Without-psychiatry-2007-07-29.vp

Psychotherapy Instead of Psychiatry? A No-brainer Psychotherapy as a science is a wide field. There are a number of comple-mentary modalities. Several schools of therapy emerged during Sigmund Freud’s lifetime and after his death in 1939. Psychotherapy may be individ-ual or group therapy. In every form of psychotherapy, no matter what method, the therapeutic relationship is the vessel for the transformation of emotions. A psychotherapist who tackles the issues of the client is, like the court jester, the only one obliged to the naked truth that reveals itself.
The idea behind psychotherapy is to try and understand one’s own world, the acquired way of living, the actual lifestyle and—if one is suffering—to change. As a patient and as a psychotherapist, I try to recognize which feel- ings, images and impulses I can sense within myself. Am I open, am I closed, do I repress, am I cut off from my feelings? As a patient, I try to share my in- ner perceptions in the form of verbal associations with my therapist.
Psychotherapy is an continuous examination of the inner world and a pro- cess that attempts to achieve a social diagnosis (literally to see through the so- cial situation). Psychotherapy is a way of rehearsing the feelings that are lived in other relationships. As a patient I can be honest, truthful and learn new things about myself in the presence of a therapist. I may realize painfully how my world has been formed in false and self-protective ways. What kind of story goes along with my “false-self” system that I have acquired in order to survive my primary, ready-made family and social situation? What kinds of limiting addictive habits have I developed to protect myself? Symptoms are the necessary pointers on the path to finding my own emo- tional truth. The experience gained in therapy about a new integration of body, self and soul enables a fresh approach to life: the therapeutic experi- Theodor Itten: Psychotherapy Instead of Psychiatry? A No-brainer ence as a patient allows me to distance myself from the story that has shaped the current phase of my life and discern a new life plan. As a dejected, over-burdened and melancholy person, I experience myself as a prisoner held in a small room. Emotionally trapped and restrained as I am telling my life-story to the therapist, we can find a way out of this room together.
The therapist asks himself: what is he concealing for the time being? What is taboo? What traumatic experiences are fraught with emotions that create a fear of being overwhelmed? As a patient, I do not want to know at this moment, why I ended up in this room, rather, I am more interested in knowing how I can get out again. Once outside, I can find enough room to breathe and feel safe, then I can start to explore this question. Now I find out why I entered this space. What was the meaning of my melancholy? How was it that I didn’t recognize the signals of my emotional fragmentation? If I recognized them, why didn’t I take my early warning signs seriously as a saving, helpful blink (Gladwell, 2005)? Nine out of 100 people experience injuries before they learn to speak.
Many mental disorders are the result of early trauma in relationships—emo-tional wounds. In psychotherapy, I can explore why, as an adult, I continue to carry these injuries around with me like a story that has not come to an end.
Some colleagues describe psychotherapy as a journey charged with the re- kindling of the soul. We all need our own metaphors. I can flip out, freak out, become “psychotic” so that I no longer have to consciously feel my inner emotional pain, especially when it becomes too bad and gets the better of me.
Or I take no notice of the signs of things that might be good for me—singing or running around for instance—and become inhibited once again. I become further alienated in order to conform. Neurosis or stomach pains are the price to pay, and I submit to a social morale whose ethics limits my vitality.
The sources of my healing are within me, but repressed. Slow means quicker, less is more. To linger in creative idleness so that something can emerge from within. At the beginning, there is always some form of contact, often physical, eye contact. body-rhythm, depth and fullness of breath. Feel- ing the presence or absence of vitality. To listen inside of myself. With this inner foundation, I can use the bridge of therapy to get from my past, where trauma and existential fears rule, towards resourcefulness and the ability to Throughout early family history and childhood, everyone has developed a form of protection that ensures their own survival. This turns into a particular character style as one grows older. The emotional context of life is found, as a person comes into the world, at a particular time and in a particular place. The inner attributes remain. Whether this first fold and the diversity of life are ex-perienced as a blemish or as the source of vital energy and meaningfulness— can be influenced. A person in psychotherapy gets to know the source of his/ her feelings and again has the opportunity to choose a path other than the fa-miliar and trusted one. In this way, we can develop a new habit to replace the old one that causes suffering and step into our own future.
