My Psychiatrist Doesn't Listen to Me

I've heard this said about myself as often as I've heard it said about colleagues.
There was a time when people could go to a psychiatrist and he would spend 50 minutes apparently "listening". I have tapes from my own psychoanalytic therapy series with patients in which I literally speak only a few words.  I listened and I listened very carefully.
This 'therapy' was found not to be beneficial for most people.  The public health funding system no longer provides funding for psychoanalysis because it was found most beneficial with only a certain selection of patients and commonly those very same patients could well afford to pay for this intensive in depth therapy.  Psychoanalytic therapy in which a person is seen weekly for roughly 10 to 40 sessions is still utilized and it's "evidence based" efficacy was well documented In the Ontario book, Standards and Guidelines for Psychotherapies, editors Dr. Paul Cameron, Dr. John Deadman, and Dr. John Ennis.
Over the years selection criteria were developed for the "listening therapies" which in contrast to new standard therapy, Cognitive Behavioural Therapy, is more like a typical tutorial.
More often than not though a patient who says his psychiatrist doesn't 'listen' to them is really saying 'my psychiatrist' doesn't 'agree' with me.  I am routinely called the 'non listening' psychiatrist when I tell people
1) Abstain from alcohol, your alcoholism is killing you.
2) Stop doing illicit street drugs.  They are causing your insaniety. They are not the solution.
3) Your partner isn't the problem. You are the problem.  You picked him/her or you trained him/her to be the way they are today. Leave them or change yourself so they can change.  But remember you take yourself with you and your likelihood of poor mate choices increases with the number of failures.
4) You are ready to return to work and work is generally good for mental illness.
These are the most 'offensive' things that I routinely have to tell people and when I do they become ballistic and routinely 'fire' me, and always say I don't 'listen'.  The person commonly figures that the way I will 'agree' with them, especially the painful marijuana addicts, is if they have enough time to 'convince me'.  They see their role on 'selling me' on their 'sickness'.
There were studies on long term and short term therapies and they found that whether you waited weeks or months to tell a person to return to work who would benefit from work, didn't matter.  Even with a strong 'therapeutic alliance' an alcoholic is going to reject you when you ask them to 'change' their behaviour.
Hence, Motivation therapy, with Prochaska's Stages of readiness.  Modern therapies are expected to identify what change is required and then assess when the patient is in the precontemplation, contemplation, determination or action phase of therapy. The limitted resources of society sponsored therapies are then used realistically and appropriately.
Today most people who see a psychiatrist are a very different lot than the ones who saw a psychoanalyst in the past. Today the psychiatrist is part of the medical model and providing 'specialist consultation' similar to a neurologist.  Most psychiatrist may not even be psychiatric psychotherapists and only be psychopharmacologist.
In the glory days of psychoanalysis, the rich paid hundreds of dollars a day 5 days a week for years to suffer through a very tortuous process of self discovery. It wasn't counselling and it was indeed very effective for those highly selected motivated individuals who were willing to invest that much money into their growth personally.  It wasn't found to be very effective in the prison population and of limitted value in those areas where patients were 'sent' rather that 'came' to therapy. It was also more effective when patients paid for their therapy rather than having it paid for by third parties.  The higher the education and the younger and more successful a person was before entering psychoanalysis the more likely the outcome would be positive.
I spent years 'listening' to patients, have hours upon hours of taped sessions where I say only a few words but this is not with patients who have addictions.  The analysts collectively considered alcoholics and addicts as 'untreatable' by the 'listening' therapies though there was progress made when these were done in 'group therapies.'  Transactional analysis remains a successful group therapy and Games Alcoholics Play remains a true classic.
Modern therapies are specific to the patients 'condition', personality disorders often benefitting from a socratic dialogue more than insight therapy, for instance. Supportive therapies are most effective for patients who have regressed to where they are having problems with self care, maintaining work or relationship. 12 Step faclitation therapies are talk therapies which are most effective with impulse dyscontrol therapies.
