Paul Genova, MD

Like more and more cancer patients today, I have outlived several prognoses and am still hanging around, in a diminished life, trying to outlive the latest. Sooner or later, all of us get swept up into one or another of the collectively available cancer story lines in the culture. The following reflections come from more than 5 years of telling myself such stories, listening to fellow patients tell me theirs, having friends or doctors tell me one of these stories about myself (eg, “You’re a fighter!” [not really] . . . “You have such a great attitude” [no] . . . “You must have learned so much about yourself” [yes and no], etc).

Often, when I try my hardest to honestly relate what has happened or is happening to me, I find that people hear me selectively, tending to mold my story into 1 of the 2 basic stories I’ve identified. At other times I’ve caught myself inwardly trying to create one of these narratives, sometimes for months on end. Life gets hard without a script. My own up-and-down course increasingly refuses to fit into a coherent story line the longer it goes on. (The longer any of us survive, the more this tends to be the case.)

I aim here not to relate yet another cancer autobiography but to use my experience (1) to break down some of the limiting boundaries of story itself that may isolate cancer patients and their loved ones, each from the other, knowing surely that my readership includes both groups, and (2) to show how any story one tells one’s self may foreclose possibilities both for living life fully and for treatment and survival.

Each of these stories, by the way, can be done with or without God and with or without actually dying. The 2 stories are as follows.

This story is about overcoming. It is the typical willpower/mastery, American Dream, up-by-the-bootstraps, Norman Vincent Peale–type narrative (“You’re a fighter!”), in which the patient never gives up, never says die, stays “positive” in word and deed, never lies in bed despairing when he/she could possibly get up and get some exercise . . . you get the idea. It conforms with mainstream America’s denial of all unpleasant things that are not preludes to more “riches” of some sort-even if said riches are not recovery but the proverbial “good,” inspiring, exemplary death (“He was a fighter to the end; he never lost his good attitude,” etc). You see this a lot in obituary columns, which people in my situation tend to read, and to which they feel inadequate by comparison. The medical system especially is often geared to seeing people this way and wanting them to be this way. When one is doing well, one often gets the you’re-a-fighter/ what-an-attitude comments from doctors. Nurses are who you want to see first when things have gone wrong.

This “alternative” narrative is about spiritual refinement or maturation of the personality through a series of drastic losses and perilous tests. It derives, often in distorted and oversimplified form, from sources such as the 

, Jung, and Joseph Campbell. And it finally turns out to be less of an alternative than it seems on the surface. People from my neck of the psychometric woods, the more “sensitive” and/or less denial-capable types (patients and loved ones) are attracted to this story line because at least it permits despair and loss of faith as real, valid experiences that one can live through and even learn from. In the first story line, of course, despair is a weakness, or worse, a sin in the God version.

The ever more mainstream, “alternative” culture supports this second, spiritual-journey tale in the form of numerous memoirs and self-help books and in the attitudes of various health practitioners and well-meaning “spiritual” friends (which is not to say, fortunately, that all such books and spiritual friends thoroughly fall for it). As a narrative, its underlying connection with the first is that it, too, requires denial: denial of the randomness, the disproportionate nature and (in the God version) downright cruelty of the suffering endured, or inflicted upon, patients, even if they die in some more enlightened, loving and forgiving state-again, the promised “riches”-which is not always the case!

So, our 2 stories differ more in style than substance. There is a standard of judgment, there are the people who have supposedly aced one or the other narratives, and we read or hear and compare ourselves unfavorably to their stories. Who really knows the inner lives of these “heroes”? My years of sitting next to some of them in chemotherapy chairs from Birmingham, England, to Little Rock, Ark, as well as my own struggles with myself and with people’s “hero” projections onto me, tell of more complicated and individual inner situations. But one thing we all share. This is the dread of flunking out. It’s the same sort of reaction most of us have already had to the simple-minded “single solution” tales we heard at the time of first cancer diagnosis: so-and-so did a macrobiotic diet. So-and-so did watercolors every day, etc. I’m flunking, I’m flunking. . . . But somehow, either early in the course or later, it’s much harder to accept that “the race is not to the swift [my emphasis] . . . time and chance happeneth to them all,” as the author of Ecclesiastes wrote in the third century B.C.

Creating some quasi-parental judge in one’s mind or in Heaven, even if we ourselves don’t make the grade, is apparently easier to take than unpredictable, random loss. Martin Seligman’s famous monkeys needed a reliable warning, a knowledge of “when” to survive repeated electric shocks without developing posttraumatic stress disorder–like symptoms. I have often written that we humans, in comparable life situations, will do almost anything with our superior cognitive powers to invent a reliable “why.” One must assume that nature knows best and that these explanatory “why stories” have survival value, even healing potential. But this is only true up to a point for some of us who are blessed or cursed with insight into the process (and living long enough with cancer does tend to confer this dubious blessing). Sooner or later the stories let us down.

Telling myself a story-for example, a dramatic story No. 2 of a hero trying to stay exquisitely aware and honest, writing feverishly through long winter nights in England as I faced my own possible death-got to be a trap. What if I woke up and wanted to be unaware one day, or wanted to lie to myself, or do nothing but play guitar for the duration? Or, most important, what if I didn’t die, but just dragged along in some boring long-term illness. Or even: what if mundane, linear Western medical science progressed and I got totally better? But such was not the stuff of myth, I realized. One had to admit that either tragic-but-enlightened death or retreat to a Himalayan monastery made by far the better story! In the mythic story I would have to become fully, gloriously alive in some idealized way that does not correspond to the textures of real human liv-ing, manifesting through my written words, perhaps, a Bodhisattva! Some of my well-meaning correspondents seemed unconsciously to encourage my inspiring literary performance. I switched to guitar in the nick of time.

This personal example applies only to me, but I submit that all such stories, whether they fall into my rough No. 1 and No. 2 categories, can wield incredible yet subtle power over those of us who live and die with cancer. They create inward attitudes that become self-fulfilling prophecies. They foreclose possibilities for new endeavors, new relationships, and unexpected sources of healing or of solace. They may also lead us to ignore or minimize promising options for further medical treatment.

Returning to my own example, I also need, at the present moment, to be able to look at the reality of my quite possible early death without a myth in the way. If I die it will be a mess, not a heart-warming movie scene. There will be a lot of loose ends, hurts-never-apologized-for, poems half-written, songs never learned, events in my children’s lives not participated in, lovely years with my wife never lived, friends never seen again, great meals not eaten, etc. And getting there will be no fun either. I am a person of flickering but persistent faith, a faith based not on the promise of happy endings but instead on recurrent perceptions of an underlying connectedness in things. I have no particular belief in an individual afterlife in which I remain recognizably me. Something of me may go on but perhaps only the deepest part, of which I have been only occasionally, indirectly aware. The fact is that I love this ego-based life of being me as I know me, doing what I like to do. I do not want to leave it.

To conclude. Among my best allies against the tyranny of collective stories have been the kinds of simple solace that are unique for each of us: in my case, reading, traditional prayer, walking the dog, playing my instruments. Beyond those, I have found that starting new things is the best defense against the suffocating demons of “closure” and “tying up loose ends.” Make more loose ends! As long as you are really living, there will be loose ends! And the best allies of all remain the friends, family, and colleagues who have been able, through it all, to finally hear what I am really saying about my experience. I thank God for them. I also hope that these words may help some who find themselves telling a cancer story, or trapped in one, that does not fit and that saps the unpredictable force of even a seriously threatened life.

Articles

Like more and more cancer patients today, I have outlived several prognoses and am still hanging around, in a diminished life, trying to outlive the latest. Sooner or later, all of us get swept up into one or another of the collectively available cancer story lines in the culture.

Two Stories We Tell Ourselves About Cancer

In the land of psychotherapy for depression, crowned by the research literature, cognitive therapy has long reigned supreme. Is the emperor as fully clothed as everyone seems to think?

