Peter L. Giovacchini, MD

In recent years, psychiatry and psychoanalysis have been drifting apart. As has been stated, psychiatry is losing its mind as it concentrates on chemistry and biology. This is a pity, because it is always good to have a mind.

Psychoanalysis' unique contribution is its adherence to the belief that patients' behavior, attitudes and feelings are meaningful even when they appear to be most irrational. The intrapsychic focus stresses unconscious motivation, which means that the causes of emotional disturbances frequently stem from inner sources. To some degree, it assumes that patients are the masters of their own destiny, that they are not just the hapless victims of cruel circumstances. This means that, in most instances, there is a potential for control and this leads to the hope that emotional equilibrium can be established.

Moving away from the intrapsychic focus takes us into the realm of biology and neurochemistry, areas that are making significant advances. Unfortunately this movement has led to a polarization between the inner workings of the mind from a psychological perspective and external traumas as they impact on the brain. The brain and the mind have once again become separated, leading to a Cartesian dualism that in the past had been considered naive and anachronistic.

History is repeating itself. In the first decade of this century, psychodynamic explorations and the intrapsychic origin of emotional disorders were gaining acceptance by psychoanalysts and some prominent psychiatrists. Patients suffering from what was then called general paralysis of the insane or paresis, a sizable group of hospitalized patients, brought forth considerable primary process material and were being studied from a psychological perspective. The hopes these pursuits engendered were abruptly shattered when the Japanese bacteriologist Noguchi discovered the organism treponema palidum, a spirochete, to be the causative agent of what proved to be syphilis of the brain and the cause of general paresis. The efforts of investigators intensified in their pursuit of organic causes for other emotional entities, particularly psychoses. Their biological orientations led to the discovery of electric and insulin shock therapies.

Nevertheless, there was a slow and gradual ascendancy of psychodynamic thinking reaching its apogee shortly after the end of World War II. Then something similar to Noguchi's discovery happened; chlorpromazine was synthesized. Now we had a monumental breakthrough, a magical cure for psychoses, that rivaled the importance of penicillin and reinforced the search for organic etiologies. Since then there has been a continuous outpouring of drugs that are more or less effective in controlling behavior and symptomatic expression.

Psychopharmacological, somatic, behavioral and cognitive approaches assume a simple linear etiological sequence. They may achieve symptomatic control and restore functioning, but changes are restricted to the surface of the personality and ignore the subtle aspects of deeper psychic elements. Improvement, if it occurs, is often at the expense of the patient's fundamental humanity and the obliteration of autonomy.

The decline of the intrapsychic focus seems to be associated with a certain notable deterioration of Western civilization. Most inner cities have become jungles, as murder, rape and incest are so commonplace that most of us are no longer shocked by the prevalence of such crimes. There has been a notable increase in the divorce rate, the number of dysfunctional families as well as many reported cases of sexual and physical abuse. Many of our elementary and high schools are in shambles, and the pursuit of learning and aesthetic goals has in many segments of our society practically disappeared.Reflection, introspection, contemplation and even empathy have been shoved aside in favor of action which often escalates to violence. Ours is a materialistic concrete society, and our approaches to mental illness seem to be a reflection of the decline of values as exemplified by current mechanistic outlooks.

Today, problems have to be quickly resolved with computer-like speed. Subtle complexities are avoided, and solutions with "how-to" clarity and simplicity are eagerly sought.

Medicine and mental health are to a large measure in the hands of laymen or, more aptly stated, businessmen. Their motives are based on profits rather than healing and humanistic values. To some degree they have succeeded in infusing their values into our profession as evidenced by the many doctors who seek simple cause-and-effect sequences and quick cures.

Untrained and lay practitioners have also invaded our areas of endeavor, leading to an abundance of simplistic procedures and sheer incompetence when dealing with sensitive, vulnerable psyches that are immersed in misery and desperately seeking help. In many instances they are met with a mechanistic approach and formulaic procedures.

What most therapeutic approaches have in common is that they do not have an intrapsychic focus. In fact, in some cognitive therapies the inner life of the psyche is assiduously avoided. Their aims are limited to behavioral control.

Our therapeutic perspective aimed at behavioral manipulation should not be taken for granted. Some clinicians are concerned about "psychiatry losing its mind" as well as the violence and insanity that keeps escalating in our society which, in some ways, may be connected with the decline of the intrapsychic focus.

Although many patients are products of their culture and seek instant relief, there are others who cannot accept superficial solutions and do not want to relinquish symptomatic adaptations until basic issues are resolved.

For example, a single man in his early 30s was hospitalized because his auditory hallucinations became disruptive. He had heard voices since adolescence. He did not tell anyone about hearing disembodied voices because he was afraid he would be judged insane.

He lived alone and had practically no social relationships. His only contact was an older brother who lived in another city with whom he occasionally corresponded or talked on the telephone.