Cognitive Behaviour Therapies include home work, writing and behaviour assignments. They're not dominated with the patient talking but rather focus on the patient 'doing' things differently.
Today the patient who gets better is the patient who 'listens' as the model of psychotherapy is based increasingly on 'psychoeducation'.  The learning of 'social skills' is evidence based today. Freud's work and the early psychoanalysts in general were 'explorers' . They were like the 19th century biologists who were 'observing' in hopes of understanding. Today thanks to the psychoanalytic work of years specific therapies have been developed that are themselves evidence based.  Focus has moved from diagnosis, which thanks to the early explorers is much better established with tools such as ICD 10 and DSMIV tr than ever before, and more focussed on therapy.
I don't need to listen a person tell me for 6 months about their appendicitis symptons anymore than I need to "listen' for 6 months to a person tell me about their life of woe and self pity before I can prescribe not only medications which if taken have a 80% success rate but also therapies which are equally effective today. In combindation biopsychosocial therapies are more effective than ever before and the treatment of psychiatric illness is approaching the success of physical therapies in those who are capable of 'listening' and taking direction.
Noncompliance with medical regimen or nonadherence to therapy can run about 30% in the physical disease population but as high as 80% in the psychiatric disease population.  It's important that the psychiatrist 'listen' to what patients are saying but they may today be more interested in why the patient didn't follow through with last week's recommendations rather than discussing ad infinitum the blaming of mother for lack of breast feeding.

Therapies for Depression

Depression is a broad term to describe a psychiatric state of literally, unhappiness.  So called Clinical Depression refers to some such state that persists for at least a couple of weeks. It's associated with a depressed mood, most of day, most every day.  Sleep and motivation and cognitive function can all be affected.  There have been a wide variety of terms over the year to describe this state.  It's been called dysthymia, major affective disorder, mood disorder, major mood disorder, and at it's most extreme melancholia.  It's differentiated from the blahs by being a bit more severe and lasting a bit longer. It's differentiated from Grief or Bereavement, the natural state of loss when a loved one is lost, by lasting much longer.
At the turn of the century a study in Pennsylvania at a farm when Quakers kept people who came with mental illness treating them with tender loving care but not much else, the length of 'untreated major depression' was approximately 9 months.  Adjustment disorders, a reaction to a negative event in one's life such as the loss of a job or the break up of a dating realationship was considered to be about 6 months. The depth of suffering with an adjustment disorder could be as great as major mood disorder but if the disorder laster longer or was greater then the term major mood disorder or major affective disorder was used to describe the experience.  There have been some who wrongly defined adjustment disorders as 'minor' depressions but adjustment referred to the presence of an identifiable stressor. In Major Mood Disorder alone a person might have a stressor or not.
Indeed there is a tendency in the pharmacological industry associated psychiatric diagnosis to described disorders independent of the causation. Hence the 'antidepressants' medication is likened to 'fever' medication, like Aspirin and Acetomenophen.  People can have pain for a variety of reasons but aspirin or tylenol tend to treat the 'pain' regardless. There's this kind of non specific benefit noted with the antidepressant medications so that in association the term "major mood disorder' has by convention been likened to the condition a psychiatrist would use an antidepressant with.
That said depression and moods in general can be altered by a variety of factors in terms of the individual, their relationship or environment.  A large number of physical medica conditions give rise to depression. Often the first presentation of an underlying major medical physical illness is depression. Cancer, Diabetes, Heart Disease, Chronic low grade infections, Anemia, Metabolic Diseases, all commonly present with depression as the first sympton of the disorder.  For this reason people with persisting depression often benefit from seeing their family doctor who can readily rule out the major and more likely conditions that may present as depression.