We psychotherapists love the world of the soul and have developed our own therapeutic styles. After undergraduate studies in the humanities and so-cial sciences, and occasionally in medicine, we were all initially patients dur- ing our training therapy. Modern therapeutic training is organized in one of the four basic modalities (depth psychological/psychoanalytic, behavioral, body-oriented, or humanistic) and lasts about five to six years including a The therapeutic relationship accounts for 30% of the curative effect. The life circumstances of the patient, his or her awareness, language, education, work and class status contribute to 40% of the curative effect. The placebo ef- fect, i.e., the belief in the healing powers of psychotherapy, contributes 15 percent, as significant as the specific psychotherapeutic method (Lambert & Bergin, 1994; Tschuschke & Kächele, 1998).
Psychotherapy is an art of healing the soul. As in any professional field there are of course those who have chosen the wrong profession. Those look- ing for help must, therefore, keep their eyes open, allow their trust to grow and pay attention to their own perceptions. Entering into relationships always carries a risk of negative experiences (see Märtens & Petzold, 2002).
Individuals who become involved in psychotherapy actively observe their life situation, their way of experiencing and behaving, and their childhood Theodor Itten: Psychotherapy Instead of Psychiatry? A No-brainer and life patterns. Psychotherapy functions as a support when making the There is time and space for your own wishes, your own rhythm and life- style. Psychotherapy is based on a commitment in the relationship to repair-ing? the fracture of the soul, the emotional vulnerability.
Psychiatry is a medical service practiced within the social context. Quite a few practicing doctors have broken their Hippocratic oath: Primum nil noce-re—First do no harm. Academic psychiatry dominated the helping profes-sions at the beginning of the 19th century with its motto “mental illnesses are diseases of the brain,” and in doing so relegated psychotherapy for people with serious mental problems and diagnoses such as “schizophrenia” to a less than helpful role. Psychotherapy would be of better use if psychiatry recog-nized its role in enhancing compliance and helping formulate diagnoses.
Apart from that, the respective psychiatric methods of the time were sup-posed to be used. Such an approach does not reengage the patient in commu- Electroshock and neuroleptics lead to many varieties of harm among the recipients and the traumatizing effects of coercive treatment can also cause Modern psychiatric work consists of making physically healthy people ill with so-called “medications,” that are basically toxic synthetic substances.
In-depth, uncovering psychotherapeutic methods are thereby curtailed right from the start, the power of self-healing is undercut and psychotic processes are frozen. Psychiatrists such as Klaus Ernst of the University Clinic Zurich came to this conclusion when, at the beginning of the 1950s they conducted systematic self-experiments with the neuroleptic prototype chlorpromazine (trade names Chloractil, Largactil, Thorazine etc.). After testing it on himself and his wife Cécile, Ernst pointed out the double-edge effects of modern neu- roleptic symptom suppression; his detailed description gives an idea of why the opportunity of successfully conducting a psychotherapy that aims at re-solving conflicts under psychiatric drugs, especially neuroleptics is so com- We are especially concerned about the creation of—as far as wecan tell today—a reversible localized organic brain syndrome (fa-miliar to us from lobotomy and characterized by disinhibition, aim-less activity as well as apathy, lack of initiative, awkwardness,emotional indifference, affective flattening, euphorically tingedlack of judgment, tactlessness and egocentricity—Th. I.). Assum-ing that this occurs raises the question about its relationship to ad-junct occupational rehabilitation and psychotherapy. Regardingthe first we can be brief. The Largactil cure fits in nicely with everytype of routine work therapy. After only a few days, the patients getup of their own accord and are able to work without any seriousorthostatic problems (which might occur while working in an up-right position). Needless to say, we are talking about light work un-der staff supervision. The problem of combining Largactil withpsychotherapy is more complicated. Remembering our self-experi-ments we can barely imagine that psychotherapy could have takenplace at the same time…Furthermore, we have to distinguish be-tween supportive and uncovering psychotherapy. The relaxing ef-fect of the medication is a good prerequisite for the former. But it iscertain that the drug suppresses the entire affective spectrum andnot merely its pathological elements. Such a broad suppressionmight also affect impulses issuing from our self-healing tenden-cies. Individual, albeit, irreproducible impressions of acute pa-tients led us to wonder whether the medicinally caused apathy didnot in fact lead to a solidification of the psychotic development, af-fecting both relapse and remission (Ernst, 1954, p. 588).
What was true for the first neuroleptic, chlorpromazine—the affective blunt- ing and the development of an artificial “thick skin” applies basically just as much to the neuroleptics that came to market more recently. Their effect is similarly based on the impairment and modulation of central nervous and intrapsychic processes as characterized by Ernst.
