Lawrence D. Blum, MD

While the diagnostic categories of DSM-III and DSM-IV (and soon DSM-5) have provided the basis for much useful research, little has been written about how much of DSM-and how much “evidence-based medicine”-is built on a foundation of fantasy. DSM itself, unfortunately, does not acknowledge the existence or importance of fantasy. If it did, it would be a much more scientifically based, useful resource. An exploration of some central DSM fantasies will help point out some of its limitations.

DSM embraces several key fantasies that form the basis for psychiatric teaching. Some of the most significant are the following:

• 	DSM categories correspond well to people in the real world

• 	Diagnosis can (and should) be made only on the basis of 

• 	Classification within a category implies a difference from other categories and meaningful commonality with other components of the same category

That the mind of the patient, which cannot be objectively observed or measured, can be clinically and scientifically ignored is a central fantasy underlying all of this. Thus, although vast amounts of research have been dedicated to DSM, elements of fantasy inevitably remain. Case vignettes will help illustrate some of the principal fantasies.

Fantasy 1: DSM categories correspond with people in the real world

To a certain extent, this is not a fantasy. It is important to note that there really are people who have psychiatric disorders (eg, depression, borderline personality disorder, bipolar disorder, schizophrenia) and for whom these descriptive diagnoses are compelling and significant. But just as with the individual human mind, the presence of aspects of reality frequently serves to obscure aspects of fantasy-in this case, DSM categories are useful for most or all patients. How many patients outside of research studies fit neatly into DSM categories?

Does it really make sense to squeeze people into DSM categories in which they don’t fit? Does it make sense to say that all people who fit into multiple categories have “comorbidities,” or would it be better to acknowledge that many people have complex pictures that defy DSM categories? What of the many people whose difficulties bear little or no resemblance to any DSM category? Why maintain the fantasy of the utility of DSM in these instances? To illustrate the difficulty, here are 3 typical examples of patients that DSM seems to ignore.

DSM does not correspond with these patients-but the fantasy that DSM applies to most patients in the real world continues to be broadly shared, as does the fantasy that we can ignore patients’ fantasy lives. Just as with our patients’ fantasies, our professional fantasies must be meaningful, there for a reason. These DSM fantasies help alleviate anxiety about complexity. They allow us to think that there are simple solutions, even when we are dealing with people. The vignettes above also alert us to the next DSM fantasy.

Mr A came into treatment when his brother, with whom he had been living for 3 months, pointed out to him that contrary to his stated intent, he was not actually looking for a job. Over several sessions, Mr A proved to be a capable, skilled worker, as long as he was in a structured environment and had a boss he respected. Brutally murderous dreams suggested that outside of this circumstance, Mr A nearly paralyzed himself in an effort to control tremendous rage following a very difficult, traumatic childhood that he otherwise casually ignored.

What does DSM offer to help us understand or categorize Mr A’s blithe acceptance of his inertia? Where is the code for “paralyzes self to control murderous rage and wishes?” Despite its absence from DSM, might it not be the most precise and therapeutically salient diagnosis?

********************************************************************************************************************

Dr B works in a highly technical, high-risk area of medicine. She came for evaluation, wondering whether she suffered from “burnout” or depression, thinking maybe she should retire from practice. Her mood was low, but she had few other symptoms of depression. She was preoccupied with the idea that she had hurt patients and mentioned that she began each day by mentally replaying, in sequence, every case of her career in which she felt she had hurt someone. She justified this ritual with the idea that it helped prevent recurrent errors, despite the fact that she’d been over each case hundreds of times and there was nothing left to learn. Further exploration revealed that she had not in fact hurt these patients; they were people whose terrible illnesses had led to unfortunate outcomes that Dr B had been unable to prevent. Dr B gradually began to admit that contrary to the way she treated herself as a near criminally negligent physician, she was at the peak of her career, and her colleagues routinely consulted her on, or referred to her, their most difficult cases.

I let Dr B know that I understood why she wondered about burnout and depression, but that it seemed to me that if we needed a label, we should say that she was suffering from a guilt disorder. I also pointed out to her how she started each day with penance to try, unsuccessfully, to relieve the guilt, and that her guilty self-accusations had nothing to do with reality. In all the cases she had mentioned, she hadn’t actually hurt anyone, so the guilt, while felt in relation to her work, must have its origins elsewhere.

She later told me that she couldn’t believe she hadn’t recognized the guilt herself, and that she felt so light after our initial discussion that she laughed out loud while walking down the street back to work. Work became much less of a burden for her, and she went on to do a lot more therapeutic work easing guilty punishments and restrictions from many parts of her life. Guilty self-punishment and self-restriction can destroy a person’s life, but it is not in DSM. What happens to such patients if they must be treated according to DSM diagnoses?