Many of my patients have come to me after months of psychological treatments or counselling when they had an undiagnosed physical disease which was causing the person to have low mood, loss of energy and sleep problems and cognitive difficulties. The diagnosis of depression was correct. It's just that the cause and treatment had been wrong.  I saw one poor gentleman after a year of weekly psychotherapy and all manner of discussion of his sex life when he had an anemic condition. When the anemia was treated his mood improved and he no longer had need for psychological treatment and certainly was disheartened by the year of therapy, the $10,000 of dollars cost and the loss of work and relationship which had occurred. In several cases depression was the way my patients breast cancer presented. I did an appropriate medical screening history and found that they had other symptons of concern.  Hundreds of cases that have come to me for depression, even those who have seen family physicians before me have turned out to have a physical illness which when treated caused the patient to no longer need antidepressants or depression therapy.
The message there is 'screening'.  Give a boy a hammer and everything is a nail. That's the problem with counsellors.  They over diagnosis psychological depression and miss the other often common causes.
Psychosocial reasons for depression abound.  Often people become depressed by lack of exercise.  Scientific studies have shown that 1 half hour of aerobic exercise daily has the equivalent benefit on mood as taking prozac 10 mg daily has.
Often people who have eating disorders are depressed. Both obesity and anorexia are associated with depression.
All the addictions are associated with depressions.  Alcohol is a 'depressive'.  Cocaine is a 'stimulant' but it quickly depletes the bodies stimulant neurotransmitters and causes a depression as a result.  Addictions are generally associated with a dramatic high followed by a low. Sex addicts get this and eventually the flogging of the dead horse phenomena in addiction leads to chronic depression and dysthymia.  Bipolar II in the diagnosis associated with addiction until proven otherwise.
Chronic anxiety states lead to depression. Indeed the Seligman 'learned helplessness' studies suggest that depression is a chronic anxiety state.  There's work with neuro implants that suggest that chronic anxiety may set up a derailed neurotransmitter pathway that requires a 'brain pacemaker' to disrupt and restore a person to having normal neurotransmitter release.
Electroshock therapy served to 'reset' this distrurbed neurotransmitter system.  Serotonin deficiency was disagnosed in the cerebral spinal fluid of suicidals and the general pharmacalogical explanation for depression was a low serotonin or noradrenaline state.  It's now recognised that there's more likely an imbalance between varying neuro pathways serving to maintain equilibrium.
All manner of therapies have therefore been scientifically shown to be beneficial in the treatment depression.  Prevalence studies of depression show as much as 30% of a population base may have some form of depression at any time.
Talking therapies - counselling - psychotherapy -have all been shown to be beneficall. The is much competition between the various 'schools' of thought and the 'latest' brand of therapy but one very interesting study some years ago showed that psychiatrists with 10 years of clinical therapy experience regardless of their theoretical basis had the same general benefit.
The 'convention' is to use a 'cognitive behavioural therapy' today, mostly because it's so easy to train a person in and therefore costs less. Psychodynamic therapies have equal if not greater success in the treatment of depressive disorders but require more training and are more difficult to learn than 'cognitive behavioural therapy'.
Generally speaking 'relationship therapies' have been good with most depressions.  Garden variety depressions were what we always gave the new residents as they tended to respond to any form of positive hopeful encounter.
Having branched out in to other areas of study I've seen that "pastoral counselling' has been effectively treating depression quietly for centuries because it combines cognitive behavioural therapies idea, with relationship therapy and even has the 'lending the ego' elements which were beneficial in psychoanalytic therapies.
The advantage of psychotherapies over doing nothing was the generally speaking it's been shown that therapy shortens the length of the dysfunction associated with depression and the risk of suicide.  Considering untreated depression can last 9 months, most counselling therapies result in a depressive episode getting better in 6 to 10 weeks.
Indeed prozac the antidepressant was considered a success because it was shown to have relatively equivalent benefit to 10 weeks of psychotherapy.  Combined psychotherapy and psychopharmacology, the person improved symptomatically but the potential for recurrence was also reduced.
