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The conscious Id

Posted on January 12, 2014 at 7:50 PM Comments comments (94)
The conscious Id - lecture delivered at the New York Psychoanalytic Institute


1. How the body is represented in the brain. 

The 'external' body 

There are two aspects of the body that are present in the brain and they are represented differently. The first is the 'external body' - the somato-topic body image, a map of the body represented on the surface of the brain in a point-to-point fashion. It is derived from the classical sensory receptors distributed over the surface of the body and projected on the surface of the brain. The body image is constructed out of a convergence, a hetero-modal conjoining of different exteroceptive sensory projections zones. The part of the brain which represents our external body also represents in the same manner all external objects. The external body is in other words an object, perceived in the same way that we perceive the external world. The motor projection zone, the motor-homunculus is also part of the map of body, in this case the muscular and  skeletal body which gives effect to our voluntary movements. All voluntary movements give rise to sensations - there is kinesthetic and proproceptive change as we make a movement. 

The 'internal' body 

The internal milieu is represented deeper in the brain. These brain structures monitor the vegetative or autonomic states of the body. The brain representations of this part of the body function largely automatically but they also arouse the representation of the external body to serve the vital needs of the internal body in the outside world. There is a hierarchical interdependence between the two different aspects of the body as they are represented in the brain. These two different aspects of the body each generate very different types of consciousness. The interoceptive aspect of the brain gives rise to states of consciousness, the sort of background awareness, the 'page' on which the words of consciousness are written. 

States of the body as 'subject' involve not only levels of consciousness like 'sleep' versus 'wakefulness' but also qualities of consciousness. Interoceptive consciousness is intrinsically affective - emotional. Affect is the modality of interoceptive perception, by which we qualify our interoceptive states of awareness. The key note  is registered in the pleasure/unpleasure series (associated with the periaqueductal gray). These affective states tell us what is 'good' and what is 'bad', biologically speaking. Consciousness evolved to enable us to attribute 'good' and 'bad' valences to our experience. External experience does not need to be conscious - this is evident in 'blind sight', where visual awareness is transmitted to lower brain structures, and the patients are able to navigate spacially on the basis of this unconscious sense of vision. Consciousness 'colours' external perception and attributes value to it. 

The motor aspect of the pleasure/unpleasure series is approach/avoidance behaviour. Arising from the periaqueductal gray  (PAG) and ascending to the lymbic system there are different motivational circuits. These are also known as the circuits for the basic emotions. Each one of these has a motor stereotype attached to it, which is necessary for survival and reproductive success. Examples: foraging behaviour, copulating behaviour, aggressive attack, nurture and grooming, attaching to a maternal object, freezing and fleeing. Each of these basic aspects or instincts, has a particular feeling state attached to it, this is a higher elaboration of affect than what happens at the basic level of the PAG. Feelings like fear, anger, separation distress (panic), are basic instinctive emotions which are hard-wired (unconditioned responses) into particular circuits of the brain. They are not things that we learn, they are things that we inherit - ways of feeling and ways of acting that are our phylogenetic inheritance. There is a great chemical specificity to these basic instinctual/emotional circuits. They give rise to associative learning in the process of early experience. 

3. Exteroceptive Ego, Interoceptive Id

It is easy to recognise these two aspects of the body in the Freudian metapsychology. The external body is represented in the Ego, the internal body in the Id. "The ego is first and foremost a bodily ego; it is not merely a surface entity, but is itself the projection of a surface. If we wish to find an anatomical analogy for it we can best identify it with the 'cortical homunculus' of the anatomists (...) (Freud, The Ego and the Id). 
"the ego is ultimately derived from bodily sensations, chiefly those springing from the surface of the body. It may be this be regarded as a mental projection of the surface of the body (...)" (Freud, Footnote to the Ego and the Id)

About the bodily origin of the Id, Freud wrote this: "The id, cut off from the external world, has a world of perception of its own. It detects with extraordinary acuteness certain changes in its interior, especially oscillations in the tensions of its instinctual needs, and these changes become conscious as feelings in the pleasure-unpleasure series. It is hard to say, to be sure, by what means and with the help of what sensory terminal organs these perceptions come about. But it is an established fact that self-perceptions-coenaesthetic feelings and feelings of pleasure-unpleasure- govern the passage of events in the id with despotic force. The id obeys the inexorable pleasure principle". (Freud, 1939)

"An instinct (in the original "Trieb", meaning drive) appears to us as a concept on the frontier between mental and the somatic, as the psychical representative of the stimuli originating from within the organism and reaching the mind, as a measure of the demand made upon the mind for work in consequence of its connection with the body" (Freud, 1915) 

"And what is an affect in the dynamic sense? It is in any case something highly composite. An affect includes in the first place particular motor innervations or discharges and secondly certain feelings; the latter are of two kinds - perceptions of the motor actions that have occurred and the direct feelings of pleasure and unpleasure, which, as we say, give the affect its keynote. But I do not think that with this enumeration we have arrived at the essence of an affect. We seem to see deeper in the case of some affects and to recognize that the core which holds the combination we have described together in the repetition of some particular significant experience. This experience could only be a very early impression of a very general nature, placed in the prehistory not of the individual but the species. (Freud, 1916-1917)