To conclude, modern psychiatry, especially academic psychiatric, is one great labeling lie. It has very little to do with the mind. More and more psy-chotherapy units from the time of social and community psychiatry (for ex-ample in England from 1960s onwards) are being closed down while psycho- therapists and psychologists are being let go. Human suffering is disappear- Theodor Itten: Psychotherapy Instead of Psychiatry? A No-brainer ing into a medical explanatory model. Psychiatrists, suffering from a scien-tific inferiority complex, consider themselves and people with mental prob-lems as objects with defective genes and disturbed neuronal networks. Their diagnostic look blocks any possible empathic fellowship with other human Bertram P. Karon, professor of psychology at Michigan State University and author of a ground-breaking book, Psychotherapy of Schizophrenia(1994), has devoted more time than anyone else to the reasons why psychia-trists are so reluctant to endorse psychotherapy for people who have been di-agnosed with schizophrenia. As early as the 1950s, he demonstrated a posi-tive effect of psychotherapy for people considered acutely schizophrenic. He addressed this in a speech at the Washington School of Psychiatry in March … schizophrenia is a human experience with meaning, meaningthat is hard to uncover, but it only takes patience, kindness, a toler-ance for not understanding, a willingness to understand the humancondition at its most painful, a tolerance for desperate defenses,and a willingness to take psychoanalytic ideas seriously when pa-tients talk about them. Understanding persons with schizophreniameans facing facts about ourselves, our families, and our societythat we do not want to know, or to know again (in the case of re-pressed feelings and experiences)…The real tragedy of schizo-phrenia is not the severity of the symptoms and the suffering thatresults for patients and for their families, but that we know psycho-analytic therapies that work and we are not using them. Familiesand patients are settling for treatments that aim at making the pa-tient a lifelong cripple who is not too disturbing. Psychoeducation-al programs, which could be helpful, usually give false informationwhich makes worse the burdens of both patients and their families(2003, p. 90).
Karon repeatedly critized the untruth of the apparent superiority of biological psychiatric methods such as psychiatric drugs and electric shocks over psy- Sometimes it is argued that research shows psychotherapy is nothelpful. However, when the Michigan State Psychotherapy Project (Karon and VandenBos, 1981) randomly assigned schizophrenicpatients to (a) an average of 70 sessions of psychoanalytic psycho-therapy per patient, (b) medication used effectively, or (c) a com-bination of the two, blind evaluation showed that psychotherapyalone, or with initial medication that was withdrawn as the patientscould tolerate it, led to earlier discharge from the hospital, kept thepatients out of the hospital, and improved their thought disordersmore than medication did, and the patients lived a more human lifein a variety of ways. Psychotherapy with maintenance medicationwas better than medication alone, but not as good in the long run aspsychotherapy alone or with initial medication that was with-drawn. Because of the hospitalization and particularly re-hospi-talization findings, psychotherapy was much less expensive over afour-year period than traditional treatment with medications…With schizophrenics, the treatment of choice is psychotherapy witha competent therapist who has relevant experience or training. Ifthe patient, the therapist, and the setting can tolerate it the psycho-therapy is best conducted without medication. If the patient asksfor it, or the therapist is uncomfortable talking with disorganizedpatients, or the setting requires it, medication can be used, but itshould be withdrawn as rapidly as the patient can tolerate (ibid., pp.
97/106).
According to Karon, biological psychiatric methods have the advantage over elaborate psychotherapeutic ones in that it is not necessary to engage with the individual problems of the patients. The psychotherapist Karon did not just speak about the conveniences for psychiatrists but also about their interest in Today, medication is the predominant treatment that does not re-quire understanding symptoms of schizophrenia. Medication re-duces disturbing affect and some of its immediate consequences;some of the patients’ behavior improves; and they become morecompliant. This is sometimes very helpful because other people al-most always fear schizophrenics. People tend to be cruel when theyare afraid. Because cruelty makes schizophrenic people moreschizophrenic, there are advantages to making schizophrenic peo-ple less frightening…A study funded by the American Psychiatric Theodor Itten: Psychotherapy Instead of Psychiatry? A No-brainer Association reported that psychiatrists who practice psychotherapycannot make much more than $100,000 per year, but that a practiceconfined to medication and evaluation will yield $300,000 cer-tainly a strong incentive (ibid., pp. 100-101).