Just back from college, a young woman is describing her near-fatal overdose. She is one of those people who ostensibly has everything going for her, yet has been dogged by melancholy for years. Excellent psychiatric treatment at school, including medication, had her feeling "almost well" and succeeding academically by semester's end, but one night, with nothing obvious bothering her, she slowly downed a month's supply of three medications. She doesn't remember any clear intent or intense feeling of despair--just a sort of "absent-minded daze."

Having been found and having survived her coma on an intensive care unit ventilator, she again feels back to normal and is as puzzled as I am over what happened (although I can label it a dissociative episode).

This kind of story is as common as it is baffling. To academics who might object that there could be a comorbidity lurking here, I reply that the real world has no exclusion criteria.

If our trainees are ever in a position to treat a case like this in a role more substantial than medication consultant, they will need a workable theory of mind to approach it. At a minimum, any such theory will have to give them some way to think about unconscious motivation. Instead, training programs are feeding our residents good old American common sense and glorifying it into a theory of mind that is completely inadequate to such everyday tragedies and mysteries. Why? Let's listen to Schuyler (2003), guest editor of the May issue of 

Managed care has stressed cost-effectiveness and a bottom-line related bias for brief therapy. Cognitive therapy fit the bill. Psychotherapy researchers have emphasized 'manualized therapies' to promote standardization to facilitate study. Cognitive therapy fit the bill. Psychodynamics takes a long time to master, with often ponderous readings and substantial irrelevance for the trainee. Trading upon its here-and-now focus, its harnessing of the patient's problem-solving skills, its rejection of the unconscious and transference, the cognitive model can be taught to trainees quickly. Cognitive therapy fits the bill.

But cognitive therapy does not fit the bill for the case of my college student. The problem to be solved is not clear and didn't seem to be in the here-and-now when she overdosed; there-and-then elements are likely to be relevant. It may take more than a brief effort to bring them to light, and I won't have the option of rejecting the Unconscious in that effort.

Reject the Unconscious! One might as well try to reject the air. Any psychiatric training worthy of the name will have to include a psychodynamic psychotherapy modality that "takes a long time to master." Some difficult reading may indeed be necessary! Psychiatry is, after all, a medical specialty. You don't see nephrologists deciding to "reject the glomerulus" as a shortcut to learning dialysis.

Call the Unconscious a construct if you will, but this will not help my patient. Like many other deeper realities in science-the continental drift, the evolution of species, the gravitational bending of space--the Unconscious must be inferred from more tangible and observable realities. It can't be seen like a glomerulus can (though brain structures important to its functioning certainly can--see below), and there may be better ways to think about it (e.g., multiple "coconscious modules" of mental functioning). But one thing is certain: my patient and I are stuck with the Unconscious whether it is rejected or not.

This kind of situation leads many an experienced clinician to echo Beiber (2003) in a recent review examining the evidence-based mandate for cognitive therapy:

I remain ambivalent. On the one hand I see results with some patients, but I also see failures with other patients, who react to this form of therapy as a naive view of the world. The idea that depression is based on cognitive interpretation and that this interpretation can be modified can be experienced by the patient as a large empathic failure.

Evidence-based medicine is both a set of statistical techniques and a fashionable movement in internal medicine. An explanation of why its methodology misses some of the most important aspects of psychiatric treatment is beyond my scope here, and I refer the reader to the paper by Williams and Garner (2002). For the purposes of this essay, I am willing to grant that cognitive therapy is helpful for many patients, much of the time. However, the questions of why it works and what it really is need to be answered before we let it replace psychodynamics as psychiatry's workaday theory of mind and therapeutic interaction.

What may be good for a subgroup of patients may nonetheless be bad for psychiatry if we elevate it to the dominant worldview of our profession and our major training modality for psychotherapy. Here are some of the reasons why, which I will discuss:

Cognitive therapy does not reflect current knowledge of how the brain works;

Cognitive therapy does not really reject transference;


Cognitive therapy unquestioningly supports the social status quo;


Cognitive therapy gives patients no means of responding to unsolvable problems: to the inherently tragic nature of life.

It is well-established that activity in the amygdala and other parts of the limbic system, which assign emotional significance to incoming sensory stimuli, is initially independent of cortical input (e.g., the influence of negative beliefs). Direct pathways through the thalamus light up the amygdala in half the time required for signals to reach this structure indirectly via thalamo-cortical pathways.

Thus, affective responses often occur before any integrated cognitive processing does. Previous overwhelming experiences are stored haphazardly by a stress-impaired hippocampus as unintegrated sensory-affective fragments. These can operate unconsciously to further distort the cognitive functioning that does eventually occur. As Shean (2001) stated:

A depressed patient may be responding at an affective level to inner somatic and outer stimuli that have not been contextualized or organized but represent unrecognized elements of previous experiences. These affective reactions can occur independently of any form of cortical processing.

I believe this is exactly what was happening when my young patient overdosed.

In sum, while beliefs can influence emotions, neuroscience says that the bulk of the influence is in the other direction. Psychodynamics has said this all along.

Turning from the demands of neuroscience to those of ordinary logic, we find cognitive therapy equally wanting. It simply labels as irrational any inference patients may make that does not conform to the most optimistic possibility! Ignoring the patient's history and arrogating to itself the power to judge what is or is not a realistic conclusion to draw from that history, cognitive therapy, in the words of Fancher (1995), "lends the authority of the therapy industry to positive illusions."

Of course, any good general psychotherapist, regardless of their theoretical orientation, will try to highlight neglected possibilities, to challenge black-and-white thinking, to encourage "shifts of set" when appropriate and indicated. But there is something obscene about the image of a young, inexperienced trainee reducing the problems of--for example--a 60-year-old minority woman who has lived a life of abandonment, abuse and economic deprivation to three columns on a blackboard and presuming to correct the "errors" in her thinking. Fortunately, many trainees have the presence of mind and the compassion to wake up to what they are being told to do. For, as one patient of mine memorably said of her brush with cognitive therapy: "People have been telling me how to think all my life!"

With its error-correcting stance, it is apparent that cognitive therapy is not rejecting transference. Instead, it is trying to hold transference constant in a benign authoritarian form and hoping to forget about it. Time and again I see puzzled therapists wondering why things aren't going according to plan when patients sabotage their authority!

The very best critique of cognitive therapy (and I have already drawn upon some good ones) was written a century ago by William James in 

 (1902). James, the father of American psychology and a sufferer from severe recurrent (and occasionally, psychotic) depression, took on modern cognitive therapy's direct ancestor, the mindcure movement of the 19th century (which also begat Christian Science). He conceded:

Diverting one's attention from evil is splendid as long as it will work. It will work with many persons, and within the sphere of its successful operation there is nothing to be said against it. But it breaks down impotently as soon as melancholy comes ... The only relief that healthy-mindedness can give is by saying: 'Stuff and nonsense! Cheer up old fellow, you'll be alright erelong, if you will only drop your morbidness!'

Mincing no words, James called this "religion of healthy-mindedness" "unspeakably blind and shallow."

For the common-sense remedies of cognitive therapy to work, two unexamined and truly incorrect core schemata must be maintained. First is that the social status quo is essentially fair and just, with fulfilling possibilities available to all who keep an open mind. As Fancher (1995) puts it, "People can fit, if they just think straight."

Indeed, it would be both comforting and therapeutic to believe that our society gives everyone a fair shake. Social alienation has a proven negative effect on mental and physical health. The problem is patients who are depressed often have plenty of real-life evidence that society isn't fair or safe. In the name of rationality, cognitive therapy invalidates their experience and the most reasonable inferences to be drawn from it.

The second schema is that bad things are never really final. James (1902) again: "Systematic healthy-mindedness fails to accord sorrow, pain and death any positive and active attention whatever." In other words, the tragic view of life is a cognitive distortion, and those hapless souls who hold it--many of our culture's most creative people-are in error.