3. The exteroceptive fallacy

This parallelism between exteroceptive and interoceptive brain mechanisms on the one hand and Ego and Id on the other, gives rise to a radical revision of Freud's metapsychology. Freud never questioned the classical neuro-behavioural assumption that consciousness was a cortical function. "It will be seen that there is nothing daringly new in these assumptions; we have merely adopted the views on localization held by cerebral anatomy, which locates the 'seat' of consciousness in the cerebral cortex- the outermost, enveloping layer of the central organ." (Freud, 1923) 

Freud understood that consciousness also entailed an interoceptive affective dimension. "I believe we can say that Freud's insights on the nature of affect are consonant with the most advanced contemporary neuroscience views." (Damasio, 1999) 

In making the assumption that consciousness is cortical, Freud was following a long tradition, which continues today. "When electrical stimuli applied to the amygdala of humans elicit feelings of fear, it is not because the amygdala 'feels' fear, but instead because the various networks that the amygdala activates ultimately provide working memory with inputs that are labeled as fear. This is all compatible with the Freudian notion that conscious emotion is the awareness of something that is basically unconscious." (LeDeux, 1999) (This is the read-out theory of emotions) 

The latest incarnation of this tradition is the theory of Bud Craig. He believes that there is a primary cortical projection zone for the internal body, and this projection zone is in the cortex, in the posterior aspect of the insula. This posterior insula Bud Craig describes as the basis for self-consciousness (awareness of the self). 

4. Consciousness without cortex
Recent research demonstrates unequivocally that the cortical-centric view of consciousness and the self are wrong. According to the theory above, a patient with a completely obliterated insula should, lack subjective selfhood, he should lack the page upon which consciousness is 'written', but this is not the case. Damasio (2011) interviewed such a patient, who retained a sense of self.

High-brain encephaly, condition in which the child is born with no cortex whatsoever, usually due to a cerebro-vascular event in utero. As result of this stroke in the womb the higher part of the brain fails to develop at all. Bjorn Merker (2007) has a lot of experience working with many such patients. "These children are not only awake and alert, but show responsiveness to their surroundings in the form of emotional or oriental reactions to environmental events, most readily to sounds, but also to salient visual stimuli. They express pleasure by smiling and laughter and aversion by fussing, arching of the back and crying in many gradations their faces being animated by these emotional states. The familiar adult can employ this responsiveness to build play sequences (...)." 

5. Consciousness is endogenous

There is in the cases of high-brain encephaly severe degradation in the type of consciousness that are associated or derived from the external body. By contrast, the background 'page' of consciousness, the raw phenomenal self onto which object experience is written is fully present. The body as subject is fundamentally intact, as is instinctual affect and motivation. The only intact ego function in these cases seems to be a rudimentary form of associative, implicit learning derived from unconscious perception impacting on their instincts. It seems that all cortico-centric views of consciousness are wrong, Freud's included. 

If consciousness is not cortical, where is it generated? Basic states of consciousness like wakefulness versus sleep are regulated in sub-cortical structures (brain-stem), as are states of vigilance and arousal. Cases of lesions to these structures have demonstrated the veracity of this view. When damage occurs in the periaqueductal gray (PAG) consciousness is obliterated entirely. PAG is the smallest area of brain that needs to be lesioned in order to totally obliterate consciousness. We also know from epilepsy studies that consciousness is generated in the upper brain-stem regions. Penfield (1954) observed that seisures occurring cortically only impair one aspect of consciousness. It is only when they reach central-cephalic structures in the upper brain-stem that consciousness is lost. 

All that is new is the realisation by people like Panksepp and Damasio that conscious states generated by these upper brain-stem functions are intrinsically affective or emotional. Consciousness is generated in the part of the mind that is driven by our internal bodily needs that activates instinctual motivational behaviours that are innate, hard wired (Id). Ego consciousness is derived from the Id, not the other way around. This is important, because it turns the talking cure on its head. For Freud, the value of words is their exteroceptive origin, their capacity to extend consciousness downwards. All the evidence points in the opposite direction. 

6. Mental solids (object representations). 

Representations of the actual world, that are stored in the cortex. They can be activated both externally and internally. They serve both perception and cognition (recognition). Such processes are unconscious in themselves. It's only when they are engaged by upper brain-stem consciousness that they come to mind. What renders objects conscious is their incentive salience to us - their biological relevance in the pleasure-unpleasure series. 

Inhibitory constraints are required. Inhibition of actions entails toleration of frustration - that is an overriding the pleasure principle but more efficient and secure satisfaction of biological imperatives is achieved this way. Thinking is interposed between drives and action (working memory - trial action).