Just like Karon, the psychotherapist Arnold Retzer, former medical director of the Department of Psychoanalytic Research and Family Therapy at the University of Heidelberg, who has devoted himself to family systems ther-apy, spoke about the positive results achieved with psychotherapy for people diagnosed with “schizophrenia.” In an extensive study, a total of 60 families were examined three years after the completion of family therapy; the pa-tients who had been diagnosed as manic-depressive, schizoaffective, and schizophrenic (his terminology) showed a significant reduction in relapses … a reduction of prescriptions for medications and a positive effecton vocational and educational outcomes. A far-reaching dissolu-tion of the disease concept among patient and family members isassociated with positive developments in the above mentioned ar-eas. It is sensible and potentially successful to conduct systematicfamily therapy with psychotic patients and their families as early aspossible (Retzer, 2004, p. 189).
The Poetry of Experience without Psychiatric Drugs The Scottish psychoanalyst Ronald David Laing (1927-1989) was consid- ered a radical psychiatrist during his lifetime, as well as paragon and teacher of many psychotherapists. He believed “…that to give serious consideration to the issues that arise from seeing the same differently itself contributes to lessening some of the fear, pain, madness and folly in the world” (Laing, Taking a look at your life even when things get quite confused at times is a good idea and helps protect you against becoming dogmatic. If I am mentally disturbed or if my soul is in turmoil it may be that I can’t manage my usual ev- eryday life and all the things I have to do. To arrive at a useful clarity and to obtain temporary emotional and social protection I can turn to psychother- apy—particularly if I cannot manage to help myself. If I become unbearable for others, for whatever reason, then I need a safe place, a place of calm, a place where I can rest up, such as in the therapeutic communities of the Phila-delphia Association, London, the various Soteria Houses and other commu-nal therapeutic centers. Meals are provided, I have a roof over my head, a bed I can crawl into and the assurance of being able to pursue my healing process at my own pace. The therapeutic staff in these type of settings are there for me, accompany me on my path which may be off the beaten track with re-spect to the normal world. Being with others in a respectful manner, honoring my own and the boundaries of others, and the wisdom of the heart are the ba-sis of this healing art. Space and time are made available, so that I might be accommodated in my potential speechlessness and that I can be seen as a per-son. It is only when my needs are understood and dealt with that I can reach my goal of becoming emotionally healthy.
Laing described how patients occasionally use the therapeutic space: “They wanted to enact some sort of drama, with me there but not interfering, not stopping them, or trying to change them by ‘making interpretations,’ hypnosis, or other techniques designed to change them” (Laing, 1985, p.
131). Everyone has their own metaphor, thought Laing, with whom I spent much time over a 14-year period. With his undivided attention and empathic presence he enabled others to arrive at a calmer, more balanced, better inte- grated healthy emotional state. An example: A 9-year old girl, who has been mute for several months at home, is brought by her father to see Laing. Once into the consulting room, Laing tells the father to come back in one hour to fetch her. It was a one-off session as the parents had already seen and consulted a school psychologist, an educational psychotherapist, and a psychiatrist. But nothing had worked so far. The child would not speak. So her parents thought of taking her to this rather famous but also strange psychiatrist and try him as a last resort before she sending her to a clinic. So she comes to meet Laing. This is a case story he told us stu- dents, and as far as I know it has not been published by him. After her father had left, Laing said to the 9-year old girl, once he was sitting comfortably in his chair and the girl was still standing in the middle of the room: You may do whatever you can and want, but you don’t have to doanything. You may be silent here and You don’t have to speak tome, you don’t have to perform, stay with me for 50 minutes, as I’m Theodor Itten: Psychotherapy Instead of Psychiatry? A No-brainer staying with you, and we’ll just see what happens. So let’s just re-lax (Laing, 1980).
He realized that the girl was taking this in and she was walking slowly to-wards him with her arms raised parallel in front of her, and the palms of her hands facing Laing. So Laing put his hands up as well, to mirror and receive her hands. They touched and he closed his eyes. Laing followed the slow movements of her small hands, circling up and down, forward and back, like a playful dance of the hands. The whole thing lasted almost the entire 50 min-utes. When the father came to pick up the girl he paid Laing 70 £ right away, which was rather a lot of money in the early 1970s, when a standard session would cost around 30 £. The father was a bit startled, but he paid up and they Laing forgot about the girl. But when he went to a party in the mid 1970s, a young women came up to him, introduced herself and said: Can you remem-ber the small girl who was brought to you mute by her father for a consulta-tion 12 years ago? No, said he, I can’t remember. What was the occasion andsituation? She said, I was the girl with the dancing hands: Wow, he said, nowI remember, I was always curious what happened to you. She said: Well, myfather was rather cross with you about the large fee and once we drove off heasked me: What did he do with you for this kind of money? So I said: it isnone of your business. At first he wanted to smack me, but then he becameoverjoyed when he suddenly realized that I was speaking again. Laing andthe young woman toasted to life.
