“The Master-Word is Work”. Osler. I remember studying Buddhism where work was called Dharma. Dharma was a central form of prayer. I struggled always in marriage with the balance of love and work. I lost my first marriage in some part by choosing work as I lost my second marriage in choosing love.. I was lost when I found my work colliding outright with my third marriage. All the oaths I’d taken, now considered so out dated and quite silly by the ruling party set.
“It’s just a job,” the police doctor said.
That’s when overnight the profession was destroyed. We were now just ‘health care workers’ .Government lawyers and beurocrats re wrote the codes that had once been part of the ancient order created by the Guild not by these Johnny Come Lately temporary masters.
I’d lost the love of my life because I couldn’t adapt to the plunge that came with the new government’s view of medicine as merely a ‘commodity’. The patient overnight became a client and now was but a customer. We were told to ‘act like doctors’ because that ‘sold’ the brand’. Not “be a doctor.” The teachers were no longer wise but very clever and idealogical. We were to be ‘posers’
I was afraid. Old and out maneuvered. My interest had been in developing a technique to address personality disorders. Personality disorders were my interest. Specifically borderline personality disorders. Then later PTSD, head injury and addictions. Addictions were like a chemical head injury more subtle than the more obvious mechanical head injury. The technique of therapeutic alliance and change had failed with analytic and cognitive processes, especially anything that suggested superiority.
Freud postulated the disturbance lay in the anal developmental stage, what Erickson would associate with struggle for autonomy. Others felt the ‘fixation’ or ‘entanglement’ occurred later in stages of adolescence:leaving home, forming same sex friendship, then mixed sex friends hip then recreating a new home. It was in those areas of development that emotional growth seemed to arrest.
Having musical training and experience I found I could hear the age of the trauma or the failure to develop in the tonal nature of the voice. A child like sound that was pained as opposed to pleasant. Coupled with other indicators of behaviour exploration of this almost invariably disclosed what might be characterized as blockage. From there asking about ‘what when wrong when you were 12 or 15 or 17? would result in an outpouring.
I early described insight psychotherapy as best described like addressing a log jam on the river. In northern Canada I’d seen a man dancing across the logs until he identified the key log. Once this was moved it a allowed the whole collection of logs to flow on down to the sea. Learning from my most adept mentors ,and I really was blessed to train with and observe some of the most gifted, I saw this image best described the process. After, another log jam might form further down the river but more often than not it just didn’t get that entangled. Perhaps the patient learned how to slow the stream or react more quickly to the beginning of the process. Yet it really didn’t matter. Brief focal therapy spoke to the process. It also explained why some only needed a discrete psychotherapeutic intervention while others returned time and again. Some jams took longer to untangle.. The logs, of course, represented emotional baggage, in the parlance of the day.
The government mental health success rate even in engaging patients was less than 30%. Having studied community medicine, public health and public health research, mental health services were decades behind the approaches used with physical health. Cameron’s watershed book on psychotherapies documented the evidence based approaches in psychiatry Still it was utterly by the single party insurance program of government funded medicine.
Ultimately Cognitive Behaviour Therapy, a kind of crude education package coupled with mental massage took over from the standard Rogerian mental massage of the time. Both therapeutic strategies popular with generalists and counselors had the benefit that they were no more likely to do harm than physical massage however they were wholly unlike the advanced form of psychotherapies. The latter carried with them the requirement for extensive training and the real prospect of causing harm.
I trained in analytic approaches which had proved, despite extensive trials, inadequate in the treatment of addiction. They had been beneficial for borderline personality disorder and PTSD. Analytic therapy is the most passive therapeutic model. Frankly the best therapists are intensively aware while the worst are planning their shopping list. Supposedly outcome analysis should decide what a person was doing. However in government services there was really little accountability. In private therapy the patient lacking change would wonder about the financial loss. Free psychotherapy was least likely to be effective as studied in Texas where the best results were achieved when patients had to pay a portion of the service. The Canadian government has consistently remained unscientific and mired in ‘free stuff’ thinking for ‘vote buying’ which limits greatly the efficacy of medicine. The rate limiting step is the mediocre and most fearful, ‘people pleasers’ by definition.