7. The reflexive ego

The external body representation represents 'me' as an object, experienced like other objects. It is a re-presentation of the subject, not the subject itself. We experience the illusion that the body is the locus of our consciousness. The body 'owns' the self the same way the child projects itself in the animated avatars in a computer games. These self-representations rapidly come to be treated by the child as if they really were the child itself. Kover and Ersen (2008) - performed body-swap experiments, in which a camera on the forehead of a mannequin (a false body) being projected into the goggles worn by an experimental body rapidly creates the illusion in the subject that the mannequin is their body. They come to feel it as being 'my body'. They are projected into being this mannequin robotic body. The objectivity of the illusion is demonstrated by the fact that fear responses can be elicited in the subject by threatening the false body with a knife.

This illusion is the same as the 'rubber hand illusion' in which the real hand is screened from view and the rubber hand is placed at the elbow. Both the real hand and the rubber hand are stroked simultaneously but only the rubber hand is seen. The subject rapidly comes to feel that the rubber hand is the real hand. (Also see 'phantom-limb phenomena). These phenomena demonstrate that the bodily self of everyday experience is an acquired representation - a memory image. fMRI studies show that 'bits' can be added or extracted from the cortical homunculi easily (the locus of Freud's bodily ego).The ephemary nature of the sensory motor homunculi is also demonstrated by the motor neuron phenomena. They are neurons which fire in the pre-motor cortex when we perform a certain movement. They also fire when we watch someone else perform the same movement. From the point of view of these neurons exactly the same thing is happening, it makes no difference which one is making the movement. How do we come to know which movement is ours (belongs to this object called 'my body') as opposed to that object called 'her body'. How do we tell the difference? 

Vittorio Galesi suggests that in the prefrontal cortex additional inhibitory activity occurs which makes the distinction, when it is not 'me' performing the movement. Interestingly this does not happen in schizophrenic subjects. So in this respect the differentiation between 'self' and 'other' is controlled by the prefrontal lobe. In the primary process mode there is no distinction between self and object representations. Second order re-representation enables the subject to differentiate between 'self' and 'other objects'. It can re-represent itself as "me seeing something separate from myself". This "me doing things" is felt to be the agent of everyday experience. The gap between the primary phenomenal consciousness emanating from the Id and the secondary re-representation is illustrated in the experiments of Benjamin Libet, which show that there is a lag half a second between the subjects making a movement and  thinking I am going to make the move now. (Subjects start making the movement before they are consciously 'deciding' to execute it). He interpreted this to mean "we unconsciously decide to make the movement before we consciously decide to make the movement". 

This declarative self generated by higher-order re-representations is also felt to be the agent of episodic memory. The whole trend of the secondary process is to reduce surprise, to increase predictability and automaticity and thereby to decrease consciousness, to transform declarative, explicit cognitions into non-declarative, implicit cognitions, to minimise the need for the affective presence of the Id. 

8. If the Id is conscious... 
All this has massive implications for freudian metapsychology, including the metapsychology of the talking cure. "Where id was, there ego shall be" (Freud, 1933, New Introductory Lectures). 


The nature of communication in the talking cure.

Posted on January 12, 2014 at 6:36 PM Comments comments (106)

Mark Solms is the director of the Arnold Pfeffer Center for Neuro-Psychoanalysis at the New York Psychoanalytic Institute; a lecturer at the University College Londons Department of Psychology; a consultant in neuropsychology at the Anna Freud Center in London; and an honorary lecturer in the Academic Department of Neurosurgery at St. Bartholomews and the Royal London School of Medicine. Over the last 15 years, Dr. Solms has been the driving force in establishing the new field of neuro-psychoanalysis, which brings together the fields of neuroscience and psychoanalysis.

What is the nature of communication between the analyst and the patient 

Defining psychoanalysis as "the talking cure" is somewhat misleading, a misnomer. We have the mystical-sounding phrase from Freud about the communication from the unconscious of the patient to the unconscious of the analyst. We speak of empathic attunement and projective identification as a form of communication between patient and analyst, which is reflected in the countertransference. The nature of communication in the analytic room somehow fails to be conveyed in the words that are transcribed down from a recording of the analytic session. Something goes on inside of the patient and the analyst in parallel with the talking which cannot be readily captured. 

The building blocks of the meaning-making process. 

The most rudimentary form of a conscious thing that stands for something occurs within ourselves about ourselves, to ourselves. Communication is communication of meaning. The best theory that we are working with revolves around the notion that consciousness originates in structures within the very deep core of our brain stems. These structures which project very widely to the forebrain, are representing aspects of the state of ones self, the subjective state, the visceral bodily state. This state of self is meaningfully being represented as a feeling of consciousness which either feels good or bad. Action tendencies are intrinsically interwoven to these feeling states. Pleasurable feelings are associated with approach behaviours, they motivate approach behaviours. 

Negative/painful feelings are associated with avoidance behaviours. These raw feeling states originate in the periaqueductal gray (PAG). Even in such elementary forms of consciousness, something is conveyed but not necessarily intentionally. We see that in herd-contagion behaviour. 