Mr C came to treatment after yet another crushing disappointment in a romantic relationship. He did not have overt symptoms of depression or anxiety. Briefly, it turned out that a seductive mother and parental divorce had left him with amplified incestuous feelings, wishes, and fantasies that led him to withdraw from intimate relationships.

Again, there is no DSM diagnostic code for this situation, although variations of it are extremely common.

Fantasy 2: Diagnosis can and should be based on observable behavior

What supports this fantasy that we can limit ourselves to observable behavior? In none of the patients described here can a diagnosis be made without also accounting for the customary, crucial, emotional conflicts in the mind. That one can limit attention to behavior and ignore the complexity of the human mind and call it science, or that one can toss away most of the evidence and call it “evidence-based-these are fantasies. Obviously, the internal conflicts of the patients described here may be difficult to categorize and measure. But what we need is more sophisticated science that accounts for the mind, not an unscientific attempt to dismiss much of our best data.

Perhaps in addition to facilitating a circumscribed form of science, “behavior only” fantasy helps us defend against the messiness and discomfort of many of our feelings and fantasies, as we would expect from working with our patients.

Beyond this foundational fantasy underlying our current DSM-that we can manage with only observable behavior-let’s consider a number of what we might call corollary fantasies.

Fantasy 3: DSM categories are meaningfully separate

Much research has established that many DSM categories are indeed discrete and useful, but again, this should not lead the student or reader to unquestioningly accept that this is always the case. As noted, many patients in the real world do not read the textbooks and confine themselves to our given categories. The fact that anxiety and depressive symptoms occur simultaneously has recently become a widely recognized limitation of DSM. The concept of “comorbidity,” the idea of having diagnoses from 2 categories at once, has merit on the one hand, but on the other is an attempt to bolster an inadequate system. By analogy to color, is the pattern better understood as blue and yellow, or as green, stripes, a check, or a complex multicolored plaid?

Beyond its limited utility, what propels the fantasy of separateness? To me, it always seems like another compulsive symptom: Don’t let the peas touch the potatoes! Do we professionals tend to be compulsive? Of course!

Fantasy 4: A DSM category represents a homogeneous entity

Mr D and Mr E-both of whom received a diagnosis of DSM unipolar depression-are often assumed to have the same psychiatric disorder. Mr D, who had narcissistic features, became depressed in his 40s, because his professional accomplishments had fallen short of his grand expectations and his relationships had proved unrewarding. Mr E, after spending 2 years valiantly caring for his dying parents, became depressed after they died. His parents’ illnesses had revived his well-earned, usually suppressed, childhood wishes to murder them. No longer serving penance of endlessly caring for them, he could not tolerate his now conscious joy and relief at their deaths, and he became deeply, guiltily depressed.

To what extent is it therapeutically useful to consider that these men had the same psychiatric disorder? Does using the vague DSM term “affective disorder” offer an apparent explanation that takes attention away from significant affects, such as anger, anxiety, guilt, and sadness?

One might ask similar questions in relation to Ms F, Ms G, and Ms H, all of whom have anxiety and, not meeting criteria for any of the DSM discrete anxiety diagnoses, would be said to have anxiety disorder NOS (not otherwise specified). Ms F had anxiety with separations and with the possibility of more independence from her mother; Ms G had become anxious over peripartum struggles with intolerable anger directed toward her baby; and Ms H, who had been sexually abused as a child, became anxious whenever a man expressed interest in her.

In all of these cases, DSM treats different entities as the same, offering a rather nonspecific diagnosis and ignoring the possibility of a more specific (and potentially useful) dynamic diagnosis. In these examples, DSM, if taken seriously, inhibits useful thought about treatment instead of promoting it.

What supports the fantasy that these different patients should be given the same diagnosis? Again, I think this fantasy helps decrease anxiety about the complexity of human feelings and conflicts. It offers a relieving feeling of simplicity.

Fantasy 5: A diagnosis can be made at the beginning of the treatment

When DSM-III came out in the 1980s, I recall a senior psychiatrist who found it a source of great amusement: “They want the diagnosis at the beginning!” He would struggle to say this through his laughter, adding that one only really understood the diagnosis-the underlying pathological structures and fantasies-late in the treatment. Obviously, in many situations, it is essential to make a provisional diagnosis promptly, but it is worth remembering how limited this initial impression can be and how much situations can change and evolve. Anxiety symptoms may arise in depressed patients as their depression lifts. Anxiety can cover sadness and depression. This fantasy is encouraged by our wishes for professional omniscience, in addition to being supported by many of the same reasons as the fantasies that precede it.