Individual therapy is expensive as any labour intensive therapy is. Therefore there have been studies on group therapy especially with cognitive behaviour therapy which really lends itself to the class room. Indeed I  might argue that individual therapy of the CBT nature should only be considered when group therapy had failed.
Misery loves company. A significant success of the self help movement has been it's ability to counteract the tendency to isolation.
Spiritual people as evidenced by a measurable variable such as church attendance have less likelihood of depression and respond to treatment better with greater success.
Seligman at his Authentic Happiness site has been doing research on improving the various traits that counteract depression, two specifically being hope and reslience.
While a lot of people think that depression should be a reason to not be working, not working can actually make depression worse. Clearly a pilot who has depression may present a risk for his passengers but if he is sent home 'to rest' , the isolation might indeed make the depression worse. A very effective therapeutic strategy employed by the British Columbia worksafe program was to have depressed patients attend a daily coffee house thereby ensuring that they had the occupation benefits associated with group therapy and socialization.  People who isolate worsen their depression.
However depressives can run in 'packs'. Individually I've treated dozens of patients by encouraging them to reduce the contact with 'sick' people in their social network. It's the 'dosage' of the relationship that is sickening. One women became physically ill if she talked to her deeply mentally ill mother for more than a half hour a week. The mother was dependent and clinging and literallly what caloquially we'd call a soul sucker. In contrast one of my male patients had only to talk to his father for an hour and his father was constantly demeaning to him causing him to be literally suicidal.  Again by limitting the dose of the relationship to 15 minute contacts the man was able to get better. I routinely ask depressed patients to avoid the news in whatever form since it's commonly old and depressing.
Music therapy has been shown to be a treatment for depression. It's especially beneificall if people are themselves participating in making the music.
Given the wide range of successful treatments available it's usually beneficial to consider the efficiency and cost effectiveness of a therapy.
Magnetic therapies have been shown to be very effective for therapy and equivalent in some patients as medication therapy however right now the cost is higher than electroconvulsive therapies.
Hypno therapy is an effective therapy for depression as is neurotherapy.
Often the therapy that is used is the one most available in the community.  It's also is affected by what experience the therapists have. In eastern Canada it's common that there are a psychotherapeutically trained psychiatrist with extensive experience in a variety of non pharmacological treatments as well as pharmacalogical treatments and physical treatments. In western canada it's most common that the psychiatrists are only trained in psychopharmacology or if trained in other forms of therapy these are supported by the community financially or professionally.
Massage therapy is very attractive to patients. I once asked my heroin addicts if they had the choice of going to detox or massage therapy which would they choose.  They'd naturally choose massage therapy.  Unfortunately there's no evidence that massage therapy is an effective treatment for heroin addiction.  Abstinence is and detox is not nearly as pleasant as doing heroin and getting a government funded massage.
No one ever questions what individuals do to treat their own depressions. This is in fact the 'right' to 'pursuit of happiness'.  I personally find riding my Harley Davidson Electraglide an antidepressant but it's most unfortunate I can't convince an insurance body to pay for my motorcycle. Similiarly i personly think that if I were depressed I'd benefit from a year of high paid tropical therapy on a beach. I suspect I could devise a scientific study to show that this did work but the cost would be prohibitive for any insurance company.
Much of the failure in treatment of depression has been due to the failure of patients to follow medical regimens, such simple suggestions as don't drink alcohol or exercise a half hour a day, or get out of bed.
Dance therapy is an effective therapy for depression.  I used dance and psychodrama to effectively treat depressed patients. There's just no support in the very conservative medical system for me to do these therapies. I'd need a larger office or space where I could do dance. I have a group therapy that helps depression but even to have a group therapy in my office I have to pay the higher overhead costs for the office that can hold 10 people at a time.  Further the medical service plan discourages me from having group therapy because it's more time and effort for my staff to arrange and bill and yet there's no commiserate increase in the therapy cost.