The approach mechanism is essentially a seeking mechanism. It has to do with detecting needs that can only be met in the outside world. It is almost an implicit predictive mechanism: "Unless I go looking for food, I am not going to survive". The feeling that comes with it is mildly optimistic, mildly curious - "something good is going to happen and I want to be there kind of feeling". Freud defined emotions as "mnemic residues of biological situations of universal significance". The universality of significance makes us all know what it means when we see it. Basic emotion systems link our core consciousness to the outside world and those around us. Emotions are a perceptual modality, they are a medium of consciousness just as vision, smell, hearing are a medium of consciousness.  

When another animal (human) feels something and another sees it, hears it, smell it (there are all sorts of ways in which the state of an animal is conveyed) then one knows what the other animal is feeling. These are things which we can't afford to learn, they are "mnemic residues" - we just know what it means, although we may not be able to demonstrate. Empathic knowing When I see that experience it activates the same system in me. I know what it is because it is activated in me. Mirror-neurons allow a higher level elaboration of this basic system. Mirror-neurons were accidentally discovered in a research lab in Italy. When a monkey with a brain activity recording device on its brain observes another monkey eating a banana, the same areas in the brain of the observing monkey are activated. There is a mirroring of the motor-neuron activity in the acting monkey, which is activated in the brain of the perceiving monkey. 

The prefrontal cortex allows for a suppression of the basic emotional systems, inhibiting the action tendencies associated with them. They enable us to not have to act on the feeling, to create virtual scenarios, to represent the relation between things. A 'non-doing' kind of thinking evolves - a highly abstracted, symbolic thinking removed from the emotional core. It is our 'pride and joy' but the price is that it alienates us from our feelings. We develop this curious inability to know what is driving our own actions. 

In therapy the analyst is taught to listen with his "third ear", with an evenly suspended attention. The analyst does not listen to the words, because they only convey part of the story - she picks something up, she feel something, which is akin to a biological situation with universal significance. This way we recognise the patient's emotional configuration, and we use the words to convey our understanding. The talking cure is not about the talking - the talking is about feelings. 

Brain affective systems

Posted on January 12, 2014 at 5:30 PM Comments comments (110)
Jaak Panksepp Ph.D: "Ancestral Memories: Brain Affective Systems, Ancient Emotional Vocalizations, and the Sources of Our Communicative Urges." Over the last 35 years, Dr. Panksepp has almost singlehandedly created the field of affective neuroscience. His book, Affective Neuroscience: The Foundation of Human and Animal Emotions, is the definitive textbook for the field. He is the Baily Endowed Chair of Animal Well-Being Science at Washington State University, an Emeritus Professor in the Department of Psychology at Bowling Green State University, and the author of A Textbook of Biological Psychiatry.

Effectiveness of Psychodynamic psychotherapy

Posted on December 2, 2013 at 11:02 AM Comments comments (95)
A 2010 study by Johnathan Shedler of University of Colorado about the efficacy of psychodynamic psychotherpy, published in the American Psychologyst. Available in PDF format here: www.apa.org/pubs/journals/releases/amp-65-2-98.pdf

Not Knowing is the Royal Road to Feeling Both a Shameful Fool and Creative Healer

Posted on July 2, 2013 at 10:26 AM Comments comments (2)
A moving article by psychiatrist and psychotherapist Robert Lewis asking:  "How does one both be the  responsible healer who maintains the frame and the wounded healer inside the frame with the wounded  patient? In some ways, one hopes to embody a presence, not unlike that of the parent who both takes responsibility for his child and yet remembers that the child (patient) knows at least as much about where  your journey together must go."

The Interface Between Neurobiology and Psychotherapy

Posted on May 23, 2013 at 7:34 AM Comments comments (107)
This is an interview available online, through Online Events [you will need to set up an account].

A history of psychotherapy from a radical anti-psychiatry perspective

Posted on November 22, 2012 at 8:10 AM Comments comments (100)
The healing word in past present and future.
By Thomas Szatz

AUTHOR'S NOTE: This article is adapted from the text of an invited address presented at the Milton Erickson Evolution of Psychotherapy Conference, Las Vegas, Nevada, December 13 through 17, 1995, and from a keynote address presented at the First Congress of the World Council for Psychotherapy; Vienna, Austria, June 30 through July 4, 1996.

Summary
After presenting a brief review of the history of helping people solely by language (listening and speaking), the author reemphasizes the intrinsically verbal, noncoercive nature of the cure of souls (and of psychoanalysis as a model of psychotherapy); the intrinsically nonverbal, voluntary nature of the cure of bodies (medical treatment); and the intrinsically physical-and-verbal, coercive nature of the cure of minds (psychiatric treatment). Commingling and confusing these distinct enterprises and the accompanying emphasis on diagno
sis and treatment have destroyed the cultural and legal conditions required for the practice of purely verbal, non-coercive helping (psychotherapy).