Carl Jung once wrote that the most important problems in life are never solved, only outgrown. Pain, loss, alienation from the larger culture, frustrated loves, ambitions that won't go away--such things we do not solve; at best we come to terms with them.

But that process, while often lengthy and painful, yields rewards undreamed of in cognitive therapy's socially adaptive outcomes. For, to finish with James (1902):

The evil facts which it refuses to account for are a genuine portion of reality; and they may after all be the best key to life's significance, and possibly the only openers of our eyes to the deepest levels of truth.

 Beiber MR (2003), Book review of Treating Chronic and Severe Mental Disorders: Handbook of Empirically Supported Interventions. Am J Psychiatry 160(5):1023-1024.
 

 Fancher RT (1995), The middlebrow land of cognitive therapy. In: Cultures of Healing: Correcting the Image of American Mental Health Care. New York: W.H. Freeman, pp195-250.
 

 James W (1902), The Varieties of Religious Experience. New York: Mentor Books.
 

 Schuyler D (2003), Cognitive therapy: change through problem solving. Primary Psychiatry 10(5):31-32.
 

 Shean G (2001), A critical look at the assumptions of cognitive therapy. Psychiatry 64(2):158-164.
 

 Williams DD, Garner J (2002), The case against "the evidence": a different perspective on evidence-based medicine. Br J Psychiatry 180:8-12.

Cognitive Therapy's Faulty Schema

 article by Michael First, MD, and Robert L. Spitzer, MD)

 diagnostic system has outlived its usefulness by about two decades. It should be abandoned, not revised. Its primary achievement was to force American psychiatrists to recognize that not all patients presenting with florid psychoses had schizophrenia. More generally, it aimed to force the idea of operationally defined syndromes down the throat of a profession that was still, in the 1970s, dominated by the vague and archaic concepts of psychoanalysis at its American 1950s worst.

These goals have long since been accomplished, and, like the preceding analytic vagueness, it is time for the arbitrary, legalistic symptom checklists of the 

 to go. (The lag time would be about the same, 20 years or so.) Let me say at the outset that I do not wish to disparage all the hard and well-intentioned labors of the various work groups that developed the different sections of these books in their several editions or to deny the enormous amount of information summarized therein. But again, the aggregate is an awkward, ponderous, off-putting beast that discredits and diminishes psychiatry and the insight of those who practice it.

Consider the fact that your clinical practice is governed by a diagnostic system that:

is a laughingstock for the other medical specialties;

requires continual apologies to primary care doctors, medical students, residents, and the occasional lawyer or judge;

most of our thoughtful colleagues privately rail against;;

insists upon rigid categories that often serve only to confuse and misinform patients and their clinical workers (sometimes abetted by televised drug advertising);

is so intellectually incoherent as to raise eyebrows among the well-educated, critical thinkers in our own psychotherapy clientele;

persuades the world at large that psychiatry no longer has anything of interest to say about the human condition.

If it were within your power to do so, wouldn't you get rid of this system?

Let us make a tour of some of the diagnostic categories we all use and abuse. 

 comes immediately to mind. Some argue that schizoaffective disorder should be a rare diagnosis. As unhappy as I am with the 

 description, they reach an opposite conclusion to my own. Rightly criticizing the arbitrariness of the current criteria for this disorder (two weeks of hallucinations or delusions in the absence of prominent mood symptoms, but prominent mood symptoms for a "substantial portion" of the illness), one authority has even speculated that the confusion about schizoaffective disorder deters medical students from entering psychiatry!

I rather think that it is today's incarnation of the 

, that deters medical students from entering psychiatry. Strict diagnostic criteria (which some want to repair by making them still stricter) reflect neither biological nor clinical reality. These realities simply will not yield to anyone's desire for precision. On the research front, recent studies suggest that there is considerable overlap in the genetic vulnerability for schizophrenia and for bipolar disorders. What is the point of false precision when the genes themselves are imprecise?

And when I make my weekly visit to the revolving-door world of Mental Health Clinicland, where brief med checks are the usual context for my best efforts, schizoaffective disorder is among the most common diagnoses I make. One reason, of course, is that reliable histories of precisely defined symptom clusters and periods of time are usually impossible to obtain, while many of my patients have both psychotic and mood disorder features most of the time, fitting neither of the 

's clear bipolar or schizophrenic pictures.

Another reason is that the clinical syndromes we treat, whatever their genetic underpinnings, are themselves changing. If the reader will permit a brief digression, the schizoaffective debate reminds me of debates over whether black lung disease was a real illness when I was in general practice in East Kentucky years ago. Some physicians, particularly those hired by mining companies' liability insurers, held that it was simply chronic obstructive pulmonary disease (COPD). Indeed, most of the miners who suffered from it were also smokers. But the fact was that black lung behaved differently than typical COPD. At least in my care, it seemed to have a restrictive, as well as an obstructive, nature and needed more and earlier steroid treatment. These men had spent their lives breathing coal dust.

Today, our young bipolar patients are spending their lives ingesting antidepressants, cocaine, methamphetamine, methylenedioxymethamphetamine (MDMA) and hallucinogens over prolonged periods. These chemicals change their brains, just as coal dust changes lungs. Inter-episode recovery, a hallmark of classic bipolar disorder, becomes a thing of the past. Delusions, hallucinations and mood-cycling become entrenched, and antipsychotic maintenance essential. I could try to be strict and pile up two or three Axis I diagnoses to describe this entity, thereby confusing everyone else involved in the patient's care. Instead, and with no apology, I call it 

, which is more easily explained to nonpsychiatrists as a nonhomogeneous in-between category.

 and find countless howlers and paradoxes, as I am sure many readers have already done. More important are major problems like the relationship of narrowly defined posttraumatic stress disorder to the commonly found clinical entity of "chronic complex PTSD," which includes mood-cycling, dissociative and/or psychotic features, and predictable personality and boundary derangements. Again, we need to pile up several Axis I and II labels to strictly diagnose--and obfuscate--a familiar clinical presentation.

Aside from conversion disorder, the somatoform disorders are a mess (four pain symptoms, two gastrointestinal symptoms and so on). Primary care physicians never use these diagnoses, instead sticking with the clinical presentations they see, such as fibromyalgia syndrome. Anxiety disorders are artificially separated from the mood and psychotic disorders with which they are usually intertwined, yielding the frequent question, "If I have an anxiety disorder, why are you treating me with an antidepressant?" How many cases of pure generalized anxiety disorder have you seen? Of isolated social phobia? And so on.

The personality disorders section, categorical as it is, has been very effective in stifling nascent psychodynamic thinking among our trainees. Many of these "disorders" are extreme forms of various dimensions of normal personality. Their very extremeness is often, indeed, state-dependent with regard to other psychiatric illness and general stress level. The truly dynamic aspects of some of the more interesting ones, such as narcissistic and borderline personalities, have been bled out of the 

 categories. For example, a "deflated" aspect of narcissism, which presents with outward "low self-esteem" around a grandiose core, exists in variable equilibrium with the outwardly grandiose aspect described in 

, wherein it is nowhere to be found (see my essay "The Endless Walk of the Fool" in The Thaw [The Analytic Press, 2002]). And although observing how these character-disordered patients respond in treatment is the sine qua non of psychodynamic diagnosis, fundamental descriptions of such responses, such as the discussions of borderline personality organization by Otto Kernberg, M.D., are omitted.

In fact, psychiatrists who specialize in any one of the major subject areas in the 

 seem almost universally frustrated by "their" section of the book. This is equally true of analysts specializing in personality disorders, clinical researchers in major mental illness, traumatologists and neurobiological investigators. Overlapping dimensions, or spectra, of pathology much more accurately reflect clinical reality, whether we are talking about the narcissistic/borderline personality spectrum or the bipolar, schizophrenia, obsessive-compulsive or autistic spectra. When they can, biologically oriented researchers come up with their own criteria (like the negative/positive symptom clusters in schizophrenia), while psychodynamic and cognitive-behavioral writers put forward alternative ways to look at personality function in therapy settings. The 

's relationship to all this is as a Berlitz phrase book is to the Tower of Babel.