I envision the day when psychiatry and psychology re-embrace the mind, along with the brain and behavior. Then, diagnosis will routinely and comprehensively include descriptive, developmental, and dynamic mental and behavioral features of patients. Neurosis, or some way of conceptualizing mental conflicts, will return to DSM. The absence of such a concept will no longer result in the unfortunate in-attention to patients’ dynamics that the recent DSMs tend to foster. Descriptive and dynamic psychiatry will ride off together into the sun-set, even as clichs vanish from my writing.

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I envision the day when psychiatry and psychology re-embrace the mind, along with the brain and behavior.

Five Key Fantasies Embraced by DSM

While  the diagnostic categories of DSM-III and DSM-IV (and soon DSM-5) have provided  the basis for much useful research, little has been written about how much of  DSM-and how much “evidence-based medicine”-is built on a foundation of fantasy.  DSM itself, unfortunately, does not acknowledge the existence or importance of  fantasy. If it did, it would be a much more scientifically based, useful  resource. An exploration of some central DSM fantasies will help point out some  of its limitations.

DSM  embraces several key fantasies that form the basis for psychiatric teaching.  Some of the most significant are the following:

•  DSM categories correspond well to people in the real world
 •  Diagnosis can (and should) be made only on the basis of 


 •  Classification within a category implies a difference from other categories and  meaningful commonality with other components of the same category

That  the mind of the patient, which cannot be objectively observed or measured, can  be clinically and scientifically ignored is a central fantasy underlying all of  this. Thus, although vast amounts of research have been dedicated to DSM,  elements of fantasy inevitably remain. 

 will help illustrate some  of the principal fantasies.

Fantasy 1: DSM categories correspond  with people in the real world

 
 To  a certain extent, this is not a fantasy. It is important to note that there  really are people who have psychiatric disorders (eg, depression, borderline  personality disorder, bipolar disorder, schizophrenia) and for whom these  descriptive diagnoses are compelling and significant. But just as with the  individual human mind, the presence of aspects of reality frequently serves to  obscure aspects of fantasy-in this case, DSM categories are useful for most or  all patients. How many patients outside of research studies fit neatly into DSM  categories?

Does  it really make sense to squeeze people into DSM categories in which they don’t  fit? Does it make sense to say that all people who fit into multiple categories  have “comorbidities,” or would it be better to acknowledge that many people  have complex pictures that defy DSM categories? What of the many people whose  difficulties bear little or no resemblance to any DSM category? Why maintain  the fantasy of the utility of DSM in these instances? To illustrate the  difficulty, here are 3 typical examples of patients that DSM seems to ignore.

Mr  A came into treatment when his brother, whom he had been living with for 3  months, pointed out to him that contrary to his stated intent, he was not  actually looking for a job. Over several sessions, Mr A proved to be a capable,  skilled worker, as long as he was in a structured environment and had a boss he  respected. Brutally murderous dreams suggested that outside of this  circumstance, Mr A nearly paralyzed himself in an effort to control tremendous  rage following a very difficult, traumatic childhood that he otherwise casually  ignored. What does DSM offer to help us understand or categorize Mr A’s blithe  acceptance of his inertia? Where is the code for “paralyzes self to control  murderous rage and wishes?” Despite its absence from DSM, might it not be the  most precise and therapeutically salient diagnosis?

Dr  B works in a highly technical, high-risk area of medicine. She came for  evaluation, wondering whether she suffered from “burnout” or depression,  thinking maybe she should retire from practice. Her mood was low, but she had  few other symptoms of depression. She was preoccupied with the idea that she  had hurt patients and mentioned that she began each day by mentally replaying,  in sequence, every case of her career in which she felt she had hurt someone. She  justified this ritual with the idea that it helped prevent recurrent errors,  despite the fact that she’d been over each case hundreds of times and there was  nothing left to learn. Further exploration revealed that she had not in fact  hurt these patients; they were people whose terrible illnesses had led to  unfortunate outcomes that Dr B had been unable to prevent. Dr B gradually began  to admit that contrary to the way she treated herself as a near criminally  negligent physician, she was at the peak of her career, and her colleagues  routinely consulted her on, or referred to her, their most difficult cases.

I  let Dr B know that I understood why she wondered about burnout and depression,  but that it seemed to me that if we needed a label, we should say that she was  suffering from a guilt disorder. I also pointed out to her how she started each  day with penance to try, unsuccessfully, to relieve the guilt, and that her  guilty self-accusations had nothing to do with reality. In all the cases she  had mentioned, she hadn’t actually hurt anyone, so the guilt, while felt in  relation to her work, must have its origins elsewhere.

She  later told me that she couldn’t believe she hadn’t recognized the guilt  herself, and that she felt so light after our initial discussion that she  laughed out loud while walking down the street back to work. Work became much  less of a burden for her, and she went on to do a lot more therapeutic work  easing guilty punishments and restrictions from many parts of her life. Guilty  self-punishment and self-restriction can destroy a person’s life, but it is not  in DSM. What happens to such patients if they must be treated according to DSM  diagnoses?