Psychoanalysis is, in toto, a language art, a language praxis. There can be neither mute patients nor deaf analysts. Psychoanalysis is as immediate to word and syntax as mining is to the earth.
(Steiner, 1989, p.107)

In the Apology, Socrates articulated his vocation as philosopher, by which he meant a person who cares for the soul (psyche). Because only persons have souls, this view stamped him as an ally of the individual and an adversary of the "compact majority" (community or polis), a role he made no effort to conceal. Addressing the Athenian authorities, he pledged, "Gentlemen, I owe a greater obedience to God than to you" (Plato, 1961, p.15). He then defined his role, as physician of the soul, as follows:

It is my belief that no greater good has befallen you in this city than my service to my God. For I spend all my time going about trying to persuade you, young and old, to make your chief concern not for your bodies nor for your possessions, but for the highest welfare of your souls. (p.16)

For the post-Socratic philosophers, especially the Stoics, the philosopher was a physician of the soul who, employing the healing word (iatroi logoi), offered counsel to persons perplexed by problems in living. Seneca, for example, advised his mother, grieving over his exile to Corsica, to give herself up to "the study of philosophy, sovereign remedy for sadness" (McNeil, 1951, p.28).

After the triumph of Christianity, the priest as confessor and/or counselor replaced the philosopher as rhetorician of consolation. For most of the next nearly 2,000 years, doctors of divinity (and parish priests) served as the curers of the Western soul. The cure of bodies, at the same time, became the domain of doctors of medicine (and barber surgeons). 

The ensuing distinction between the cure of souls and the cure of bodies was recognized as early as the 14th century. Petrarch (Francesco Petrarca, 1304-1374)the great Renaissance poet and philosopher, often called "the first humanist"-warned against the literal interpretation of the medical metaphor of rhetorical healing. Declaring that "the care of the mind calls for the philosopher," he urged that doctors should use herbs not words" and leave the cure of minds to the "true philosophers and orators" (McClure, 1991, pp.20, 51).
I should now like to summarize how I see the birth, growth, and present state of modern psychotherapy.

The real name of Anna 0.-the patient who, according to Freud, discovered catharsis and psychoanalysis-was Bertha Pappenheim. In 1880, when Pappenheim became Joseph Breuer's patient, she was a 21-year-old woman living the existentially stifled life of an intelligent, overprotected daughter of wealthy Viennese Jewish parents. In an effort to escape from the meaningless existence to which her family and social station condemned her, she pretended to be ill and was duly diagnosed as suffering from hysteria. 

Aided by the affection and sympathy of an exceptionally humane physician, who lavished vast amounts of time on her, Pappenheim rediscovered the ancient power of the healing word or, more precisely, of the healing dialogue. The patient used the English terms talking cure and chimney sweeping to describe the therapy. Her physician named it catharsis, a Greek term (Breuer & Freud, 1893-1895; Freeman, 1972). It was unthinkable, for patient as well as doctor, to call a spade by its proper German name, that is, to call the healing word das heilende Wort or its use Heilung durch den Geist (spiritual healing) (Zweig, 1932). Using ordinary German words to describe these phenomena would have risked having the patient labeled a malingerer and the physician a quack.

To be sure, the word treatment, like the word disease, has a wide range of meanings. For example, we say that a man treats his dog badly, and we call seeing a good play a treat. I do not wish to quibble about the meaning of words or constrain their colloquial use. However, I do wish to draw a clear distinction between the physical (impersonal) cure of bodily diseases (exemplified by the surgical removal of an inflamed appendix) and the spiritual (personal) cure of souls in distress (exemplified by the Catholic confessional and psychotherapy). I regard the former as literal treatments, the latter as metaphorical treatments.

It is important to note here that many of the so-called symptoms Pappenheim exhibited were plainly self-made and related to her use of speech. For example, she had mysterious spells, during which she was mute in German, her mother tongue, but could speak in English. Not surprisingly, Breuer, an astute and scientifically trained physician, realised that the talking cure was not a genuine medical treatment and quickly abandoned its use.

As fate had it, one of Breuer's protégées was a young physician named Sigmund Freud, to whom Breuer related his misadventure with Pappenheim. Thereupon, Freud decided to make listening and talking to patients his lifework-not as an incidental part of the therapeutic effort, like other physicians, but as an integral part of it, indeed its sole ingredient. In the sophisticated intellectual climate of pre-World War I Vienna, it did not take long before Freud's sweeping claims about the efficacy of the treatment he called psychoanalysis were exposed as 'The disease of which it claims to be the cure" ("Die Psychoamalyse istjene Krankheit, fur deren Behandlung sie sicht halt") (cited in Szasz, 1990, p.24). Karl Kraus, the author of that aphorism, objected to the talking cure, not because it consisted of talking but because it was miscast as a treatment.

Because Freud was a practicing physician who treated persons officially denominated as patients and because he defined psychoanalysis as a treatment of mental diseases, we must now situate psychoanalysis-as the paradigm of modern psychotherapy-in the context of the history of psychiatry.