So there's lots of therapies and lots work. The choice of therapy and indeed the choices available are numerous. People don't need to be depressed. Talk about it and get help.
When I started in psychiatry I commonly talked with patients and rather quickly they got better. Often just listening to people who had otherwise well established lives served to result in their mood improving.  Later I would see more complex problems with less and less resources and more and more demands on my services.  As a result I tended to use medications more often. Commonly I have the pleasure and benefit of working with a psychologist or occupational therapist who does the lions share of talk therapy.  I'm a consultant and diagnostician and the the psychopharmacologist in these arrangements.  The psychologists and counsellors and occupation therapists can't prescribe medications and aren't aware of the whole medical and neurological aspects of depression which can be an important part.  A number of the psychologists I work with a specifically trained in a subset of patients and their experience and training makes them especially good with this group of patients. My experience and training is really broad based with some subspecialty areas so it's refreshing to work with psychologists who are subspecialists themselves. Increasingly family physicians are working psychologically with patients so that makes things easier all round.
I still come across alot of depressed negative people in my daily walk in life.  It's like the number of addicts who actually access treatment. Very few. So commonly I'm treating an addict in the office but there are a dozen or so more who deny they have addiction and attribute their regular social and occupational problems to the 'other guy'.  Similiarly depressive people often are the last to seek help which is unfortunate too.
When I consider psychiatric illness I often think it was akin to physical illness in the 30's. All manner of people had physical illness like heart disease or treatable infections or cancers but they never sought help for them. As a result the morbidity and mortality rate only one or two generations ago was so much higher.  Today people have much more 'quantity' of life in general but the 'quality 'is still an issue.
Ironically alot of people think that they'd be happy if they were rich but wealth is not a cure for depression and not a guarantee against it.  I used to think if I lived on a tropical island I d not see depression becuase I'd associated it more with the dreary winter months but when I worked on a tropical island I saw just as much depression.  I have been thankful for the wide range of therapies that I've learned, the excellent psychopharmacologies and elegant psychotherapies.

Eclectic Psychotherapy - 3) Insight Psychotherapy

I am best described as an "Eclectic Psychotherapist".  I was originally trained in psychoanalytic psychotherapy.  Note my dog, Gilbert,  on the couch!
In psychoanalytic psychotherapy, the therapist is verbally passive to a large degree. The patient is taught "free association".  Free association is a very different process from the directed communication that most people encounter in counselling which is very much  a 'rational' and 'conscious' often 'educational' process.  Free association by contrast is learning to speak about whatever comes to mind continuously without censoring.  The therapist listens to this 'unconscious' processing of whatever is on the mind of the patient.  The patient may recall dreams, events from the the past and anything that may be associated with the primary material being presented.  Eventually as 'patterns of assoctiations' become apparent the therapist shares these 'insights' with the patient and asks for feed back..  Commonly the therapist asks the patient what they think a dream, free association, or focus of thought means.  Therapy is often a quest for meaning and if Jungian an attempt to tie the meanings to the greater world of archetypes. Another more generic term for 'psychoanalytic psychotherapy is 'insight' psychotherapy.  The patient with the help of therapist is gaining 'insight' into otherwise unconscious process and beginning to make sense of otherwise obscure behaviour and thought process.
In psychoanalytic therapy Freud considered the internal processes of the mind to be a kind of family dialogue with the id, the out of control unconscious, the ego, the conscious and the superego the controlling unconscious.  Eric Berne in Transactional Analysis made sense of these divisions by describing Freud's Id as "the child", the Superego as the Parent, and the Ego as the adult.  Later variations on this included the good child and bad chlld, good parent and bad parent. The ego or adult was the individual who managed the demands of the id and superego.  Kernberg was by far my favourite theorist and practitioner of modern psychoanayltic psychoatherapy though it took Masterson to better communicate the developments of the field.  Kohut developed Self psychology which looked beneath the ego to perhaps what might be called the true potential.