And then there are those horrible Axes. I suppose they were designed with good intentions. They made us think always of the medical picture (Axis III) and originally tried to save a place for psychodynamics (Axis II). Today, we all know to think of the medical situation, and the Axis I=biology/Axis II=psychology distinction is blurred: patients with schizotypy have the eye-tracking abnormalities of schizophrenia, people with chronic PTSD often have borderline psychodynamics.

The Global Assessment of Function (Axis V) is good for generating the following quip: "Subtract 20 if you want to get the treatment plan approved!" And Axis IV, "psychosocial problems," shows no appreciation of the varying symbolic import of life events. These subjective judgments are not part of a diagnosis. They belong in a good narrative note with specific examples and a little originality in the use of adjectives!

Granted, there are disclaimers in the current manual's introduction about not taking categories literally and not regarding 

 diagnoses as a complete understanding of the patient. But these muted caveats do not help to reverse the fact that the 

, by its very existence in its present form, implicitly encourages the entire mental health care system to do those very things. It is a tacit endorsement of false precision and superficial literalism in psychiatric assessment.

Two questions arise from this situation, and the first is, Why? Why maintain and elaborate a diagnostic system that no one is happy with? A skeptic need look no further than the catalogues full of 

 software and the like that fill every psychiatrist's mailbox. The 

 is a big moneymaker for the APA. Who dares practice--indeed who can practice--without the reigning bible close at hand? I maintain that the APA is holding back the development of the profession it represents by maintaining its income and its institutional hegemony over American mental health care with the 

A final question is: What do I suggest instead? My regular readers well know that I am better at tearing down than at building, but I will try.

Researchers, of course, will always need research diagnostic criteria and are good at coming up with them. These same researchers ought to also pay some attention to operationalizing and studying the real, dirty categories that real clinicians use. This is already happening to some extent, as the pitfalls of excluding most of the patients we treat from research studies have become apparent.

 would provide a perfectly good alternative for billing and coding purposes, and perhaps the APA could let the World Health Organization take back the job of developing future code bibles, rather than duplicating the task. While we will always need an administrative diagnostic system, the APA's resources are better spent finding ways to get people excited about--and interested in--the rich scope of the field it represents, instead of endlessly rehashing an arid and intimidating set of menus.

As clinical psychiatrists communicating among ourselves and to other specialties and concerned parties, we need not take diagnostic categories literally. We can save the major valid diagnostic syndromes like paranoid schizophrenia, or panic disorder with agoraphobia, but append other features freely and, most important, change our basic diagnostic stance to a dimensional rather than a categorical one. Arbitrary checklists and time cutoffs ("more than two weeks," "less than six months") can be dispensed with in favor of our best global diagnostic impressions. The focus of psychiatric treatment should be a single diagnosis--a single person--in most cases, with no tiresome Axes involved. Impressions of personality contributions, "stressors" (how I hate the word--its generic tone invites us to leave the patient's story out!), relevant medical illness and so on can go back into a narrative note to be discussed in a nuanced way. Attempts to quantify functioning can be confined to research and otherwise left to lawyers, government agencies, insurance companies and the psychiatrists they employ.

Will this ever happen? As my French-Canadian grandmother used to say, "Don't hold your breath!"

(Interested readers are advised to go to the Web site by Paul McHugh, M.D., [

www.hopkinsmedicine.org/jhhpsychiatry/perspec1.htm

] and read his systematic and cogent 1992 discussion of these same issues. From his lofty position as chair of psychiatry at Johns Hopkins University, he has long advocated for change in our diagnostic system.)

Decades of labor have been poured into the formulation of the DSM and its descendants. Is this system of classification still useful and relevant to clinical practice? Should psychiatrists continue to revise it or get rid of it altogether?

Dump the DSM>!

The patient with whom I am exchanging pleasantries and sports scores is a second-generation pedophile. It is only a small exaggeration to say that he is on every medication known to man. Brutally and repeatedly sodomized by his stepfather through childhood and adolescence, he is himself a gentle person who experiences his deep aquifers of rage only when they spout forth under pressure in threatening auditory hallucinations. His own brief career as a sex offender followed the same quiet, obsequious, ingratiating style, and he inflicted no physical violence on the boys involved. It ended in a trip to the state prison, a dangerous place for convicted pedophiles, particularly for this slight and timid individual. I can make some fairly safe assumptions about what happened to him there.

Although I have known this patient for a number of years, my formal role with him in the clinic setting where I work part-time is limited to writing his prescriptions. If I really did all the paperwork I am supposed to do in connection with this, we would have no human interaction whatever. As it is, the mental health center's assigned clinician does the frontline work, and each new clinician chooses one of two basic tacks when my patient's name is transferred to their caseload. Some, focusing on his "major mental illness" diagnosis of schizoaffective disorder, concentrate on the management aspect, filling his weekly medication caddies or getting him to the cooking group. Others, usually inexperienced or idealistic or both, take on his posttraumatic stress disorder and his history with varying degrees of skill and intuitive common sense (few have meaningful supervision--their supervisor usually only shows them which forms to fill out and when). 

Ontogeny recapitulates phylogeny in the careers of this second group of clinicians, as it did in my own. Regardless of what any of us may have read, each generation of would-be therapists has to make Freud's original mistake of uncovering too much with the wrong patients and making them worse. This is the foremost vulgar error of psychodynamics, and the reason why many clinicians, trying to play it safe, thereafter avoid "content" altogether, or learn to see it only as something to be replaced by more adaptive cognitive schemata.

In this case, with sensitive history-taking and puzzling through recurrent nightmares, my patient's most recent idealist (an unusually gifted one) succeeded in precipitating a florid psychotic episode with command hallucinations both suicidal and homicidal. Perhaps some different, adaptive schema would not have been such a boring idea after all. The newly re-stabilized patient is fresh from the hospital.

Needless to say, with what influence I have, I try to support the management-minded clinicians' efforts and to dampen the idealists, but either way, clinicians only last at most a year or two. I am always left, as now, with my pedophile and his ongoing quest to be as numb as possible.

For the sake of emphasis, I will recite his medication list, with total daily doses (most are divided into fours, as frequent dosing is reassuring to him; the caddy boxes are reliable friends). Clonazepam 5 mg, oxcarbazepine 600 mg, risperidone 12 mg, trifluoperazine 20 mg, valproate 2000 mg, fluoxetine 80 mg and trazodone 200 mg at bedtime. And there may be more. Not to mention his insulin and oral hypoglycemic, his ACE inhibitor, his COX-2 inhibitor, his statin, his triptan, his proton-pump inhibitor, his inhalers. And the occasional zolpidem or oxycodone thrown in by a well-meaning on-call general physician. Altogether, a lot of things are being inhibited here. And God knows what interactions are going on beyond the binary scope of my software.

This man is younger than I am, and he can hardly move. Sometimes after seeing him, I walk up and down the hills across the street as fast as I can until I am sweating and breathless just to prove that movement is possible.

Academics, chief residents, inpatient docs, scoff all you want. I defy anyone with a serious public outpatient practice to tell me you do not have at least one, usually several, patients like this. They are one of psychiatry's ill-kept secrets, and I recall discovering them among my attendings' clientele when I was an on-call resident years ago. Luckily, my attendings were of a philosophical generation. Their explanations went straight to the big picture and skipped any attempt to make pharmacological sense or to apologize. These are broken people, they told me. Their lives are unbearable if experienced with any clarity. We help them to stay numb as an alternative to having them, or someone else nearby, get physically hurt or die. And then, over the years, we find something in them to appreciate or to make contact with, some little bit of life left within them. Such appreciation, such contact, must be seen as having value in itself and not as a means to an end. 