For centuries, madmen and "mad" doctors alike were banished to madhouses, located on the outskirts of towns or in the countryside. Alienists-renamed psychiatrists in the 19th century-worked, and often lived, in insane asylums, where they oversaw desolate scenes of human misery When Freud came on this scene, insane persons were considered to be legally incompetent, insanity was considered to be an incurable illness, and individuals denominated as insane were incarcerated in insane asylums, usually for life. Because Freud's work appeared to have little relevance to the work of professionals engaged in caring for insane persons (many of whom suffered from the neurological ravages of syphilis), European psychiatrists first ignored psychoanalysis and then rejected it as unsuitable for serious cases of mental illness.

In contrast, American psychiatrists, imbued with characteristically American therapeutic optimism considered no disease indefeasible and embraced psychoanalysis as an ally in the war on mental illness. Pari passu, American psychoanalysts defined psychoanalysis-ostensibly to protect the public from quacks-as a medical activity and excluded nonmedical analysts from among their ranks. This marriage between psychiatry and psychoanalysis was a catastrophe for both parties but more so for psychoanalysis and, derivatively, for psychotherapy It is important that we understand the nature and consequences of this fateful misalliance.

In the 18th century Western societies began to delegate to mad doctors (subsequently called alienists, psychiatrists, mental health professionals, and therapists) the task of separating insane persons from sane persons and incarcerating the, former in mad-houses. To justify this enterprise, psychiatrists fabricated appropriate pseudomedical explanations about why some people display certain kinds of unwanted behaviors, about the dangers they pose to themselves and society as a result, and about the interventions mental healers must use to protect patients from themselves and the public from the patients.

At the beginning of this century; psychoanalysts appeared on the scene and claimed to be especially adept at explaining why people behave the way they do. American psychiatrists seized on these explanations as useful addenda to their own mystifications. The amalgamation of psychiatric and psychoanalytic theories received further impetus during World War II. Many of the analysts were recent refugees from Nazism who felt it was their patriotic duty to respond to the needs of the military. There, they were happy to do the bidding of their superiors, finding men fit or unfit for duty as the military authorities decreed. This use of psychoanalytic concepts was phony, but expedient, for the military as well as for psychoanalysis. The result was that psychoanalysis and psychiatry were joined, and for a brief period, the prestige of this superficially psychoanalyticized psychiatry carried over into civilian life.

But, it was all show. Psychiatrists in public mental hospitals, privately practicing psychiatrists who treated their patients with electric shock, and psychiatrists accredited as analysts all pretended that the similarities far outweighed the differences among them. In the process, the core elements of curing souls with healing words (noncoercively, facilitating personal freedom and responsibility) were replaced by the core elements of treating mad minds (coercively, imposing statist-medical controls on the insane). The aims and values of these two conflicting undertakings may be summarized as follows:

To effect a cure, the psychiatrist coerces and controls the patient: He or she incarcerates and imposes various chemical and physical interventions on the subject against his or her will.
To conduct a dialogue, the psychoanalyst contracts and cooperates with the patient: He or she listens and talks to his or her interlocutor, who pays for the service received. (Szasz, 1988)

These differences between the psychiatric and psychoanalytic relationships replicate the differences between two familiar types of political relationships, namely, paternalistic absolutism (unlimited government) and classical liberalism (limited government and the rule of law). The essence of individual liberty is the absence of capricious, unlawful coercions (traditionally present) in relations between rulers and ruled. 

Failure by the state to respect private property and its interference in voluntary acts between consenting adults destroy individual liberty. Mutatis mutandis, the essence of psychoanalysis, is the absence of coercions (traditionally present) in relations between psychiatrists and mental patients. The analyst's failure to respect the analysand's personal autonomy (paternalism) and his or her interference in the client's life (betrayal of confidentiality and coercion) destroy the psychoanalytic relationship.

In its initial stages, psychoanalysis represented a genuinely new social development, namely a noncoercive, secular help (therapy) for problems in living (called neuroses). The term psychoanalysis was then used to denote a confidential dialogue between an expert and a client, the former rejecting the role of custodial psychiatrist, the latter assuming the role of responsible, voluntary patient. Recast in such light, it is hardly surprising that psychiatry acquired neither the aims nor the practices of psychoanalysis. It could not have done so and fulfilled its social mandate. The two enterprises rest on totally different premises and entail mutually incompatible practices.

Traditional psychiatrists were salaried physicians who worked in mental institutions; their source of income was the state; they functioned as agents of their bureaucratic superiors and patients' relatives. 'Typical mental hospital inmates were poor people, cast in the patient role against their will, housed in public mental hospitals.

Classical psychoanalysts were self-employed professionals who worked in private offices; their source of income was their patients; they functioned as their patients' agents. Typical analytic patients were rich people (usually wealthier than their analysts), cast in the patient-role by themselves, living in their own homes or wherever they pleased.

The basic differences between psychiatry and psychoanalysis are dramatically captured in the following statements by, respectively, Benjamin Rush, the father of American psychiatry and Sigmund Freud, the father of psychoanalysis:
Rush:   Let our pupil be taught that he does not belong to himself, but that he is public property" (cited in Richman, 1994, p.45). "Let us view them [mankind] as patients in a hospital. The more they resist our efforts to serve them, the more they have need of our services,, (as cited in Woods, 1967).