I trained as hypnotist and actually hypnotized people for surgery as well as doing extensive hypnotherapy at one time. This form of therapy has the therapist the exact opposite of the passive analytic therapist The hypnotist is the most active of therapists. As an analytic therapist.I had tapes in which I never spoke and judged my therapy by the infrequency of my speech. The best therapy by this calculation was often only one line while the patient spoke freely.
I recently spoke with a government general practitioner who was utterly ignorant of ‘art’, ‘science’ , history, or ‘technique’ of psychotherapy. They were so ‘loud’ in their ‘counter transference, their ‘controlling fear based need’ and ‘dominance issues’ oozing out of them. They had only trained in the “Parent child” modality of counselling. In psychiatry which requires anywhere from 4 to 8 years of training in psychotherapy this monkey approach is called ‘me Tarzan you jane’ “My brain good. Your brain bad.” “Me talk to you, make your brain good.” “Me feed you, give you pill.”
The pharmaceutical industry loved CBT or cognitive behavioural therapy because it fit this ‘parent child’ “doctor patient model’ in which the role of the doctor as parent feeds the child patient pills. I remember when I began as a family physician to do psychotherapy I had such difficulty dropping all the caregiver modality I’d learned for general medicine this ‘doctor child’ care giver modality to become a useful psychotherapist for my patient. The patient meanwhile wants to be ‘fed’ and to be fed in the ‘set’ way which they’re learned in a multitude of transaction. The Judgemental GP talked exactly as the ‘good mother’ to the patient having never been training in ‘counter transference manipulation’ The patient was adept at ‘seducing’ ‘good mothers and hated hers and his but the arrogant can’t learn from this. Not in their weeks or months of counselling training and their superiority due to ‘position prestige’. Psychotherapy is humbling. It’s a struggle. The patient is sick and the therapist allies with the healthy ego to struggle with the behaviours , coping strategies, which the patient persists in clinging to despite these now threatening to kill them. The GP had obviously only talked to a very few suicidal patients. Among psychiatrists we judge each other by our ability to talk a patient off the ledge not just once but over and over and over again, like the cancer surgeon. I doubt she’d ever lost one or accepted that her lack of skill had caused the death. As a junior clinician she’d not had the experience that humbles as truly as death. Death is a numbers game, like gambling. You can have a winning streak as a beginner then the suicidal change to impossible to reach or you get bored and move to the big stakes games. In psychiatry this is in the area of psychopathy with psychosomatic medicine complicated by addiction. Three and even 4 dimensional chess at it’s finest. Dancing with the devil. Sailing in a storm, keeping the boat a float and edging out of the Center of the fury.
There are great general practitioner psychotherapists just like their are great general practitioner surgeons but no general practitioner can be great if they don’t appreciate the experience and training that comes with specialization. Only the police doctors can have the arrogance of fools.
Unfortunately in recent years the failure of the legal paradigm has lead to the increasing spread of the even cruder ‘arbitration model’ with the doctor who wants to be rich imitating the lawyer or beurocrat as carefully as possible so as not to threaten these characters despareate for control. These arbitration models work for the in tact. There’s a safety for all in the retreat to the rational space far from the centre of the psychotherapeutic encounter.
The psychotherapeutic encounter is every moment for the psychiatric psychotherapist. In the medical model there is the aloof doctor observing the patient like the old physicists observed the experiment. But the psychiatrist patient is the experience. From the moment of contact it’s a transference counter transference dance and the healing begins. My surgical teachers taught me that the essence of surgery was the holding of the scalpel just as my psychiatric psychotherapy treachers taught me it was the ‘greeting’, the ‘eye contact’ , the choice of ‘questions’. Psychotherapy was sacred. It was zen. It was this living thing that is now packaged by a factor as a commodity and they want to sell it as a commodity. These very grandiose servants of the regime want power and power alone and want to destroy the guild so they don’t acknowledge the guild or experience of the guild or the rules of the guild. They aren’t even unionized and long stopped being professional in all but appearance.
