can go separately. Harry himself is hardly described as a picture-perfect boy from TV commercials. He is thin, small, has untidy hair. He wears eyeglasses. He is described as an ungainly child. Only his shiny, green eyes are beautiful.
The popularity of the series also illustrates how much children prefer imaginative and fantasy reading to reality-based classics like Susie Goes to the Grocery Store or Fun With Dick and Jane. Writing in The Boston Sunday Globe (July 9, 2000), Susan Linn notes Winnicott's belief "that children thrive in environments that have safe boundaries, but do not impinge on their ability to think and act spontaneously." Fantasy stories are as important a formative influence as reality-oriented books. One interesting feature of the Harry Potter series is how wishes and fears, of the future and past, are reflected in a magical mirror called "Erised" - meaning desire. Every child who looks into Erised can see something. Harry's wish to glimpse his parents is fulfilled; his mother cries as she waves to him. Some wicked characters look into Erised. It shows them how they can take revenge on Harry. Yet just because the mirror shows wishes, it doesn't mean that it will grant them.
Here again, Rowling is using literary riches from the past. Mirrors have a long history in folk legends. They are dualistic objects of good and evil. The power of a reflection can be frightening. Gazing at themselves was fatal for both Narcissus, and unlucky men who looked at Medusa. The magic mirror in Snow White answered the stepmother's question: "Mirror, Mirror, on the wall/who's the fairest one of all?" It also incited the stepmother to attempt homicide. Mirrors, though, are sometimes saviors, as when Jason borrowed Athena the Goddess of Wisdom's reflecting shield in order to slay Medusa.
Dualisms and monstrosities run rampant throughout Harry Potter books. Such fantasized wild things, as Bettelheim suggests, come from children themselves, from their desires, fears, and projected wishes. Wild things come from children's realizations that the outside world is dangerous. Wild things thrive in many classics of children's literature. Maurice Sendak's classic story Where the Wild Things Are has its hero falling into a wild, dark world at night, clad in pajamas. In Doctor Seuss's Horton Hears A Who, nasty adult animals run around threatening baby elephant Horton's tiny, magic world, yelling, "Boil that dust-speck!" The Last of the Mohicans, Treasure Island, Kidnapped, Robinson Crusoe, The Swiss Family Robinson, even the satiric Gulliver's Travels, all deal with the conquering of wild surroundings - with the conquering of the uncontrollable.
Harry himself copes not just with the wild, but with ultimate evil. His greatest, most terrifying enemy, Lord Voldemort - whose name we are warned, cannot be mentioned - of course reminds us of God, whose name cannot be mentioned either. The name Voldemort, too, as Joan Accocella points out in The New Yorker, may come from a combination of two languages, vol-ful, de-of, mort-death. So the God-like Voldemort also resembles the Angel of Death, or Lucifer.
Concealing himself, Voldemort may remind readers of any number of monsters, Batman's foe Scarface, the scarred and masked Phantom of the Opera's Phantom, the eye-patched Captain Hook in Peter Pan. Voldemort is like the boogie man, the wolf in Hansel and Grettel. He serves the same function as Hagen from the Nibelungen legend, who betrays Siegfried to his enemies. All these monsters appear in destructuralized form.
How does a small child cope with fear of the monstrous? Fraiberg gives an example in The Magic Years. A five-year-old says, "My Daddy is so strong. If there were two tigers in my room? My Daddy would kill them immediately." What is this statement but the child's omnipotent, magic, animistic belief in his adored father's strength?
So in a child's life, the good wizards are the good parents when they prove to be good. His parents are evil wizards when they prove to be bad, denying pleasure, when being punitive or unreliable. In such circumstances the parents' names cannot be mentioned, any more than Voldemort's. The child cannot call his parents insulting names, nor say the curses in his head.
Fraiberg even suggests that a child's future mental health "depends upon ...[his] solution to the ogre problem." She adds: "... Even the most loving and dedicated parents discover that in a child's world a good fairy is easily transformed into a witch, the friendly lion turns into a ferocious beast, the benevolent king becomes a monster...." Denied his way, a child transmogrifies his parent into something horrid, a monster for the duration of his rage.
Other negative qualities are incorporated in certain animals or represented by certain human figures. Names hide foibles. In the first Harry Potter book there is Professor Snape - whose name could stand for snake - and the nasty schoolboy Malfoy - whose name could imply bad fable. Other nasty schoolboys, Crabbe and Goyle, remind one of crabs and gargoyles, the stone menagerie clinging to Notre Dame cathedral.
There are interesting twists. Sometimes Rowling's wit is that the names characterize the opposite. There is a three-headed dog who acts ferocious, but whose name is Fluffy. Fluffy is the keeper of a secret place, like Cerebrus. In Rowling's magic kingdom, a child's inner helpless fears and frightening views of the "ordinary," Muggle, grown-up world are mirrored.
Why do many grown-ups like Harry Potter? According to Freud, scratch a grown-up and find a child underneath. Ferenczi's famous article, Child Analysis in the Grown Up discusses how ongoing prejudices, fears, hopes, all have their roots in human development. We know that any grown-up person can regress under internal or external stresses; the essence of post-traumatic stress disorder is well-known.