Mr  C came to treatment after yet another crushing disappointment in a romantic  relationship. He did not have overt symptoms of depression or anxiety. Briefly,  it turned out that a seductive mother and parental divorce had left him with  amplified incestuous feelings, wishes, and fantasies that led him to withdraw  from intimate relationships. Again, there is no DSM diagnostic code for this  situation, although variations of it are extremely common.

The  DSM does not correspond with these patients-but the fantasy that the DSM  applies to most patients in the real world continues to be broadly shared, as  does the fantasy that we can ignore patients’ fantasy lives. Just as with our  patients’ fantasies, our professional fantasies must be meaningful, there for a  reason. These DSM fantasies help alleviate anxiety about complexity. They allow  us to think that there are simple solutions, even when we are dealing with  people. The vignettes above also alert us to the next DSM fantasy.

Fantasy 2: Diagnosis can and should be  based on observable behavior

 
 What  supports this fantasy that we can limit ourselves to observable behavior? In  none of the patients described above can a diagnosis be made without also  accounting for the customary, crucial, emotional conflicts in the mind. That  one can limit attention to behavior and ignore the complexity of the human mind  and call it science, or that one can toss away most of the evidence and call it  “evidence-based-these are fantasies. Obviously, the internal conflicts of the  patients described above may be difficult to categorize and measure. But what  we need is more sophisticated science that accounts for the mind, not an  unscientific attempt to dismiss much of our best data.

Perhaps  in addition to facilitating a circumscribed form of science, “behavior only”  fantasy helps us defend against the messiness and discomfort of many of our  feelings and fantasies, as we would expect from working with our patients.

Beyond  this foundational fantasy underlying our current DSM-that we can manage with  only observable behavior-let’s consider a number of what we might call  corollary fantasies.

Fantasy 3: DSM categories are  meaningfully separate

 
 Much  research has established that many DSM categories are indeed discrete and  useful, but again, this should not lead the student or reader to  unquestioningly accept that this is always the case. As noted above, many  patients in the real world do not read the textbooks and confine themselves to  our given categories. The fact that anxiety and depressive symptoms occur  simultaneously has recently become a widely recognized limitation of DSM. The  concept of “comorbidity,” the idea of having diagnoses from 2 categories at  once, has merit on the one hand, but on the other is an attempt to bolster an  inadequate system. By analogy to color, is the pattern better understood as blue  and yellow, or as green, stripes, a check, or a complex multicolored plaid?

Beyond  its limited utility, what propels the fantasy of separateness? To me, it always  seems like another compulsive symptom: Don’t let the peas touch the potatoes!  Do we professionals tend to be compulsive? Of course!

Fantasy 4: A DSM category represents a  homogeneous entity


 Mr  D and Mr E-both of whom received a diagnosis of DSM unipolar depression-are  often assumed to have the same psychiatric disorder. Mr D, who had narcissistic  features, became depressed in his 40s, because his professional accomplishments  had fallen short of his grand expectations and his relationships had proved  unrewarding. Mr E, after spending 2 years valiantly caring for his dying  parents, became depressed after they died. His parents’ illnesses had revived  his well-earned, usually suppressed, childhood wishes to murder them. No longer  serving penance of endlessly caring for them, he could not tolerate his now  conscious joy and relief at their deaths, and he became deeply, guiltily  depressed.

To  what extent is it therapeutically useful to consider that these men had the  same psychiatric disorder? Does using the vague DSM term “affective disorder”  offer an apparent explanation that takes attention away from significant  affects, such as anger, anxiety, guilt, and sadness?

One  might ask similar questions in relation to Ms F, Ms G, and Ms H, all of whom  have anxiety and, not meeting criteria for any of the DSM discrete anxiety  diagnoses, would be said to have anxiety disorder NOS (not otherwise  specified). Ms F had anxiety with separations and with the possibility of more  independence from her mother; Ms G had become anxious over peripartum struggles  with intolerable anger directed toward her baby; and Ms H, who had been  sexually abused as a child, became anxious whenever a man expressed interest in  her.

In  all of these cases, DSM treats different entities as the same, offering a  rather nonspecific diagnosis and ignoring the possibility of a more specific (and  potentially useful) dynamic diagnosis. In these examples, DSM, if taken  seriously, inhibits useful thought about treatment instead of promoting it.

What  supports the fantasy that these different patients should be given the same diagnosis? Again, I think this fantasy helps decrease anxiety  about the complexity of human feelings and conflicts. It offers a relieving  feeling of simplicity.