The defences were unconscious processes, later called 'coping strategies' in the conscious realm for dealing with unacceptable material. Hence 'denial' might be noted by the therapist who found that the patient couldn't talk about sex and couldn't remember a year in their life when they were in a particular foster home.  Projection might be interpreted when a patient described a 'bad' sibling and how they were so hurtful when in fact in time the patient might gain insight into how they were infact 'projecting' their envy at the next born child.  Acting out was a defence like somatization which served the pateint by keeping them in the dark about some truth that motivated them.  Hence a person might have sex with people indiscriminately when in fact they feared rejection so jumped the gun, acting out some childhood trauma.  Commonly in psychoanalytic psychotherapy the 'patterns' of behaviour noted today derived from dramas that began in the childhood of the patient, in their family. Bradshaw was very good at explaining these early childhood dramas Transference referred to the patients tendency to transfer emotions and roles from past onto the present especially on the therapist.  The therapist in insight psychoanalytic pscyhotherapy 'interpreted' the relationship of therapy in the here and now.
Depth therapy was specifically looking into the darker recesses, the sex and aggression, which Freud said dominated the development.  Interpreting patients 'sexual feelings' towards therapists, or 'lack of sexual feelings' towards therapists (defended against) and feelings of 'hostility" or 'fear' of therapist and working these through without 'acting out' lead to a person being grounded and confident in relationships with clear sense of their own behaviour, their 'boundaries' to use a poor modern term for the membranousness of human relationships, but really having 'insight' into their own motivation and seeing when other's falsely accused them of other motivations or denied their own underlying motivations.  Often there are 'motives in motives' and the the patients of psychoanalytic psychotherapy become very conscious of the behaviour of themselves and those around them.
Indeed administrators and leaders of society commonly sought psychoanalytic psychotherapy so that they would not just mess up society and their workplace with the unresolved issues of their childhood.
Today psychoanalysis despite it's hugely demonstrated benefits is rarely covered by health care because cheaper and often more effective less labor intensive therapies have been developped to address specific psychiatric problems.  Psychoanalytic psychotherapy, as evidenced in Cameron's book on cost effectiveness of therapies for the Ontario Government , is still widely used and hugely beneficial. It's limitations is in the rigors of training which fewer people are willing to undergo. A cornerstone of true psychoanalytic psychotherapy training is for the therapist to themselves be in therapy. This is often too humbling for the modern practitioners who claim 'bigger and better' brains and see their role as 'fixing' patients.
The fact is, experienced therapists rarely today are 'purists' and hence the designation "eclectic'.  One may begin with one therapy but in time and with more advanced training add to the original basis.  Psychoanalytic psycotherapy and psychoanalysis are still considered the best trainings for therapists because, frankly, too many counsellors use therapy to work out their own issues and to propagate their own agendas.  Insight helps patients and therapists alike.
I will go on to discuss the therapies I learned in the order which I learned them giving some insight into the terms used so that people might be better 'consumers' and make more sense of their own experience, their therapy and possibly guide them better in the direction of what they need rather than simply accepting what is offered.

Eclectic Therapy -2) Hypnotherapy

I am indeed an "Eclectic Therapist' simply because of all the training and experience in a variety of psychotherapies I've formally and informally learned and applied.  Maybe if I was ever really a great therapist I'd not have to continue learning as I've had  all these years. The fact is I'm fascinated by the human mind and behaviour and the more I actually learn the more I realize how little I actually know.
Having already learned "Counselling" and "Supportive Psychotherapy"  I next learned Hypnotherapy.  I was working as a country general practitioner in southern Manitoba at the time.  I was doing deliveries every couple of weeks and doing minor surgery. I had already learned how to anesthetize every part of the body with a long needle.  The one time I was forced by an emergency to do a high forceps delivery I was very thankful for this knowledge. Otherwise I'd have had to do a caesarian section with spinal block. I hadn't done a spinal block myself though witnessed enough. I'd done countless spinal taps and the block isn't that much more technically difficult, just potentially more lethal.  Anesthetists aren't well appreciated by the public but they are the unsung heros of surgery and obstetrics.  I have thanked my lucky stars many times when I've had the benefit of an anesthetist present.