Freud:   Nothing takes place in a psychoanalytic treatment but an interchange of words between the patient and the analyst" (Freud, 1905, p.283). "The patient should be educated to liberate and fulfill his own nature, not to resemble ourselves" (Freud, 1919, p.165).

The merger between psychiatry and psychoanalysis was a hope-less match, a marriage of convenience in which each party proceeded to rob its partner of whatever seemed of value. Psychiatry acquired the worst features of psychoanalysis its pseudo-explanations and vocabulary of stigmatizations; psychoanalysis acquired the worst features of psychiatry-disloyalty to the patients self-defined interests and coercion. In short, psychoanalysts (along with psychotherapists) sold their noble, but financially unprofitable, birthright for a mess of pottage, the fakery of psychodiagnostics and psychotherapy The result is an ignoble mental health profession masquerading as biological science and medical treatment.

How did psychotherapy get itself into this mess, if a mess it be? Ironically, it was Freud himself who insisted on the self-contradictory proposition that psychoanalysis is both a dialogue and a treatment. In 1905, he wrote, "Words are the essential tool of mental treatment" (p.283). Yet, elsewhere, he asserted, "As a method of treatment it [psychoanalysis] is one among many; though, to be sure, primus inter pares [first among equals]" (Freud, 1919, p.167). Finally, in 1919-at a time when neighboring Hungary had a communist government and the Soviet Union became established as a new nation-Freud welcomed the historical inevitability of a socialist psychoanalysis administered by the modern bureaucratic welfare state as medical treatment.

It is possible to foresee that at some time or other the conscience of society will awake and remind it that the poor man should have as much right to assistance for his mind as he now has to the life-saving help offered by surgery; and that the neuroses threaten public health no less than tuberculosis, and can be left as little as the latter to the impotent care of the individual members of the community . Such treatments will be free. It may be a long time before the State comes to see these duties as urgent. Some time or other, however; it must come to this. (p.159)

Ironically, this passage appears only two pages after Freud's (1919) claim that the aim of psychoanalysis is to liberate the patient, a proposition that formed an integral part of Freud's thesis that psychoanalysis is not a treatment. Instead of curing the patient, the analyst's task, he declared, is "to bring to the patient's knowledge the unconscious repressed impulses existing in him" (p.159). Finally, in An Outline of Psychoanalysis-the summation of his lifework-Freud (1938) wrote, "We [psychoanalysts] serve the patient in various functions, as an authority and a substitute for his parents, as a teacher and educator" (p.181).

Freud's dexterity as a high-wire artist, balancing himself between his role as personal counselor and medical doctor, never deserted him. After identifying the therapist as parent, teacher, and educator, Freud quickly reasserted his lifelong commitment to a materialist medical treatment for personal problems as mental diseases. 

He wrote: But here we are concerned with therapy only insofar as it works by psychological means; and for the time being we have no other. The future may teach us to exercise a direct influence, by means of particular chemical substances, on the amounts of energy and their distribution in the mental apparatus. (Freud, 1919, p.182)

As a result of Freud's labors, it is now a part of received wisdom that psychoanalysis is a method for analyzing human behavior; that it is a valid theory for explaining the behavior not only of living persons but also of dead persons and of persons who never existed-that is, of myth, religion, legend, and literature; and that listening and talking to a person, called talk therapy, is a bona fide medical treatment.

The degeneration of psychoanalysis-and of psychotherapy in general-is an inexorable consequence of the medicalization of life, that is, of the tendency to regard despair and deviance as diseases and talking as a treatment. Viewing a person's complaints about his or her life as if they were the symptoms of a mental illness defines the complaint as a disease and the effort to ameliorate it as a treatment. However, ideas have consequences that have a habit of coming back to haunt us. If we view diabetes as a disease we rightly consider it a serious error, prima facie medical negligence, to treat a diabetic person solely by listening and talking to him or her. The same goes for viewing mental illnesses, whose disease status is established as legal fact by the DSM-IVdiagnoses attached to them, as chemical disturbances in the brain treatable with drugs. 

The upshot is that practicing the talking cure (especially by a physician) has been rendered, de jure malpractice, and hence de facto impractical and irrelevant. And that is not all. With the liquidation of the most essential prerequisite of psychotherapy, namely, that the relationship between therapist and client be based on a free contract between them, the nature of the "correct therapy" is no longer defined jointly by the two parties to the agreement; instead, henceforth, the DSM-IV "scientifically correct diagnosis" of the patient's disease determines the American Psychiatric Association-authenticated "scientifically correct treatment" that he or she needs and that the therapist must provide. (Despite this political-economic climate, or more likely because of it, many American psychologists are clamoring for prescription privileges.)