While dampening the idealism of the clinicians, I have myself practiced a sort of psychopharmacologic idealism. Every single psychotropic on the previous list has been tested with a taper since I inherited this patient several years ago. I have had small victories: buspirone is gone, oxcarbazepine has replaced carbamazepine. But any attempt at the big ones--fluoxetine, valproate, clonazepam, the antipsychotics--inevitably results in emergency department visits, phone calls from a frightened wife, broken windows, punctured walls. 

At first I thought we were having a symbolic dialogue about dependency and autonomy through his drastic reactions to any change I would make. I spent lots of phone time reassuring him and getting him to try and hang on, to wait some medically respectable interval before reinstating his former dosage. But after I stopped questioning his regime, there were no further problems until the latest therapist rocked the boat. The patient has taught me, and now he trusts me completely. Our contract is that I will keep him numb. He watches the sports channel and dozes periodically; sports is our topic today. His face is flat, his speech a bit slurred; his half-smiles, though, are still worth the wait.

On my desk beyond him is the latest issue of 

 in which Elio Frattaroli, M.D., speaks from his new book 

 (Viking, 2001). His words are an eloquent compensation for today's symptom-driven, mindless psychiatry. He speaks of unconscious conflicts and symptoms as an opportunity for spontaneous growth. True believer in psychotherapy that I am, I still find myself playing with ironic titles of my own. 

No, there is nothing mysterious here, no hidden conflict to reflect upon in the situation of my pedophile patient. The horror is mostly above board, and if we go looking for more, he lands in the hospital. 

Reflection, growth, awareness: such noble statements of value are necessarily one-sided; they always leave something important out. I still hide the newspaper's morning headlines from my 9-year-old, the suicide bombings, child abductions and rapes. From my 17-year-old, I do not. I suppose the difference is that I expect him by now to have developed his capacity for numbness. I must have been teaching him right all along.

Perhaps the Enron and WorldCom executives learned that lesson too well, oblivious to the future pain of the people from whom they stole even as these same people typed their memos and brought them their coffee. But clearly, we all learn adaptive numbness. It is a universal and essential complement to awareness. They must exist in some shifting equilibrium for us to survive in this sometimes hostile and overwhelming, sometimes hospitable and nurturing world.

 language) we are considering here parallels physical processes like hibernation and dormancy. Each seems to allow the organism to await better conditions (why else would my patient brighten while discussing sports scores?); each may end either in death or in a reawakening. I do not delude myself that even with all the time in the world I could "facilitate the maturational process" (Frattaroli, paraphrasing Winnicott) in some idealized psychotherapy with my patient. If his soul is healed, it will be by a Power greater than myself--by a change in the conditions within which he lies dormant. Both forms of psychiatry, biological and psychodynamic, may function as vast defense mechanisms against the recognition of just how bad life can be, and how helpless we are before that fact.

Today I paddle out onto my little lake at sunrise. It is as good a place for awareness as any. The loons are much tamer than they were when I was a boy: numb to the traffic noise from Route 302 that is already beginning to build, numb to me as I approach. Withdrawing to rocky coves, they will retain their numbness even as the noisy jet-skis invade, long after I go to work. Yet these indifferent-appearing loons are acutely aware of fish down deep in the cooler water, diving for them periodically. When I add my noise to the inbound traffic, I will be trying in the midst of my numbness to stay aware of the possibilities in my patient's gentle half-smile and his soul under the numbed-out surface.

How does a clinician deal with those patients for whom they can ultimately do nothing but help them stay numb for the majority of their days?

Numbing Out

(Dr. Genova returns to his column after an eight-month hiatus--with something of an explanation--Ed.)

The patient, a young gay man who once lived for a time in Salt Lake City, describes his pursuers: Mormons who know where he is and are trying to kill him. As the clinic visit goes on, I see the doubt in his eyes when I explain my medication increase, and ask about it. He admits he can't be sure; his voices are saying that I'm a Mormon too. Only, with much persuasion and oversight will he comply with my prescription, because he trusts his case manager more than anyone else in the world. 

But the case manager is not present when two clean-cut young men in suits happen to knock on his apartment door the following week. Terrified, the patient runs out the back door, half-dressed, and keeps on going. That night, exhausted, he will be found by the police, committed and forcibly medicated--as he imagines, by Mormons--his worst fears fulfilled, he thinks, before he falls into a sleep from which he does not expect to waken.

Back in my private office, I listen to a middle-aged professional man describe his new second wife in idealized terms. She knows what he's thinking before he says it; they never fight; they like the same music; he's never felt this way in a relationship before. As an aside, he notes with suppressed glee how unhappy his first wife seems to have become (it was she who had rejected him), and how she resorts to making things difficult with children and money to punish him for his own luck in love. But this only confirms and adds to his sense of happily-ever-after.

Then, consider another private patient, a bright 30-year-old man who never quite finished college or got his life underway and works as a waiter--armed, no doubt, with the same sarcastic wit he displays to me. He is unhappy; many of his contemporaries are moving on, but he can't quite deign to enter the mundane flow of bourgeois life to which his intelligence and background would easily give entry if he were willing to trim his beard, perhaps put on a tie and hold his contempt in abeyance for a spell. Every alternative involves "selling out."

Eventually, even his rather passive girlfriend tires of cleaning up after him and quits the scene. But this boy-man who fancies himself uncompromised (even as he subsists on restaurant tips from doctors and lawyers in an upscale caf,) will not leave off his story of a misunderstood and unknown genius. He remains the classic pothead intellectual, going nowhere.

The above examples were chosen to make a simple point. People become trapped in their own stories. The literature of psychotherapy has oversold the concept of healing-through-narrative-construction. We have taught beginning therapists to help their patients gain a sense of coherence and control over their lives by making those lives more resemble stories of which they, the patients, are the authors. In various forms of therapy, we even covertly supply the story lines: A hero's journey from exile or abandonment, through various trials, and ending in a triumphant return to wholeness. Overcoming adversity. Making the best of a bad hand. Mind over matter (now rehabilitated by PET scans and brain-derived neurotropic factor). The risk of such ego-strengthening maneuvers is that the development of faith in something that can't be anticipated or understood, let alone "authored," may be inhibited. There is no place in therapeutic narrative for the old gospel refrain, "Farther along we'll know all about it"; for letting go and seeing what happens.

Granted, our efforts to "re-story" our patients' often fragmented and chaotic lives, so that they make sense or acquire a consciously discernible meaning, are frequently and powerfully effective. Real life, however, is not a story, at least not as the ego conceives of stories. There is too much noise in it; too many loose endings never again picked up; digressions that do not end up relating to the whole; lacerating, jagged edges never to be filed smooth; ambiguities never to be resolved. Such messiness is the very substance of life--and the fertile source of surprise. Order can only be imposed on it in retrospect, by selective inattention to whatever doesn't fit the chosen story line. This is most easily done when nothing new is happening, and patients like those above, good storytellers all, make it their business not to allow anything new to happen. For some reason, story has become more important to them than real life, real relationships, real events. The story must be preserved at all costs. 

The young psychotic man, were he not a unique sacrificial victim of the Mormon conspiracy, would have to cope with being lonely, gay, very ill and without resources in small-town Maine; a handsome man becoming obese on the only medications that have ever quelled his paranoia and voices. But giving up the story, if indeed he can, might allow something new and surprising to happen. Better treatments may come along; prolonged remission might allow more improvement than anyone expects; someone out there may be able to see the wonderful things about him and love him, illness and all. None of this can happen if he remains possessed by the predetermined story.

And what will happen to the "happy" second marriage of the professional man? Will his new wife finally chafe at her role as the pot of gold at the end of the rainbow? Will he see her as the full person she really is, fight with her, dislike aspects of her? If he can't, their real relationship will not develop, and they will continue to inhabit a script, which includes the first wife as evil sorceress. In essence, the man will have never really left his first marriage, because he has allowed it to continue as the dominant narrative of his relational life. His new wife will never surprise him, but will only play her part as an opposite to wife number one. 