In contrast to the passive therapist model or the ‘counselling’ model which only worked when the patient was in the ‘action’ phase of therapy, as motivation therapy and prochaska showed, hypnosis actually ‘cured’ addiction and helped PTSD.” Transactional analysis was indeed the only ‘group therapy’ model that really worked prior to DBT, which interestingly, is a ‘socratic’ model came along. In Transactional analysis and the DBT and indeed in the other successful model for addiction ‘motivational therapy’ the patient and the therapist are more closely aligned. The countertransference and transference is more brotherly or sisterly than parental. Facilitate rather than directive but these words don’t catch the soul of the matter even. Reading Freud and Jung therapy notes in the original translations. Reading Ericksons case notes. This is where the understanding begins. These were the explorers. The classic ‘the Discovery of the Unconscious’ speaks to the unknown and mystery that now is taken for granted peppered as the terrain is today with neon signs.
The counter transference position of ‘parent child’ essential to surgeon and hypnosis and even with the ‘withholding observing frustrating ‘analytic therapist is more ‘brotherly or sisterly’ in the transactional, motivational and DBT.
The 12 step facilitation model which has had the greatest success of all the models is the most ‘equal’ of all , best described as a ‘peer support.
Interestingly the extensive work with PTSD showed that a person who had been in war was more able to help another vet than all the textbook gurus put together. With addiction where the block may be in early adolescence the patient is very adept at ‘behaving ‘ and ‘apperances’ having long ‘concealed’ everything from parents, bosses and therapists. They are the great chameleons.
The therapy of 12 step facilitation caries a ‘qualifying component’. In meetings the night’s chair must self disclose sufficient to be accepted as ‘one of the group. This is the same with PTSD otherwise the ‘defences’ or walls go up. One acutely suicidal patient walked into a visit with an addiction doctor who told him then that he’d shot both thighs full of opiates before medical visits. The patient walked out of that session and did not kill himself because the therapist had not judged or shamed him, which is an experience all addicts and trauma sufferers share. The problem in PTSD is not the trauma but the ‘failure’ and ‘guilt’ .Only when the ‘failure’ and ‘guilt’ are addressed can therapy be said to begin. To even understand the idea of ‘therapy beginning’ a person really needs to read ‘portnoy’s complaint’. The therapist is engaged from the first second of encounter but the patient may only to appear to be in therapy while not at all being in therapy for weeks or months. Prochaskas stages of change crudely but brilliantly breaks this up in greats swaths called pre contemplation, contemplation, determination and action. This occurs week to week between therapeutic sessions and depending on the length of time between visits, (original psychotherapy described daily therapy ,now only possible in inpatient laboratories) may begin again every psychotherapy sessions. Further today’s ‘team approach’ with the psychiatric psychotherapist’ being responsible for the ‘magic medicaiton’ while a host of others do other things , the real trick is to expose the wound in such a way that this abscesses can be drained by others who can triangular anger and fear to the psychiatrist but heal through the work of the team. Much of the entrenched illness noted in personality disorders and addiction was fear based rage and couldn’t be addressed in individual therapy at first but required group therapy to dilute the rage. The trick here was to avoid the all to temping ‘divide and conqure’ and all the other ‘divisiveness’ in the modern team where so many members are themselves working out their own adolescent transference material. These were the Robert Graves Golden Bough sorts desperate to be the ‘activist’ all in favour of being an ‘advocate’ happy to climb over the dying body of the patient to gain their 20 minutes of Andy Warhol fame. The 4 dimensional chess board gets more intriguing. Even entertaining as the vetting of lesser and lesser trained care givers bring with them all the baggage of their log jams. Gone are the days when I was the one who spent my personal hard earned cash to be in therapy for years so that I’d not sully the patients illness with my own. This process of unpacking secrets and seeing the ‘shadow’ meant that in therapy one could hear the patient not the echo of your own insaneity. Leadership and the rational and legal models and beurocratic models and counselling models have none of the ancient guildmanship. I was thought insane because I’d done years of therapy by the local thug business doctor with position power and grandiosity and arrogance that comes to every small fish in a small pond.
