As I wrote last summer, Sandor Ferenczi famously started off an entry in his clinical journal pondering this issue: "Why then should [the patient] place himself blindly in the power of the doctor? Is it not possible, or even probable, that a doctor who has not been well analyzed (and who is well analyzed?) will not cure me, but instead will act out his own neurosis or psychosis." (Ferenczi, 1932, p. 93). He then goes on to criticize Freudian psychoanalysis as becoming impersonal and intellectual.
He then iterates what many know: therapy is not a Jeffersonian democracy, where the patient is free to react to the therapist in a critical fashion. "A patient is quite justified in describing part of the behavior of such an analyst as crazy. Certain of the doctor's theories (delusions) may not be challenged, if one does...then one is a bad pupil...gets a bad grade...in a state of resistance." (Ferenczi, 1932, p. 94).
How much more so it it now, over 80 years since Ferenczi wrote such? Now in America, insurance rules the roost and demands that therapy be short-term and focussed on symptoms. Cognitive-behavioral and dialectial-behavioral are reimbursable, because they lend themselves to short-term, intellectualized solutions. Insurance demands pharmaceutical solutions, even though there is no proof that anyone was ever healed by a pill. Psychologists have sold out to suck from the teat of the insurance-industrial complex, never questioning who is the real villian here--CEOs who make over $500 million/year by rationing treatment, with absolutely no evidence based platform to cite, or the psychologists who knuckle over, or, quit insurance panels and go total free market, believing themselves to be charitable at accepting a low fee of $150/session. (Please don't tell me about your student loans, your office rents, etc--I too had to pay off student loans. I worked for a public hospital for the Guiliani years, where he ridiculed the idea of public service and refused us raises for most of his tenure. I have chosen a path where I do not have to be dependent on patient fees to earn a decent living--not lucrative--but comfortable).
Alas, I digress. Es tut mir leider. Ach, here I am, engrossed in my German comedies. Alright, I'm back.
No one is healed with a timer and a pill. I have reviewed thousands of psychotherapy cases. Invariably, month after the month, the patient says they are still depressed. Invariably, the psychiatrist, barely looking up from the prescription pad, either ups the dosage or changes the meds. Sometimes both--upping the dosage and adding a new med. Why do none think to ask: If you want your life to be different, you have to be different. You have to change your life. What can you change about your life that might make your mood improve in the coming week? What do you imagine your life would be like if you weren't depressed?" When a patient comes in after all, and says they have been depressed all their life--depression is all they know. Pills can change internal feelings, increase energy, sedate, calm. Now that the mood is different--how can you become different. Can you imagine yourself happy?
But this would be a sea change so you would SEE change. Psychiatrists would have to engage with patients in a socratic dialogue, alien to the "side effects, mental status evaluation" checklist sort of session. Alien to the "review of systems...head--normacephalic....no apparent distress....perception...intact" 15 minute session. Psychiatrists would have to educate the patient about the limits of medications and the long-term, systemic damage that medications bring--diabetes, kidney, liver, heart damage. They would have to listen to the patient. Absorb the the very real pains of urban life--poverty, rape, homelessness, alcoholism, substance abuse, food insecurity. The psychiatrists have no solutions to these pains. DBT/CBT have no solutions to these pains. All psychiatrists can do is offer potions. All therapists can do is offer mental tools to face naked the hard facts of American life: no one has a real solution. These tools will not necessarily give you better housing or better relationships. These tools do not give you vocational skills. Or literacy skills. Using these tools will not solve the very real subpar struggles of the underclass.
If you want your life to be different, you have to become....different. If taking potions helps to transform you---that's great. Facilitating becoming through modern chemistry is no sin. But becoming different is not the same as being happier. Or less anxious. In fact, now that you view the world through reality testing eyes, you may more accurately perceive the callous indifference of your treating professionals.
What psychiatrists don't talk about is healing. Pills create a path to healing--the patient has to travel the path. Healing is not a la mode these days. Probably Georg Groddeck, friend of Ferenczi, was the last to talk of such. Groddeck wrote a book in the 1920's called, "The Seelensucher," (Soul Searcher). Groddeck was also b-sh** crazy, but even the broken clock was right a twice a day. He encouraged the learning of what we now call, "Lamaze" method back in the day. He ran a fat farm in Baden-Baden filled with rigorous exercise, rigorous massages, and rigorous starvation (thin slice of bread, one egg, black coffee for breakfast).
Yet, he was such a life force that people came back, summer after summer to endure him.
Why then do our patients come in month after month, complaining they are still depressed, they are suffering from a lack of autonomy over their own mental health. Is the psychiatrist a life force? Or, are they they are looking to force the doctor to take responsibility for their life. If they don't feel better, it is the fault of the potion, not the person. Perakes (2010) refers to this as a "soul sickness." Patients come in with vague depressive symptoms--physical pains, problems falling asleep, anhedonia, headaches. Well, isn't this the human condition? What is keeping you awake. What is your body trying to remember? The body needs to heal through remembering, through verbalizing the somatic complaint. Certes it is that adding new pains via medication side effects is only making depression into the 21th Century version of an old Jewish Joke:
"A poor man living in the shtetl sought his rebbe's advice. 'Rebbe, my life is terrible. All day long, my wife and my daughters bicker, bicker, bicker. I have no peace. What should I do?'
The rebbe said, 'Do you have any chickens?'
The man replied, 'Certainly.' The rebbe advised him to move the chickens into the house with them. The next day, the man now complains about the noise not only from the family, but from the chickens. And the smell. And the poop. The rebbe now advises him to move the goats in as well. The next day, more complaints. Now he is told the move the cows in. And of course, life is total hell. So, the rebbe says, 'Well, put the cows in the barn.' The day after, the goats. The day after, the chickens. So when all the animals are back in the barn, the man returns smiling, 'Oy rebbe, such a simcha! It's so quiet and pleasant in my house, now that it's just my family and me.'"
Only removing the medication is not as easy as removing barnyard animals.