And if the pothead intellectual never cleans up and tests his grandiosity in the real, sold-out world as it is given to him, he can remain safe in his unchallenged conviction of specialness even as he descends to even lower circles of addiction or stabilizes as an embittered, underachieving caricature of himself. The world will never be good enough for him. For the young waiter, leaving this story behind involves the risk of being ordinary, the necessity of compromise and false starts, both in relationships and with the larger social world. Cutting loose from the unsung genius is, however, his only chance at real fulfillment, real love, real mastery, transient and imperfect as they are. Will he remain forever deafened by his internal narcissistic applause?

, Italo Calvino carries narrative imprisonment to its logical conclusion in the mind of his elderly narrator.

Mr. Palomar decides that from now on he will act as if he were dead, to see how the world gets along without him. For some while he has realized that things between him and the world are no longer proceeding as they used to; before, they seemed to expect something of each other, he and the world; now he no longer recalls what there was to expect, good or bad, or why this expectation kept him in a perpetually agitated, anxious state

This is the most difficult step in learning how to be dead: To become convinced that your own life is a closed whole, all in the past, to which you can add nothing and can alter none of the relationships among the various elements...

But in the end Palomar/Calvino, old and decrepit as he is, just can't bear to smother himself with a completed story.

Therefore, Mr. Palomar prepares to become a grouchy dead man, reluctant to submit to the sentence to remain exactly as he is.

Irascible as ever, he remains open to the new until his life's last instant.

Now, one last story. A tired psychiatrist in his late 30s, despairing over the direction his profession has taken toward diagnostic and biological reductionism and away from the art of listening, begins to write about it. Through a series of coincidences, this writing is eventually published ("Is American Psychiatry Terminally Ill?" June 1993 

To the psychiatrist's surprise, an outpouring of letters from other clinicians in the trenches leads to his becoming a regular columnist. Over the ensuing decade, he is privileged to hold forth on a variety of subjects. He even collects and self-publishes some of these pieces.

But his lack of success in penetrating official psychiatry and influencing its course, the deepening eclipse of psychotherapy in everyday practice, the metastasizing regulatory and documentation requirements in community treatment, the dumbed-down world of mental health trade publishing--all of these things persuade him that he is back where he started, a self-appointed Voice Crying in the Wilderness. Telling his editor that he needs time off to teach, he privately resolves to quit the column. His operative story is that of Herman Melville retiring to the customs house after the failure of 

. Like Melville writing poetry at his desk and going through the motions of his mindless job, the psychiatrist will write prescriptions and check off boxes at the clinic, do a little therapy on the side, play guitar, sail his little boat, get the kids through college. Such is the narrative drift of "negative inflation," operating much as it does in the life of the young waiter above.

But in this case, the psychiatrist's own hope, flying below the radar of his despair, sabotages the airtight story. He hasn't officially quit the paper, and he has kept on perfunctorily sending his book around. Like Palomar, he is a grouchy dead man, refusing to quite lie still. One fine day, a call from a sympathetic publisher changes everything, and leads the psychiatrist, in his next column, to proffer another of his presumptuous definitions: hope (as opposed to the aspirations of the ego) is that part of the self that doesn't already know the end of the story.

And so, dear reader, "No Shows" is back for another round. I don't know for how long or to what effect, but I am too grouchy to be a dead man, and these pages will yet see more of me.

The patient, a young gay man who once lived for a time in Salt Lake City, describes his pursuers: Mormons who know where he is and are trying to kill him. As the clinic visit goes on, I see the doubt in his eyes when I explain my medication increase, and ask about it. He admits he can't be sure; his voices are saying that I'm a Mormon too. Only, with much persuasion and oversight will he comply with my prescription, because he trusts his case manager more than anyone else in the world.

End of Story

Portland, Maine, can now lay claim to another famous man. Like our poet Henry Wadsworth Longfellow, he was inclined to champion those dispossessed from ancestral homelands. And like Joshua Chamberlain, the theologian/general who won the battle of Gettysburg, he was an imaginative tactician with a fondness for scripture. He shopped in our Wal-Mart, ate at our Pizza Hut and slept at our Comfort Inn. His name was Mohamed Atta.

The stylish Atta was first spotted in late August by an observer I consider reliable. He was seen in the company of some regular Arabic-speaking customers at a local convenience store. Beyond that report, Atta sightings have multiplied, as always happens in the nascent phases of a myth. Waitresses are sure that they served him and librarians that he used our public library's computers several times. But this Egyptian lawyer's son had long before succumbed to the temptation of becoming something more (or less) than human. In methodically orchestrating the deadliest terrorist attack in American history, he became the latest incarnation of an archetype: the Devil to us, and (since the archetypal world is always and ever polarized) the great Martyred Hero to others. Carl Jung's term for Atta's fate was "identification with the collective psyche" (1967). In its grip, one becomes "the fortunate possessor of 

 great truth," manifesting "megalomania in thefamiliar form it takes in the reformer, the prophet, and the martyr." Jung had good reason to emphasize this particular pathology, having been himself taken in by it for a time in the guise of Adolf Hitler.

While Jan. 1, 2001, officially began the new millennium, Sept. 11, 2001, was our millennial event. The devil-hero Atta, like Hitler before him, embodies the "rough beast" that William Butler Yeats foretold, the one that "slouches toward Bethlehem to be born." Like the final, sudden crack of an earthquake, Sept. 11, 2001, was the result of powerful and unseen forces -- in this case, cultural forces -- whose shifting has been underway for many decades. These forces have been pushing what we psychiatrists sometimes call 

 away from historically recent developments in the direction of individuality and back toward more typical, collective forms. 

The Self, as we and our patients experience it, is not an immutable aspect of human nature whose basic form we can take for granted. In many important aspects this Self is a culturally determined phenomenon, and it has been changing  even during the brief time that psychodynamic psychiatrists have been around to describe it. And today, whether 21st-century humans memorize the Koran or wear Tommy Hilfiger jeans, they are increasingly defined by what they belong to and not what they uniquely and individually are. We are being subsumed into a world of collective symbols. It is fitting that Atta ate his last meal at Pizza Hut before he steered a jumbo jet into the World Trade Center. His world and ours is a world of brand names.

Some of us saw this new cultural context coming, but we are all, finally, surprised by it. Barely a century old, the tradition of psychodynamic psychotherapy -- by which I mean those therapies whose aim is to restore and develop the Self rather than only to modify behaviors -- now finds itself pivotally placed. Therapists occupy this position not only because of our various skills in treating anxiety and psychological trauma. Most fundamentally, we find ourselves here because we advocate for the healing potential of individuation. In doing so, we offer an alternative both to the rantings of Osama bin Laden and to the videos of Britney Spears.

We may debate whether or not the pursuit of uniqueness in helping individual patients to understand the themes and plots of their own lives has any ultimate value. We may even persuasively argue that the pursuit of uniqueness actually further alienates our patients from an increasingly collective world, leading them away from the comforts of fitting in. But we can't deny the fact that this pursuit is the foundation of our profession. Psychodynamic psychotherapy stands in opposition to the individual's imprisonment by any set of collective symbols that would wholly define his or her identity. Whether they are a response to material deprivation (radical Islam) or to toxic overabundance (MTV), we have learned that collective symbols, taken literally, impoverish the soul.

Writing in New York before the Trade Towers fell, the historian Jacques Barzun described in detail the course of a 500-year experiment in Western culture that was coming to a close as he worked. This experiment involved the development of individual selves on an unprecedented, mass scale. Its inaugural event, the one whose opposite bookend would prove to be the Sept. 11, 2001, disaster, was Martin Luther's challenge to the Catholic hierarchy: 95 propositions nailed to the church door in Wittenberg in 1517 that questioned the Church's right to determine the status of the individual before God. Luther's was a civilized kind of "attack" on another building that stood for the reigning power structure.