One thing that may especially appeal to adults is how miracles save Harry. He survives with unexpected help. Early in the first volume, the good, kind, giant Hagrid flies in on a motorcycle to rescue Harry after many years of suffering. Likewise, many adults believe in magic, in divine intervention. A patient of mine mentioned a great miracle. He survived after being knocked 200 meters, while on his own motorcycle, by a truck. He said this shows there is a god. He did not stop to ask, "Who sent the truck?"
Grown-ups frequently feel helpless as children. They want miracles to change unfortunate situations. Rowling's books resonate with what may be termed a Cinderella complex - the ever-present inferiority complex most people suffer from.
At the mercy of the Muggles, Harry lives miserably. Harry slaves when guests come. He is left out. He doesn't get any cake or goodies. He has to clean up like Cinderella and is starved like Cinderella. Many grown ups suspect that they, too, are living in Cinderella-type situations. Reading about Harry's exclusion can kick off feelings of displacement, of not being accepted into a club. "Harry," remarks author Stephen King in The New York Times (July 23, 1000), "is a male Cinderella, waiting for someone to invite him to the ball."
Children, too, identify with Cinderella. A child's inner resources in Harry Potter are externalized. Hagrid and Dumbledore are good, ever-present parents. The Muggles represent the mean, unreasonable parents, who in the child's conception, are treating him like a slave. Often in a child's imagination or experience, he feels he is being taken advantage of. A child may be angry when not being given coffee or alcohol, while grown-ups drink it, being sent to bed while grown-ups stay up. In response a child can perceive life as a series of unexpected rewards and punishments by his powerful parents.
Fraiberg explains the relationship between childish fantasy and primitive thought: "These are 'magic' years because the child in his early years is a magician - in the psychological sense." Bettelheim concurs, describing children's thinking as "animistic." He agrees with Piaget's suggestion that children think animistically until puberty. "To the eight year old ... the sun is alive because it gives light ... the stone is alive ... as it rolls down a hill ... it is believable that man can change into an animal...."
Bettelheim emphasizes the connection between fantasy and fairy tale. Children identify with characters in fairy tales in order to wrestle with their questions of identity: "'Who am I? Where did I come from? How did the world come into being? Who created man and ... animals?' ...Fairy tales provide answers." Because parents guard children, children believe that some guardian angel will also "do so out in the world." Bettelheim suggests, as well, that adolescents deprived prematurely in childhood of imaginings, may continue believing in magic for years.
Walter Kendrick notes in Writing the Unconscious, that Freud found correlation between the creation of "literature ...and ... the clinical experience of psychoanalysis." Freud believed that some "imaginative writers ... anticipated the discoveries of psychoanalysis," citing Hoffman's tales as a particular example. According to Freud, Hoffman - author of "The Nutcracker and the Mouse King" - "intuited the importance of early-childhood experiences." Freud concluded that "Literary artists ... already plumbed the mind's depths long before...."
J.K. Rowling's popularity invites a final question. Why are some people afraid of letting children read Harry Potter and The Goblet of Fire or Harry Potter and the Chamber of Secrets? Why fear these books? Not all grown-ups admire Harry, nor what he represents. Rowling's writing is considered among the most controversial literature in the United States these days. According to Laurie Sydell of National Public Radio ("Weekend Edition," November 14, 1999), some groups "advocate banning" Harry from schoolbook shelves - along with Winnie the Pooh and Little Women. Other groups are demanding for more parental screening of libraries. Do these people fear imaginary monsters? Mirrors named Erised? Strong female characters? Do they fear Lord Voldemort himself? Children engaging in fantasy? Perhaps their fears are to be expected. The Muggles never did like Harry Potter.
Ildiko Mohacsy, M.D., is Assistant Clinical Professor of Psychiatry, Department of Child Psychiatry, Mount Sinai Medical School and Adjunct Assistant Clinical Professor of Psychiatry, Cornell Medical CenterCorrespondence to: Dr. Ildiko Mohacsy, 1065 Park Avenue, New York, NY 10128
ONE CORNERTo stand on one corner of the world (In this case Madison) Watch the sun bed down over fancy buildings
The crowd: handsome couples, high-heeled singles anticipating, The miscellaneous marching, simultaneously converse on phones;
How elegantly the white-haired lady Clad in white flows by In time-defying motion
Some sense me, with pencil set to paper, and wonder if I am an agent under cover
A dog passing by sleek and amber: needs only his nose to inform, I am nothing more or less than 'lover'
YELLOW CUP
A worn, yellow paper cup Agitated, extended by bare arms
Her back propped against the street lamp and around her breast
a brown, plastic bag Her eyes, glazed over don't register our dollars
But our voices over cell phones (about her) Startle: set her bare shoulders suddenly in motion
down the street, rattling this red herring of a yellow cup neither filled nor filling
TO SAVOR
The rarity of a pair (of socks)
MOBILE OR HOMELESS
Dreams of riding under the stars in my motor home
Dashed by reality: rotting tires, leaky gasket.
My dreams roll: their own volition carries them faster.
day and night traffic doesn't matter
The 'motor home dream' is the 'bag lady fear' in reverse
Are we mobile or homeless?
One rolls into another as fatefully as True West brothers
(Austin and Lee) turn in a jiffy between criminal and writer
our bodies haul heads and tails of the coin
We are both: mobile and homeless
Jane Simon, M.D., is the past editor of the Academy Forum.Correspondence to: Dr. Jane Simon, 145 Central Park West, #1A, New York, NY 10023