Fantasy 5: A diagnosis can be made at  the beginning of the treatment


 When  DSM-III came out in the 1980s, I recall a senior psychiatrist who found it a  source of great amusement: “They want the diagnosis at the beginning!” He would  struggle to say this through his laughter, adding that one only really  understood the diagnosis-the underlying pathological structures and fantasies-late  in the treatment. Obviously, in many situations, it is essential to make a  provisional diagnosis promptly, but it is worth remembering how limited this  initial impression can be and how much situations can change and evolve.  Anxiety symptoms may arise in depressed patients as their depression lifts.  Anxiety can cover sadness and depression. This fantasy is encouraged by our  wishes for professional omniscience, in addition to being supported by many of  the same reasons as the fantasies that precede it.


 I  envision the day when psychiatry and psychology re-embrace the mind, along with  the brain and behavior. Then, diagnosis will routinely and comprehensively  include descriptive, developmental, and dynamic mental and behavioral features  of patients. Neurosis, or some way of conceptualizing mental conflicts, will  return to DSM. The absence of such a concept will no longer result in the  unfortunate inattention to patients’ dynamics that the recent DSMs tend to  foster. Descriptive and dynamic psychiatry will ride off together into the  sunset, even as clichs vanish from my writing.

While the diagnostic categories of DSM-III and DSM-IV (and soon DSM-5) have provided the basis for much useful research, little has been written about how much of DSM-and how much “evidence-based medicine”-is built on a foundation of fantasy.

5 Key Fantasies Embraced by DSM

In my work as a psychiatrist and psychoanalyst, it is not unusual for a patient to tell me that he or she had a normal childhood. This always alarms me. Childhood has so many conflicts and worries, so many triumphs and disappointments-how can one reduce it to a notion of normality? What does invoking this concept conceal? Isn’t the idea of a normal childhood, with its denial of complexity, itself a wishful, childlike fantasy?

My patients have reported some remarkable “normal childhoods.” One was on a farm where the patient was socially isolated, suffered an accidental stabbing with a pitchfork, and broke bones falling off a truck overloaded with hay. Other “normal” childhoods have included alcoholic parents, chronically ill siblings, surgery early in childhood, and family bankruptcy. And what 

 be a normal childhood? Where? When? With how many and what sort of parents and siblings? Urban or rural? In the Nintendo era? With Smartphones?

When patients claim to have had a normal childhood, they may be hiding underlying feelings, such as embarrassment, humiliation, hurt, guilt, or anger. Often they may be protecting a parent from criticism. Denial can help to maintain an outward calm and the appearance of emotional integrity, even when these may be lacking inwardly. But there is also a cost, typically in distorted relationships or restrictions on how a person leads his life. Inner shame and guilt, secrets and self-doubt remain in place. Healing these difficulties is contingent on being able to give up the pretense of normality.

For those who are most dedicated to preserving the notion of a normal childhood, the ordinary questioning and curiosity that facilitate an exploratory, insight-oriented psychotherapy are unwelcome, threatening intrusions. When this type of reaction can be usefully examined and understood, and the worries about trying to understand diminished, the patient may indeed benefit from such psychotherapy. When the patient still finds such exploration too threatening, he may be able to participate only in a more limited treatment that is oriented toward preserving or restoring one or another idea of “normality.” The following vignettes briefly describe a patient from each of these 2 categories, those who can successfully question the notion of a normal childhood, and those who seem unable to.


Ms A, a social worker, grew up with caring working-class parents in a stable suburb of a large city. She had satisfactory relationships with her siblings and her “normal childhood” left her with no clues to understand why she always felt hurt in relationships with others, and why she always had to take care of others, to her own detriment. It had not occurred to her that childhood hospitalizations for serious illnesses are not “normal,” and had formed the template both for being hurt, by endless medical procedures, and for wanting to take care of people, like the doctors and nurses who saved her life. Helping her to understand how much of the past was alive in the present helped her to diminish its damaging interference in her life.

Mr B, a perpetually tense young lawyer with clipped speech and constant quantitative measurement of his experience, was distressed that in his late 20s he had yet to accomplish a number of his major goals. That he described a childhood spread over three continents, cultures, and languages as “normal” and unrelated to his present concerns suggested there might be much he preferred not to examine. After several meetings over many tentatively scheduled and then rescheduled appointments, he declared that he was getting insufficient return on his investment and departed having barely arrived. What made his childhood so normal I will likely never know.


Only careful attention, kind questions, and gentle confrontation of contradictions allow a patient to cautiously address the emotional struggles he or she fears to face. This is unlikely in the many common symptom-focused or do-your-homework therapies. Nor does it happen with automatic prescription of fluoxetine or one of its relatives. And it does not happen without protection of privacy. The therapist must avoid the temptation to try to impose his or her own version of normality on the patient. For example, is forgiving a tormentor normal or abnormal? Desirable or not? To what extent? How or when? The therapist must help the patient overcome defensiveness and find his own answers to questions like these.