It was further understood that 12 step facilitation therapy was fundamentally a ‘story telling’ therapy. Those patients who were oppositional, non compliant to medical regimen or ‘resistant’ could be induced to do what was wanted by hearing the message indirectly. Indirect communication is fundamental to ‘adolescent psychiatry’. Paradoxical interventions are actually age specific ‘normal’ treatment. A toddler is never told not to go into a cupboard but rather given their own cupboard with old pots and pans like the puppy is given a bone if you wish to save your shoes.
Spirituality of Imperfection by Ketchum and Kurts is a classic in the ‘wisdom’ literature and the technique of ‘story telling’ used throughout history. What couldn’t be learned by being told could be learned by hearing. An uneducated doctor who proved the Peter Principle with his arrogance and grandisity once stated ‘a doctor must never self disclose’. Meanwhile that doctor was shouting everything about himself in his clothing, speech , cadence, anger and sweat and odor. Training with an analysit through a 2 way mirror I’d had to discard wedding ring, wear grey suits and grey ties to be non descript. Sometimes I even dressed as the patient to mirror them and reduce their fear.
The patient is “taught” ‘free association’ . Free association is not just something that happens. Counselors don’t know it is first their job to teach ‘free association’ or else the patient will simply stay in the conscious realm and talk to the therapist like they would a shop keeper. It’s like any other general practice visit. Fix my boo boo. Psychoherapy then follows after the patient has learned this meditation type technique of free association, after the patient has learned to still the critic. A different cameron in Artists Way describes the technique well in ‘morning pages’. Morning pages was what the therapeutic sessions began as . It’s not something that’s possible in that form at monthly and six monthly visits. It’s hard enough when being done daily or weekly. Only after the patient has learned that does the therapist, observing and noting recurrent themes of the patients free association over the first 3 to 6 months without any ‘warmth’ or ‘sharing’ or self divulgence, only after all that does the therapist make an ‘interpretation’. The state of free association had been learned by Freud after he stopped hypnotizing patients but the state is similiar. It’s not the ‘awake’ ‘counselling session. It’s not the shop keeper mentality of the modern office encounter.
This ‘hypnosis’ based therapy has for legalistic and ‘ beurocratic control issues” been all but removed the the therapeutic laboratory. It’s used in much of the ‘boundary literatue’, more as a weapon than as a caress, developed to ‘police’ rather that ‘free therapists and patients’. The police obviously along with Judge and lawyer and banker are the antithesis of the therapist. They are opposites but can be complementary and historically there was a marriage before the vulgarity that is the abomination of the relationship today. The feminine therapist like the feminine doctor has been all but raped and cannibalized by the vulgar with their dirty petty minds and gross ignorance of the light. Lustful thugs dressed in stolen finery. They steal words and use them as if they know the meaning.
The Vorgon of Hitchhiker’s Guide to the Gallaxy fame have simply mowed through with their hopelessness and fatalism, which is clearly evidenced by ‘management’ of patients ‘versus’ ‘care’’ of patients. Customer care is so much easier to manage.
There was further a distinction always made in psychiatry between ‘therapy’ and ‘managemenent’ exactly like the addiction medicine distinction between ‘harm reduction’ or ‘palliative care’ and ‘abstinence based tehrapy’/.
Government or single party insurance systems have chosen to emphasize abortion, euthanasia and harm reduction along with ‘counselling’ or ‘ego massage’ and forego the ‘relationships’ that developed in the depth of vulnerability.