In medieval Europe until then, collectively defined human selves found their identities as part of something. Peasantry, clergy and noblemen all found their place in a putatively "divine" social scheme. An elite priesthood, literate in Latin, communicated the conventional behavioral prescriptions by means of images and icons, whose penultimate form was the didactic stained-glass window. These prescriptions included explanations of, and acceptable channels for, the various unruly human passions. For the most part, the illiterate masses complied, faithfully fulfilling their pre-ordained duties. The only alternative in their society was to be marginalized. But Luther's attack was emblematic -- like the earthquake's final crack -- of a cultural shift that had long been in process. Printing presses, literacy in vernacular languages, geographical mobility, growth of the money economy: all these conspired to give more and more opportunity to the autonomous, self-defining, questioning individual.

This historical process gathered momentum. By the 19th and 20th centuries in the West, vast numbers of adults were reading novels, poetry, history, science; they looked within themselves and recorded private reflections; they developed critical perspectives on their own societies; they sought personal meaning in their lives and engaged in the "pursuit of happiness." Apart from tiny, privileged minorities earlier in human history (Socrates' Athenian friends, Moli?re's court audiences), all of this was new. Psychotherapy, a child of the 20th century, brought the search for truth, beauty and the well-lived life out of the books and to the wide public in an immediate, interactive form: the dialogue between patient and therapist. Scientific reasoning, philosophical ideas and the narrative constructions of literature were brought to bear on the lives and problems of ordinary people in the consulting room. 

Although it was defined within society as a purchasable medical service, psychotherapy nevertheless encouraged patients to develop, from their emotional distress or their psychiatric symptoms, a critique of the social structures within which they, the patients, were embedded. And when this evolving insight went any further afield than the patient's family of origin, it was potentially subversive. And further afield it must go, for as Karen Horney (1937) recognized at the outset, our patients experience "the culturally determined difficulties in an accentuated form, mostly through the medium of childhood experiences." 

The hidden radicalism of traditional forms of psychotherapy lay in their attempt to cure by the development of awareness of social contexts; thus, freeing patients from the self-defining influence of those contexts. Jung called this attempt one at "wakening from the collective dream." Whether by untangling therapeutic transference, by re-examining the family of origin, or by looking at conflictual aspects of everyday life in the present, patients healed themselves by becoming different, unique. More than just wholly unconscious products of social influences, patients in therapy became independent selves able to reflect on those influences. Thus, in retrospect, psychotherapy can be seen as a final, democratic flowering of the Western experiment in individualism.

This idealized account belies the fact that it was ending even as it began. The same conditions that allowed psychotherapy to briefly flourish also incubated a powerful new influence toward conformity: the neo-feudal culture of the corporation, which, in all but name, replaced the nation-state as the dominant form of social organization by the late 20th century. Psychiatrists, whose working conditions are now structured by the corporate culture -- whether they practice in hospitals, clinics or private practices -- are entirely familiar with its constraints. Psychotherapy's subversive potential has been eviscerated by this culture, leaving short-term and medication-based approaches as the whole of mainstream mental health care. These approaches' avowed aim is the adaptation of the individual to the social status quo.

Some critics (notably the psychoanalyst Philip Cushman [1995]) even argue that much of the "high-end" traditional therapy that remains available functions as an unwitting accomplice of corporate culture. With its boutique-like focus on an ever-unsatisfied Self and its personal needs, a socially naive psychodynamic therapy may simply encourage patients to be good consumers. But corporate culture has a more direct servant, one whose evolution closely paralleled that of psychotherapy in the last century. Like psychotherapy, it too promised happiness. This was commercial advertising. Its genius lay in harnessing the individualistic impulse toward limitless choice and channeling it into collective forms of expression. These purchasable joys -- be they a mouthwash, a timeshare on some tropical beach or the newest anxiolytic -- are sold for their purported transformative or "therapeutic" results. Cushman ironically captures this in quoting an advertisement: "Thirty-nine flavors. Find yourself."

And so, long before Sept. 11, 2001, Western culture was already well on its way toward a new, secular medievalism. In this digital-electronic age our new icons are not stained-glass windows but TV commercials, corporate logos and clinical algorithms reproduced on PowerPoint slides. Our saints are TV and film celebrities, pop music stars, professional athletes (not the people themselves, but the images crafted for and superimposed upon them). Our secular priesthood's arcane literacy is not in Church Latin, but in what Jacques Barzun calls 

: the sciences that promise control of how information is transduced, be they computer programming, genetic engineering, marketing psychology -- or psychopharmacology. 

Thus, it makes perfect sense that the modern West finds among its final archenemies the radicalized wing of a resurgent religion that was born in the original Middle Ages and which only 50 years ago was thought by scholars to be an antiquated and dying faith. The Crusades metaphor, offered inadvertently by President Bush and seized upon by bin Laden and his allies, is more accurate than we would like to think. But now the West marches under the brand-name banners of globalization, not the Cross.

The potential role of psychotherapy in this polarized social context is best introduced by a poignant anecdote. A Washington, D.C., colleague of mine happened to have his car in the shop during the time of the September attacks and, depending on taxis to get around, found himself riding to work with a bearded Afghani driver. The driver had hung rosary beads from the mirror and an American flag from the turn-signal rod, as if these symbols could counteract the sudden symbolism of his own appearance. Together they listened to the ongoing radio news. At the end of his ride, my friend asked the driver, "How's it goingyou know, with the rosary beads and the flag?" The driver replied quietly, "Pretty good, so far."

The connection these two men had was made possible by a spontaneous act of psychotherapy. Both became aware, as individuals, of their mutual victimization by the black-and-white tyranny of collective symbols. Each saw the other as a vulnerable human being. For an instant they became a conscious community of two selves: I and Thou commiserating over the idling of a taxicab.

Around them, the rough beast slouches forward; the human psyche stands poised to enter another cycle of possession by archetypal dominants. The very possibility of a conscious, reflective community, which our fledgling tradition has helped to create, offers a flickering hope. We psychotherapists are among those whose job it will be to guard and carry forward that hope.

 Cushman P (1995), Constructing the Self, Constructing America: A Cultural History of Psychotherapy. Boston: Addison-Wesley Pub.
 

 Horney K (1937), The Neurotic Personality of Our Time. New York: W.W. Norton.
 

 Jung CG (1967), Two Essays on Analytical Psychology (Collected Works of C.G. Jung, Vol. 7), Adler G, ed., Hull RF, trans. Princeton, N.J.: Princeton University Press.

Psychodynamic concepts such as the Self and the collective unconscious are helpful in understanding "our millennial event"3/4Sept. 11, 2001. Because it aims to help patients become aware of and free themselves from social contexts, psychotherapy may be more useful than ever.

Psychotherapy After Mohamed Atta

The mainstream of our profession has ceased paying much formal attention to the help our patients get from the doctor-patient relationship itself. But patients are stubborn. They still expect to have helpful relationships with us! Witness the ill-informed boyfriend of a public-clinic patient who asked me, at the close of a medication visit, "But when is she going to see a psychiatrist? She has things to talk about!" Equally disturbing was the well-meaning enthusiasm of a young psychiatrist interviewing for work at the same facility when I told him that I use my psychotherapy training in many a patient encounter there. "Oh, like if there's time, you might do a little cognitive therapy on 'em?"

We psychotherapists have ourselves to blame for this state of affairs, having husbanded our subspecialty's development in two narrow directions while psychopharmacology and neuroscience have dramatically broadened their own worldviews. Some of us have manualized and proceduralized psychotherapy (or rather, certain psychotherapies) in imitation of procedural, technology-driven medicine, so as to be good citizens in the world of indications, interventions and outcomes. Most new psychiatrists have had some exposure to these techniques, but few seem inspired by them.

Another potentially influential group has circled the wagons for psychoanalysis and psychodynamic therapy. The large body of literature this group continues to generate takes many fascinating forms, from the quasi-literary to the quasi-neurological, but few psychiatrists-in-training read it.