Just as we strive to help patients overcome their attachment to the defensive, counterproductive idea of a normal childhood, we should attempt to do the same for psychiatry and psychology. Instead of thinking of development as leading to normality or abnormality, it is more useful, usually, to understand it as leading to types of adaptation having a complex variety of advantages and disadvantages. Clearly some people experience childhoods that are more traumatic and more challenging than others, but if we recognize that no one has a normal childhood, and that everyone’s childhood is unique, we better our opportunity to understand each individual and to be more tolerant of differences. Understanding and valuing each person’s individual experience has more to offer than the false promise of an imagined normality.


 

Childhood has so many conflicts and worries, so many triumphs and disappointments-how can one reduce it to a notion of normality?

I Had a Normal Childhood

Penis size, a topic that is often spoken about only in whispers or jokes, merits serious discussion. Not only do many men have a great deal of concern about it, but since this concern and the psychodynamic means for understanding it are seldom discussed in professional training, few psychiatrists, psychologists, and other therapists are prepared to help their male patients deal with their worries about this subject. Over the years, I’ve observed that most of my male patients have worried that their penises were “smaller than average” or “too small.”

How should we understand this challenge to statistical common sense? And why do men think women are concerned about their size?

Human concern about the penis is old and universal. Artifacts from around the world feature human forms with exaggerated genitalia. Little boys in all cultures get accustomed to touching themselves early, and if possible, often. Freud was both right and wrong about penis envy. Does it exist? Yes. In women? Occasionally. In men? Almost always. Men worry that some other guy is bigger, and that women care. Men develop fascinations with cigars, pens, cars, trains, baseball bats, knives, guns, and sausages, but not usually with frisbees, soup, pillows, or suitcases. They exhibit themselves and hide themselves, and they make endless anxious locker-room jokes. Men want to be bigger and at the same time often fear being bigger, sensing it to be dangerous. This makes realistic understanding of size surprisingly difficult.

Much of the thought and feeling on this subject is infused with concerns from childhood. In the child’s mind, and therefore on some level in the adult’s, bigger is always better. In Westerns, the bad guy is always older, dressed in darker (non-innocent) clothing, tall in the saddle, and always has a beard or moustache. He is powerful, the father, the antagonist of the beardless youth who tries to win the woman that the older man wrongly holds hostage. I have yet to meet a male patient who didn’t bring forth some present-day version of this perpetual struggle to be as big as his dad; big instead of his dad; bigger than, and with all the advantages of, his dad (or grandfather, uncle, or whomever the most primary male was). Sometimes these strivings are subtle, sometimes they are blatant, and often they are disguised by submissiveness or self-defeat. Frequently they show up as anxiety about attaining the privileges of the adult male, such as having sex, holding a good job, or earning a promotion.

Children make their best efforts, using the means at their disposal (such as fantasy) to right the terrible injustice of being little. They are envious, imperious, and wishful, even as they are also kind and loving. Smart as they are, they have little sense of reality. Plotting to get what the adults have-their partners, money, big bodies and big penises-they expect others to be up to the same tricks as they are. They know from their own fantasy schemes to get the goods from the big adults that it’s dangerous to be big and to have the treasure, because then you are a target. Just as in the Westerns, someone may be gunning for you. So they play defense as well as offense and protect their own precious possessions.

Proclaiming, believing, that what one has is too small and thus not worth stealing is a clever and convenient ploy. “I’m just a child” is a great alibi during childhood, but it’s one that many men unconsciously continue to use, long after it has served to relieve boyhood anxiety. They strike a psychological bargain: they get to keep their equipment, but at the cost of feeling little and hiding what they have. They may feel ashamed and little, but at least they’re safe from attack.

An aspect of this hiding can be discerned in public behavior. At concerts and ball games, women often go to the bathroom in the company of other women. In contrast, many men, without ever discussing it, maintain a secret agreement to go alone, or without anyone they know. Better that no one can glance at their anatomy, take their measure, find them (as they imagine it) shamefully little, or let the evil eye get a dangerous glance at their treasure. To protect themselves from imagined danger, men will sometimes urinate in toilet stalls instead of urinals, collectively sacrificing vast quantities of water to their anxiety.

Some men try to put their safety-by-self-diminishment into reverse. Having protected themselves from predation by insisting they are small (like the Billy Goats Gruff), and feeling ashamed at their presumed smallness, they then want something physical to increase the size they have mentally decreased. Some men’s size worries are magnified by a lasting feeling from boyhood of smallness in relation to their big mothers, who excluded them from private matters with big, adult men; they are then inclined to believe that women may see them as small and continue to refuse them because of it.