Long ago I wrote that the lights had been turned off in the operating theatres with only the surgeons being blamed for the outcomes. Greed and lack of hope dominate the management style which is so popular today.
In Holland where nearly a quarter of deaths follow euthanasia today, the mentally ill are a significant proportion and some hundred cases have been clearly identified as ‘forced’.
In such a climate as that when Freud famously said, ‘maybe the paranods are right’ there is no support for quality in face of the demand for cheap quantity. Who wants a nun when a hooker can be had for thousandth the price. The public sector now routinely pays doctors 2/3’s less than the private sector. Psychiatrists are the lowest paid and most abused and have the longest waitlists.
In BC I attended my last ‘union’ meeting when the lawyer back pharmaceutical doctors , the ‘young Turks ‘ as they were called that day, won the day and de factor set the course for the ‘relationship doctors’ ‘small “d” doctors to be paid 1/4 the big ‘D’ doctors who did ‘precedures’ ‘intervened on patients’”prescribing’ Maculinity prevailed! The animus was trampled and kicked and skewered.
The government fee guides have always been skewed to ‘intervention’ and ‘managment’. Cure and tehrapy are not really that ‘enteratining’. Acting like a doctor one is encouraged to see medicine as ‘entertainment’ rather than look at traditional outcome measures as morbidity and mortality, essential no longer valid when the Hippocratic Oath has been thrown out with the baby. Abortion is so much more lucrative. It’s the natural outcome of the imbalance.
Death pays more than life.
I confess I became a doctor because the challenge of ‘cure’ was so exciting. As a biologically trained doctor, first fascinated by nests and rats, I knew that we were as intrinsically sell healing as all of the stem cell research has declared. Advances in padigms, string theory and quantum physics have simply confirmed that when a doctor ‘cures’ a patient they have essentially by some witchdoctor magic induced the ‘self healing’ This is the essence of immunology. These are all self evident precepts but seem to have been missed by the technicians and wholly missed by the managers. Active Abortion and active euthanasia have no place in the traditional guild of medicine. They’re alien. The ideology that they bring, the emotional baggage, the hopelessness, the thrill, come from a different place. The judge and executioner have invaded the operating theater. The banker and insurance man in grandiosity having watched the game now insist they can play as well as those they once paid for. The piper’s tune was sweet but there’s is not so they change the language and insist that they are right. Control. Quick food. Lust is equal to love.
Piaget’s work noted that development moved from concrete thinking to abstract thinking. Unfortunately he was studying his own gifted children and his assumptions of childhood development were only studied dccades later in the adult population to find that profoundly large component of society simply couldn’t abstract. They could ‘manage’ and ‘police’ and ‘be technicians’ , they’re especially good at doing as they are ‘told’ but they lacked creativity and lacking it couldn’t recognize it in others. Indeed their tendency is to ‘stifle creativity being comfortable in conventional spaces because they are out of control and need control, like James Taylor’s Bartender song. “I need 4 walls to hold me.”
Psychiatrists were trained to walk a mile in the patients shoes down the rabbit holes and lead them back to the light. Psychiatrists became comfortable with their insaneity and their patients insaneity through their own tehrapy and supervision. The 4 years of formal apprenticeship are meaningful even if the ignorant and arrogant police doctors can’t know this. That was the essence of psychiatry. Not this ‘Junior neuorlogy’ model so popular with the government single party cheap payer system.
The research is still exciting but frankly academic models are a dime a dozen. I personally was interested in ‘clinical research’ as boring as that was and fascinated with the team model which worked so much more than the ‘laboratory’ model. Hospital psychiatriy is so basic and simple that foreign medical grads and students are licensed to practice in that “controlled” setting which appeals to police who love jails. By contrast ‘community psychiatry’ the Harley STreet model was without ‘force’. The key to success was therapeutic language and coaxing the patient to come to the light. Come out and play. We ‘re see that you don’t get hurt this time.