Neither of these two currents in psychotherapy convincingly illuminate, or render more effective, our work with the entire spectrum of patients we see in everyday general psychiatric practice.

What sense can we possibly expect our trainees to make of this Tower of Babel? Unless they are unusually persistent, they will either stick to the 

 and the meds and/or develop their own ways of conceptualizing personality and human nature, often with the help of pop psychology or New Age spirituality. In both cases, this dooms them to repeat sundry mistakes of the past, because an intellectually rigorous psychology of relationship, cognizant of boundaries and power arrangements, is missing. Should those of us who still try to teach psychotherapy in this inhospitable clime simply accept that the next generation will have to reinvent the wheel, or can we do any better for them?

We can, and it isn't all that hard. A global overview of the psychotherapeutic enterprise, based not upon theory but upon what therapists actually do, is easy to provide and reveals that there are really only three kinds of psychotherapy. I will begin my description with the rather typical odyssey of a real patient at a residency training program.

This patient's prolonged panic attack began when her mother arrived from out-of-state at the local bus terminal in a hospital johnny, seeking her care. Unable to cope, the patient was brought to the emergency department by her husband. She was so desperately anxious as to admit to suicidal ideation: the "Open sesame!" of our triage culture. At age 31, this secured her first psychiatric hospitalization and evaluation.

The patient settled down quickly with the help of anxiolytics and an alternative placement for her regressed, mentally ill mother. But during her brief stay, an alert inpatient resident noticed that she engaged in several classic compulsive rituals, including much hand-washing and showering. Referral was made for outpatient psychotherapy with another resident who would obtain supervision in the cognitive-behavioral treatment (CBT) of obsessive-compulsive disorder (OCD) in addition to the usual medication trials.

The outpatient resident got more than he had bargained for. It was difficult for him to concentrate on response-prevention and thought-stopping techniques under the silent, watchful eye of the patient's husband -- and she insisted upon his presence in order to "feel comfortable." The resident kept trying, and one day when the husband had to leave the session early, the patient volunteered that in her own mind, the pervasive sense of dirtiness that kept her always washing had something to do with repeated episodes of sexual abuse by her mother in childhood. There was also fear of retribution by her mother for "not being a good girl," which transferred in the present to her husband. His idea of good behavior was that she never leave their apartment alone.

It became clear to this intelligent resident that, beyond the illness dimension of Axis I OCD, a relational dimension would have to be entered to treat this patient successfully. A newcomer to the incoherent shipwreck of non-psychopharmacological psychiatry, he understandably groped for some of the remaining scraps of a psychological outlook that are still afloat. Childhood trauma...pathological dependence...Axis II borderline personality disorder (BPD)? Well, close enough to try dialectical-behavior therapy (DBT), opined the supervisor.

And so, aided by the husband's periodic departures after check-in, the resident soldiered on with chain analyses of anxious thoughts and other such techniques in a DBT-like individual therapy (the skills classes, of course, were unacceptably anxiety-provoking). Eventually the patient stopped coming, and when the resident finally called, she told him that she was afraid she would always be a disappointment to him and was wasting his valuable time. Could she see the hospital resident who had originally admitted her, "just to talk?"

To the second resident's chagrin, the patient proceeded to settle in comfortably with the original resident, attending regularly although she (the hospital resident) was even more of a therapeutic neophyte and knew no specific techniques. In fact, she said, "I have no idea what I'm doing!" But she is clearly doing something specifically effective for the first goal of any therapy: keeping the patient in the room. The patient is comfortable enough to dispense with the husband's presence. A second "safe place" is emerging that can compete with the safety of the husband's total control, and within which she can begin to take possession of herself.

We can imagine where things might go from here if the utilization reviewers are kept at bay. Perhaps patient and resident (or the resident's successor) will feel ready to retry the response-prevention strategies that failed at first, building on the strength of a working relationship. Or perhaps they will work directly on that relationship itself, when the idealized "safe" therapist inevitably falls from grace and disappoints (or enrages) the patient. Ideally, the patient will eventually work on both behavior and relationship, although not necessarily with the same therapist.

This patient exemplifies the everyday complexity of the real-world population psychiatrists treat. Hers is not a pure form of a 

-described illness that dutifully improves like the cases in academic studies ("OCD+CBT=OK," "BPD+DBT=OK" and so on, as I like to joke). Instead, she is the usual biopsychosocial layer cake (Table 1) of Axis I syndrome (bio-), relational disturbance (psycho-) and developmental damage (-social). Because of this, benign power -- here, the doctor who tries to do response-prevention -- is not a viable reality for her. Before she can get help, she needs help with getting help. And that is what the resident who "doesn't know what she's doing" is giving the patient.

In the real world of clinical practice, based not on theory but on the unspoken power narrative embedded in the therapeutic relationship, there are only three kinds of therapy (Table 2): supportive, directive and relational. Our patient began her odyssey in the directive column, where most contemporary psychiatric treatment starts, first with the CBT, then DBT. When she came back, it was to the supportive column, albeit to a therapist who had not yet learned its language. If all goes well, she will finish in the relational column, probably availing herself again of directive techniques along the way.

The underlying premises of each kind of therapy establish a power structure within doctor-patient relationships -- a structure that doctors may not have thought through in advance and that they might not endorse if they had. With deliberate exaggeration, therefore, let me explicitly voice the power narrative of each of these three forms of therapy to show the differences between them. 

When I speak of power, I refer to the therapist's power to define the nature of reality. Thus, in directive therapies, the unspoken narrative is, "I, the therapist, am powerful and know what is or isn't dangerous [in anxiety disorders], is or isn't negativistic [depression], is or isn't real [psychosis]. I know the diagnosis and causes of your illness, and I direct you to change your thoughts/feelings in the following way," and so on.

Such a narrative reiterates the existing social status quo and asks the patient to adjust to it. This is often a good and necessary thing, as with a potentially violent paranoid man in the emergency department, or a widowed woman whose grief has extended into major depression. But because many damaged patients are unable to let themselves be helped by a benign authority -- unable, in D.W. Winnicott's words, to "use the object" -- directive therapies don't work as often as their academic proponents would like to think.

While the supportive therapies are centered on the person rather than the symptoms, their power narrative has a remarkable underlying similarity to that of their directive cousins. "I, the therapist, am powerful-powerful enough to keep the world at bay. I will create the environment and give you the nurturance that you need. Let yourself unfold under my protection, bask in my empathy," and so on.

Instead of actively reinforcing the social status quo, this narrative provides the patient a temporary respite from it. Once again, this is often a good and necessary ("indicated") thing, as in the resident's case presented earlier. I want to stress, though, that it is a technical approach in that it purports to know what is wrong -- environmental stresses, developmental deficits from childhood -- and to be able to ameliorate or correct it through consciously (even if intuitively) modulated enactments on the part of the therapist. In comparison to directive therapy, the harsh diagnostic language is muffled and there is some implicit faith in an intrinsic healing process, which supportive therapy tries, indeed, to support. But the power arrangement in which a knowing therapist administers techniques to a malfunctioning patient remains the same. I maintain that this is even true of Kohutian self-psychology, which has developed a rich and beautiful theoretical language to describe its own version of supportive therapy. Such language does not change the fact that the therapist largely defines the nature of reality -- an arrangement much more obvious and above-board in the less humanistically couched directive therapies. Of course, what the experienced practitioners from any well-established school of psychotherapy actually do is likely to span all three of the types of therapy in this classification scheme at some time or another; it is only either very new, or very partisan, practitioners who refuse to adapt their behavior to the needs of a reasonable range of patients.

Dr. Genova offers the antidote to the complexities of manualized and proceduralized psychotherapy that have arisen in imitation of procedural, technology-driven medicine. Supportive, directive and relational types of therapy and their correlation with various power structures within the doctor-patient relationship are described.

Author | Paul Genova, MD

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