The resulting desire for a physical solution to an emotional problem has spawned the widespread penis enlargement industry, an early and no­torious purveyor of Internet spam as well as of ads in the back pages of certain magazines. (Women, of course, do something similar, trying vainly to solve problems of low self-esteem and imaginary defects through the now common ritual mutilations of plastic surgery.)

Ironically, while men are busy imagining that women want them to have bigger penises, the women would prefer that the men be self-confident enough not to be concerned about penis size. I have rarely heard a female patient trouble herself to comment about the size of her partner’s penis, but women care a lot about whether their partners are confident, decent, and can stand up for themselves and others. (Yes, there’s a pun there.) In fact, in the few times I’ve heard a woman venture a thought about the size of her partner’s penis, the more frequent concern was that it would be too big, contributing to a fantasy of injury.

So does penis size matter? What we can see is that the dimensions don’t, but the feelings and fantasies do. Men care about it and will continue to. The past is present. Junior male apes want access to the females possessed by their seniors; David still fights Goliath; Moses continues to oppose Pharaoh; and every day around the world Luke Skywalker takes on Darth Vader with a 3-foot light saber. As long as they love their mothers, boys will be certain that bigger is better. Although the boy remains present in the man, he also grows up. Even so, to move from residual childhood preoccupations to more adult accomplishment, many men need psychoanalytic therapy to help separate childhood fantasy from adult reality. When they are able to transform their childhood efforts t o even the score with the giants into working well in the world and caring about others, they feel more satisfied with themselves, and their partners are happier with them as well.

So does penis size matter? What we can see is that the dimensions don't, but the feelings and fantasies do.

Penis Size: A Consideration of Fantasy and Reality (With Only a Few Puns)

Prince Albert gets the royal treatment-by being treated the same as everyone else. Like the commoners who consult Lionel Logue, Prince Albert is helped to confront his avoidances, to tolerate his feelings, and to understand his fears and fantasies. A humane respect for emotional problems may be uncommon among humans but is captivating in this movie that has proved more popular than anyone expected. Albert’s good fortune, his path toward emotional liberation, is that his speech therapy incorporates so many features of psychoanalytic therapy. 

When Prince Albert turns to Logue for help with his debilitating, humiliating stutter, Logue promptly refuses special requests-house calls-for royalty, insisting on “my house, my rules.” He also makes the provocative demand that he and the prince should call each other by first names. Logue thus indicates to the prince that he will have to struggle with his shame and anxiety as anyone else would-royalty offers no protection from human emotions. He also immediately shows his patient that the relationship between them is a matter for observation and discussion. This setting of a framework that will allow the therapist and patient to examine and discuss the relationship that develops between them is a fundamental psychoanalytic principle. It gives patients a new window on their own minds and how they relate to other people.

Logue next devotes much effort to showing “Bertie” that his stuttering is aggravated by his anxiety: it is diminished when he is distracted by music, and he has less inhibition of speech when he can curse or sing. This recognition paves the way to help Bertie look more deeply at the substance of the emotional struggles that interfere with his speech. In psychoanalysis, this process of clarifying present concerns to reveal more hidden matters is called analyzing defenses or “resistances.” When he has successfully overcome some of his initial objections and feels less ashamed, Bertie can gradually see that as an adult he is continuing the fearful mental battles of his childhood. Bertie then tests out some of his long-suppressed challenges to his old adversaries, his father and brother, in his relationship with his therapist. As Logue tolerates these challenges without being injured and without criticizing or attacking his patient, Bertie starts to feel free to find his own voice.

A humane respect for emotional problems may be uncommon among humans but is captivating in this movie that has proved more popular than anyone expected.

Unconscious, leftover struggles from childhood influence all of us. The opportunity to play out, observe, and alter them in relation to the therapist is one of the most important contributions of psychoanalysis. If you’ve ever wondered what psychoanalytic treatments are like, 

 provides an unusually good cinematic representation of a psychoanalytic therapy. There’s no magic to the iconic couch; the key is what goes on between the two people.

We live in a quick-fix society. We focus on what people do but don’t look inside at why they do it. This is the kind of approach-just try to change the behavior-that did not work for Prince Albert and that left him discouraged about himself and about any prospect for help. But no matter the behavior, it is still wise to remember the mind, with all the complex feelings, thoughts, and emotional conflicts to which humans are subject. Treatments such as the one that helped Bertie require intense emotional involvement and much time. They aren’t for everyone, and they don’t follow a script. While most therapists are not trained to do them, psychoanalysts are. The royal treatment is still available to those who seek it out.

It is not a coincidence that such an affecting movie as 

 depicts a treatment that is so psychoanalytic. No one goes to the movies to watch a formulaic treatment-or a prescription for Prozac. We go to be involved in the full play of human emotions-love, hate, fear, lust, envy, joy, greed, the hidden and forbidden yearnings. Even a stiff-upper-lip royal needs a home for the heart. The final joy of 

 is seeing the king’s hard-won ability to speak from his heart.