But now everyone is being hurt by the Vorgons destroying the earth to put in their 8 lane intergalactic space lanes and accompanying parking lot. New World Orders and Global Governments by leaders who can’t even keep their own hoses in order that really who would trust them to watch over ours. Thick skulled salesmen. Midas.
The model of therapy which was once a week or even twice a week is now once ever 4 to 6 months. it’s not even a ‘consultation model’ because half the patients don’t have family physicians and more and more are ‘coeerced’ into psychiatric care by intrusive third party insurer’ managers’ who get gold stars for getting the patients back to work reagardless of their sanity.
Freud described mental health as the ability to work and love. The new term in psychiatry is ‘compassion fatigue’. 75% of doctors are burnt out in the US. In Canada the burn out ratio was only 45 % ‘Only”. This figure is highly skewed and reduced from the American model by the privileged Quebec doctors and administrative doctors and salaried doctors in Canada who all do a fraction of the work that front line clinicians shoulder while the administrations grow like cancer.
I find myself considering that a person who worked in a lord co store as a parts department personnel would be better capable of doing the Electronic Data part of the “new doctor administrative model’ which has us never looking at the patient and squeezing our genius into little boxes made by the fellow who because he can’t make bicycles is given the task in china of writing in English the instruction on how to use them. This Electronic record is alien to the processing of humans, like an early IBM program versus the Apple product.
At the end of my career I am reduced to a ‘health care worker’ whose prime purpose is to gather information for the ‘state’ to be used against my patient who is cynically feeling as they tell me that they don’t ‘fit’ into a world where no one but the elite can afford to live. Where the middle class has no legal representation and the principle problem that the patient brings to the psychiatrists is that they can’t afford to live in this city.
When I began psychiatry none of my patients had financial complaints. If they did we’d say that was a social worker problems But more and more the shift has been to my patients to have legal and social work problems that they have no money to address and indeed if I wish to make the most money I can provide them ‘entertainment’ by selling products like the latest ‘as like’ drug or a bout of CBT. Commodity sales are fine. There’s just not fitting the shoes to the patient. It’s a communist/socialist model where these are the shoes the state decided on and you must fit them not the other way around.
The problem for me and all the doctors and psychiatrists I know is that we ‘loved our work’. This thing gutted, raped and ravaged and played with by lawyers and managers and beurocrats is no longer a doctor patient relationship.. It’s something that gives all those outsiders great pleasure but has sucked the health and life from the original pair. The marriage is loveless and lifeless but the community is getting richer daily by the rising divorce rates. Divorce like abortion and euthanasia are the weeds that doctors don’t grow. Others do..
“I feel suicidal,” the young man told me. Politically correct, I answered ‘would you like physician assisted suicide?” It’s good work if you can get it. No wonder a person with 6 month training can replace a physician or surgeon with 12 or 16 years service. Killing comes naturally. Healing, well, that’s something doctors were the best at, the more training and experience at least was associated with the best morbity and mortality stats. But if abortion is as good an outcome for an obstetrician as a live birth, really, isn’t this communism or fascism, two sides of the same coin.
In the old model the patient picked the doctor and picked what they wanted. This new communist model has one shoe fitting all and the customer is educated to what the company wants to sell, with death obviously being cheapest. Indeed the autonomy of the physician is no longer a part of this model because the doctor is merely ‘salesman’ and the patient ‘customer’ so clearly the job in this corporate model (Dr. Robert Hare discussed the sociopathy of this in the marvellous film Coporations) is to maximize income, with as much unnecessary services as possible .
Indeed the ‘cosmetic’ model is the most lucrative model . Though a far cry from the Christian Health Care model developed by Tommy Douglas a former minister this new improved model certainly has merit. Just like the ‘free heroin’ model in addiction medicine versus ‘Betty Ford.’
Love and work. The system certainly works. But is there love. Communist models have always failed as ‘souless’. Where is there soul today.
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