At work he was also isolated, but very highly respected. In fact, he was considered a wizard in programming computers. His work consisted of solving complicated technical problems. His employers would present him with a problem and then leave him alone until he solved it, which he invariably did. He had virtually no contact with his fellow employees, his office and lab being in an isolated section of the building,	and he was pleased with this arrangement. 

His life outside of work was also quite constricted. He went to the movies almost every evening and he saw a psychiatrist once a week. He read Variety and had amassed considerable knowledge about the cinema and knew a good deal about the personal lives of movie stars. He would sometimes talk about such topics with his brother, usually on the telephone.

He saw a psychiatrist because he felt lonely and depressed and he wanted to have a person to whom he could confide about hearing voices. The psychiatrist put him on an antidepressant and a phenothiazine, both of which had little effect on him. Later when I saw him he stated that the drugs made him feel "emotionally stiffer than usual." The interpersonal aspects of the therapeutic relationship were sparse. His therapist made many suggestions urging him to socialize and frequently gave him advice. The patient paid lip-service to what he was told but did absolutely nothing to change his circumstances and to heed the advice he was so freely given, but he never missed an appointment and was always on time for his sessions.

Life went on following a fixed routine and allowing no variability until he made a particularly important discovery. As a result of his work, his employer promoted him and gave him a raise. The promotion meant he had to have more contact with fellow employees and those that were designated as his subordinates. Rather than feeling pleased with his achievements, he had a psychotic decompensation.

The voices that had engaged him in conversation now became threatening and accusatory. They reviled him as being wicked and worthless and vowed that eventually they were going to tear him apart limb by limb. He suffered intense panic and had to be hospitalized.

After two weeks the patient was put on a moderately heavy dose of haloperidol (Haldol). His hallucinations completely disappeared and his mood stabilized. While in the hospital, he negotiated with his immediate superior to go back to his old office job. His brother arranged for his discharge and stayed with him for a week after he left the hospital. He also arranged for him to see me, feeling adamant that the patient not return to his former psychiatrist.

During our first session, he ironically remarked that he was cured, because that was what he was told at the hospital. He confirmed that he no longer heard voices but, oddly enough, he wanted them back.

I learned that as a child of two elderly parents, he felt very much alone. No one ever talked to him. His much-older brother was in college and usually not available to him. He was devoid of companionship and because he did not develop any social skills and was awkward and clumsy, he made no friends. The only attention he received was from his teachers, because he was bright and an easy learner. His peers viewed him as somewhat peculiar but they did not make fun of him; they simply ignored him and the patient learned to adapt by living within himself.

He made up stories and plots and became part of the script, many being borrowed from the numerous movies he saw. During adolescence he talked to the characters he created and they began talking back to him. Soon, what were thoughts were heard as voices, either within the context of a story or fantasy, or just as another person having a conversation. He heard them with hallucinatory clarity and they seemed to fill a void.

Inasmuch as he felt miserable because he missed the voices, I suggested that he discontinue Haldol and that he could talk to me. Gradually the voices returned, but they were benign as they had previously been. I made few comments about the voices, except that he needed them and they gave him solace. In the meantime, I focused my attention on his inner life, his isolation and anxiety about making friends and moving into the external world because he felt inadequate and did not learn the adaptive skills to cope with his social milieu. He constructed schizoid defenses and created his own universe with his plots, fantasies and auditory hallucinations.

He was able to achieve his pre-hospitalization equilibrium when he stopped taking Haldol. External stresses had been reduced when his employer agreed to let him return to his old isolated office. I conjecture, however, that our relationship also contributed to his stability, because I was paying attention to him as a person as I was attempting to understand how his mind worked rather than restricting my attention to surface phenomena such as his hallucinations and lack of social involvement.

Slowly, he experimented in socializing. He increased his contacts with his brother and joined a computer club. The voices lost their significance, and his need to make up plots and fantasize diminished as he became more engaged with the real world.

Explorations of patients' psychodynamics as they determine current adjustments and symptom formation is much more interesting and fulfilling than monitoring surface behavior. Mental processes are innately fascinating and their study creates dimensions and viewpoints that expand our appreciation of the versatility of the psyche as our in-depth understanding is increased, in itself, an aesthetic experience.

I believe all psychiatrists can benefit from an adherence to the psychodynamic viewpoint. Patients are not just machines that can be regulated with drugs or behavioral manipulation. They have minds that are craving to be understood; they are looking for someone to make sense out of what appears senseless. For the general psychiatrist who is aware of some psychoanalytic principles, particularly unconscious motivation, that is the essence of the intrapsychic focus; their patients are transformed into interesting human beings rather than the passive recipients of pharmacological ministrations. How the treatment procedure fits into the therapeutic relationship is taken into account, enabling patients to pursue autonomy and mastery of their emotions. This is enhancing for both patient and therapist.

Author | Peter L. Giovacchini, MD

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