Freud's assertion that his method was a genuine treatment for genuine diseases, superior to all other treatments, naturally provoked a torrent of controversy and criticism that is still continuing. Eager to eclipse Freud, competitors typically gave faint praise to psychoanalysis as an early form of psychotherapy, the better to claim superiority for their brand of mental healing. Eager to execrate Freud, critics typically claimed that psychoanalysis "is no more effective than no treatment at all" (Eysenck, 1952). Recasting psychotherapy as dialogue transcends this futile controversy and dispels the mystery that continues to envelope mental healing, especially the question of its so-called effectiveness.

Since ancient times, people have recognized that words power-fully affect the listener and that, like double-edged swords, they cut both ways. Indeed, our vocabulary possesses numerous adjectives for characterizing both types of speech acts, such as blasphemous, impious, obscene, perjurious, pornographic, profane, and sacrilegious for words deemed to be harmful; and calming, cheering, comforting, consoling, encouraging, heartening, inspiring, motivating, and reassuring for words deemed to be helpful.

Dreading the effects of harming words and desiring the effects of healing words, every society prohibits speech acts it considers deleterious and encourages those it considers beneficial. It seems to me that the fact of censorship is proof enough that words can heal. My point here is simply to show that it is absurd to contend, as many people have contended and continue to contend, that psychotherapy is (inherently) ineffective. 

The truth is far simpler: The benefit or detriment of a particular discourse depends on the subject's susceptibility to the speaker's message. In the final analysis, just as the beauty or ugliness of a face lies in the eyes of the viewer, the benefit or detriment of a speech act lies "in the ears" of the listener. it is a priori impossible to marshal objective evidence to support or refute claims about the effectiveness or ineffectiveness of psychotherapy. The validity of this assertion is intrinsic to the ontological character of psychotherapy as discourse.

Let me now briefly restate my concept of psychotherapy as the name of a class of interactions in which two (or more) persons voluntarily listen and talk to one another. In this view, psychotherapists dispensing diverse therapies resemble clerks in a department store, each selling different merchandise under the same roof. To be sure, psychotherapists differ from clerks: Selling merchandise (or performing a standardized medical procedure) is an impersonal act that a person does in his or her persona as the purveyor of goods (or services), whereas healing with words is a personal activity, not just a job a person does but something that he or she is. It is morally fitting that it should be so. The person who seeks help through the healing word suffers not from an impersonal illness, such as an inflamed appendix, but from a distinctively personal perplexity It follows that just as it would demean both marital partners to speak of a method a husband uses to relate to his wife or vice versa, so it demeans both therapist and client to speak of a method of psychotherapy. 

Mental illness and psychotherapy are fictions. Neither exists. Only the patient, the therapist, and a particular relationship between them exist. Both participants are responsible moral agents. Each is existentially equal to the other, each influences the other, and each is responsible for his or her behavior. The therapist can neither cure the patient nor make him or her sick. However, the patient can do both of these things, for or to himself or herself, by making use of the therapist's helping or harming words (Bohart & Talman, 1996). These simple insights, commonplace to the early religious and rhetorical curers of souls and their clients, have disappeared into the mystifications of the mental health professions and the gulag of the therapeutic state.

In my view, there are as many authentic types of psychotherapies as there are authentic persons using words to help. I respect every one of these methods, provided their practitioners eschew force and fraud. My own work as a therapist was based on the premise that the focus of the therapeutic relationship can only be how the patient lives, how he or she might live, and how he or she ought to live. 

The expert's role is to engage the clients in a process of searching self-examination, with the aim of enabling them, if they so choose, to become more free and more responsible. To accomplish this task, the therapist must eschew interfering, in any way possible, in his or her client's life outside the walls of the consulting room (including receiving information from, or giving information to, anyone other than the client). Such a curer of souls must reject playing doctor or therapist. Instead of promising relief from suffering or promising any particular outcome, his or her duty is to fulfil a promise to the client, that is, to respect his or her autonomy and confidences and engage him or her in a searching, open-ended dialogue. The outcome of the interaction must be left in the client's hands because he or she has more control over it than the expert does and, more important, because that is where it rightly belongs. Although it is obvious that practicing mental healing in accordance with these principles is, in the United States today, synonymous with malpractice, mental health professionals continue to pretend that it is not.

When I assert that the outcome of the interaction must be left in the client's hands, I am simply rearticulating an insight W H. Auden phrased far more elegantly
Though it is absolutely required of a man that he should intend to help others, the power to do so is outside his control.... The final aim of every critic and teacher must be to persuade others to do without him, to realize that the gifts of the spirit are never to be had at second hand. (Auden, 1948, p.13)
To paraphrase Shakespeare, I have come to praise the healing word, not to bury it. But I must report to you that the healing word is no more: It has committed suicide by overdosing on therapy.

The modern soul doctors succumbed to the temptation to treat people as material susceptible to improvement by experts, ceased to respect the Other as a moral agent, and renamed discourse treatment. They are the sinners whose offence Auden (1968) satirized thus: "We are all here on earth to help others; what on earth the others are here for, I don't know" (p.14).


NOTE
1. In ancient Greek, as in modern German, there is no word for "mind" as anoun.


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