This brief episode demonstrates how important it is to experience a good fit in psychotherapy, in other words, the chemistry between the patient and ther- apist must be right. Good therapists accept what comes from the patients and adjust to it. They know that psychiatric drugs alter the personality and hinder or preclude a useful and effective psychotherapy just like other psycho-ac- tive substances like hashish or alcohol. They trust that their own soul can tune in and join the other person in their confusion without abandoning their own position. The little girl in Laing’s example had not been diagnosed as psychotic, but the path to that diagnosis and the corresponding prescription of psychiatric drugs was already in progress.
I would like to add a modest example of help for someone who had been psychiatrically diagnosed and who became a patient of mine: a farmer’s wife who had been suffering from summer depression for more than 20 years was referred to me by her family doctor. She had tried almost everything, had been in analytical psychotherapy, in a variety of psychiatric hospitals, had been given medication and behavior therapy. These interventions all helped her to live with her depression for a while. But she and her husband were at the end of the road. I asked her: what do you need after having had all these therapies and attempts to find a cure? What do you want from me as your new psychotherapist? She answered after thinking for a while: I want to spend the sessions in a café. One week you choose the place and the following it will be my turn. I want to tell you about my life over a cup of coffee. Alright, I thought, that is a version of the extended consulting room. After two years and approximately 65 café visits, during which we had spoken about her hurt soul which had retreated deep down into herself, and she had told me about her experiences in psychiatry and we were able to bring closure to these sto-ries and find space for her desires for her life, she wanted to finish the ther-apy. “I think” she said one afternoon, “this therapy does not go deep enough.
We sit here in cafés and chat about my life, I drive my car again, I have newpart-time job, I don’t need to kill myself anymore, I have lost the weight that Ihad gained from taking medication, I can speak better with my husband andmy children, I dream well and I go dancing again.” After that we had two fi- nal sessions in my practice to look back at the course of the therapy once more. Later I saw her occasionally in town and she was never again patholog- This is an example of “being with” and of following that which was lying dormant in the patient as a healing response and which she expressed as her desire. As simple as dancing in your dreams. To be fully alert to what hap- These brief examples are only intended to demonstrate what was discussed above: only by taking people seriously, by dealing with the complexities ofpeople’s life histories and by leading the excommunicated back into commu- nication can we really assist people in trying to tackle difficult problems of Theodor Itten: Psychotherapy Instead of Psychiatry? A No-brainer life and support them in their inner emotional pain. As serious and committed psychotherapists we meet our patients with goodwill, honesty and integrity.
Presuming they have the opportunity to make a decision and see no other way out then in should not be too difficult to decide on psychotherapy.1 Ernst, K. (1954). Psychopathologische Wirkungen des Phenothiazinderivates “Largactil” (= “Megaphen”) im Selbstversuch und bei Kranken. Archiv für Psychiatrie und Nerven-krankheiten, 192, 573-590.
Gladwell, M. (2005). Blink: The power of thinking without thinking. London: Little, Karon, B. P. (2003). The tragedy of schizophrenia without psychotherapy. Journal of The American Academy of Psychoanalysis and Dynamic Psychiatry, 31(1), 89-118.
Karon, B. P., & VandenBos, G. R. (1994). Psychotherapy of schizophrenia. Northvale, Laing, R. D. (1980). Case history at the Philadelphia Association seminar in London. Un- Laing, R. D. (1985). Wisdom, madness and folly. London: MacMillan.
Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of psychotherapy, In A. E. Ber- gin, & S. L. Garfield (Eds.), Handbook of psychotherapy and behaviour change (pp.
143-189). New York: Wiley & Sons.
Märtens, M., & Petzold, H. (Eds.) (2002). Therapieschäden – Risiken und Nebenwirkun- gen von Psychotherapie. Mainz: Matthias Grünewald.
Retzer, A. (2004). Systemische Familientherapie der Psychosen. Göttingen / Berne / To- Tschuschke, V., & Kächele, H. (1998). Was leistet Psychotherapie? Zur Diskussion um differentielle Effekte unterschiedlicher Behandlungskonzepte. In: M. Fäh, & G. Fischer (Eds.), Sinn und Unsinn in der Psychotherapieforschung (pp. 137-162). Gießen: Psy-chosozial-Verlag.
Translated from the German by Mary Murphy 1 I would like to thank Evelyne Gottwalz, Kerstin Kempker, Peter Lehmann and Martin Urban for their helpful suggestions and critical collaboration I received in the prepara-

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