If you’ve ever wondered what psychoanalytic treatments are like, The King’s Speech provides an unusually good cinematic representation of a psychoanalytic therapy.

The King’s Psychotherapy

I used to be a doctor. Next I was a provider. Now, I’m a non-covered entity. I liked being a doctor…I still do. I never liked being a provider. But being a non-covered entity is a secret victory. I’ll explain.

As a psychoanalyst and psychiatrist, my work depends entirely on confidentiality and respect for people as individuals. Treatment works only when my patients and I are able to explore very personal feelings and thoughts. If my patients are not confident that what they tell me will stay private, they will withhold their thoughts or abort the treatment. In the mid-1980s, when I began practice, what patients told doctors was kept confidential, protected by a compact dating back more than 2000 years, to Hippocrates. Along came private insurers, Medicare, and HMOs-third parties with a financial stake in medical events. Since they were paying out money, they wanted to know what they were paying for, and often began to demand private information before paying. What was personal suddenly became corporate.

To increase profits, insurance companies instituted “managed care” in psychiatry and transferred to shareholders a great deal of the resources that had formerly been spent for health care. Managed care employs many techniques to discourage the use of mental health services. One approach is to have reviewers decide whether patients’ problems meet criteria for “medical necessity” before approving payment for “procedures,” such as psychotherapy. To do this they often demand very personal information, compromising confidentiality. This demand for information, because it threatens confidentiality, can lower quality of care just by existing. Who can talk freely when unseen reviewers are eavesdropping? And, unfortunately, too many therapists are willing to go along with this system.

These same insurance companies made me a Provider. I believe they use the word “provider” as a way to address doctors, nurses, therapists of every variety, even syringe suppliers, with the same form letter. Because a “provider” need not be a doctor, the term also includes the numerous “physician-extenders” who do things that doctors used to do. Many Americans have insurance that obligates them to choose a doctor from a company list or “provider panel.” Even though I don’t participate on insurance company “provider panels” (they rarely allow for confidential, insight-oriented psychotherapy), I have received many a “Dear Provider” letter-impersonal, bureaucratic and, typically, unsigned.

Then came the Health Insurance Portability and Accountability Act (HIPAA), which made me an Entity. HIPAA was intended to help workers maintain their insurance when they changed jobs. It also directed the executive branch to develop regulations to protect medical privacy. While the rules provide new protection for psychotherapy notes, they also allow large companies (including pharmacies) to use personal health information for all sorts of nonmedical (commercial) purposes-without patients’ knowledge or consent. (Perhaps you have received a phone call from a company attempting to sell you products for an illness you thought was confidential?) In addition, the rules require hospitals and most doctors to carry out a lot of bureaucratic paperwork to make a display of privacy protection. You’ve probably signed forms at your doctor’s office to satisfy the rule that the office show you its privacy policies.

If I were to send patient information electronically-such as sending a bill to an insurer online-I would become a Covered Entity and would be forced to have my patients sign the useless forms. But, concerned about these electronic transmissions as an additional risk to confidentiality, I choose not to use them. This makes me a Non-Covered Entity. I’d prefer to be a doctor, but as an Entity, I’d much rather be Non-Covered than Covered.

Not everyone feels as I do. My internist now types on a notebook computer as we talk. Although electronic records are lost, stolen, and sold every day, he does not believe that the electronic record jeopardizes my privacy. If my records were accidentally or maliciously posted on the Internet, would they even be accurate? The problems listed on my billing slip are not necessarily those I consider important. They seem more oriented to justify to a potential third-party reviewer the substantial amount of time my doctor spends with me than an accurate description of my concerns. Would I tell him of problems about which I felt deeply embarrassed?

Now health care reform is in the wind again, and with it many questions. Will insurance companies still be allowed to skim 20% from each health care dollar? Will doctors still be reimbursed huge sums for procedures but pennies for talking with and understanding patients and their families? Can medicine be personal and private? Will people be taken care of by a doctor, a provider, or an entity?

My practice remains personal and private. Most of my patients address me as “Doctor,” but some call me Larry. I’m not particular about this: more important is that the patient be comfortable. If the patient has a strong preference about what to call me, we have the chance to learn from it. The patient’s feelings about addressing me may shed light on his or her feelings in other relationships.

Recently, the federal government has required all doctors (including this Provider/Non-Covered Entity) to have a National Provider Identification (NPI) number. It is 10 digits long, so it’s not easy to address me by it. But even if you are the bureaucrat who created NPIs, your secret will be secure with me.

Author | Lawrence D. Blum, MD

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