Despite my basic surgical training and training in intensive care medicine I was  frankly often alone and scared in the backwoods. If I had a competent nurse things were much better. I have the greatest respect and love for some of the old battle axes that helped me in those early years.  In contrast I've had nurses green or incompetent nurses screaming at the sight of blood or fainting in the emergency room. I even had to ask one nurse to leave in a delivery because her fear of childbirth was getting the patient all worked up. When she and her 'textbook knowledge' left this lovely country woman delivered easily a rather big boy.
It was in this context that I learned about hyposis as a therapy for doing medical and dental procedures. I thought that as I was often doing home visits and working in places without an anaesthetist including the country hospital where I was principally located, this 'skill' could be very beneficial.  The Amercan Society of Hypnosis had a 2 level training program taking a matters of weeks to obtain. I read extensively and took the time off work to attend the hands on training workshop and attend the examinations. When I finally got my certification I was amused that I could use the acronym CASH after my name as I truly had obtained a Certificate of the American Society of Hypnosis.  Unfortunately hypnosis never made me any money but it certainly was an eye opener.
ndeed I think all my colleagues should be required to observe surgery done under hypnosis.  It's one thing to know that 90% of pain is processed mentally and another thing to witness something so revolutionary as to see a person being cut open without even local anesthesia.  The fact is I went on to do it when I got back to my practice, electively.  I cut out moles and warts using hypnosis and had a marvellous old time for a while until I found that just using xylocaine 1% took a tenth of the time and was more certain.  It had cost me roughly $10,000 in training and loss of income and then this further experience to have a skill which really was never compensated by the health care system despite it's proven benefit. Nonetheless it sure was fun. Talk about feeling like a wizard.  Gandolf Doctor Hay!
I'd become a certified yogi too with years of formal training, papers from a highly recognised International and American Institution, and even later a trip to India where I studied advanced meditation.  I've even a childhood friend Kirk who I thought at one time had overdosed on yoga and definitely must be a saint. Despite the scientific double blind evidence of the benefits of meditation therapy (see Herbert Benson MD and Relaxation Therapy) and today (Mindfulness Therapy) that too was never compensated or paid for. Another $20,000 to $30,000 training and experience which was never 'supported' by the institutions despite the overwhelming 'evidence' scientifically and otherwise of healing benefit.
I mention this because I can't get over patients expecting doctors to 'learn' alternative therapies and keep up with latest developments in medicine when to do so we have to put out the time and money ourselves and very little except the narrowest areas of study are supported financially.  The cost of all the alternative practitioners even the phd's is minute compared to the expenses we accept to be healers in the modern sense. The richest, most powerful and hence most influential physicians do their basic training and then the minimal level of training to keep up with their 'niche'.  Relatively, I made the most money I ever made as a country gp and lost all my income to do advanced specialist training and never have been compensated for the training or the skills. Indeed I've not even been able to use a third to a half of my most advanced training because there is no support network for the training 25 years later despite the evidence supporting those therapies.  I trained as a psychiatrist with the promise of having hospital beds for the elective admission of patients for therapeutic treatments.  Even when I was a member of a hospital all I was ever able to admit were emergency suicidal or psychotic patietns because of lack of resources.  I'm not alone. Many of my surgical colleagues are trained in advanced surgical approaches but can't get operating room time becasue of the politics of hospitals and most importantly so much of what is proven scientifically and advanced is simply not funded.
Many of my finest colleagues have left the so called 'mainstream' and moved into private areas, some have even left medicine altogether ,to go completely private.  Most of those I knew who went to the US didn't go for money alone but rather they went so they could do procedures which required MRI's.  Canadians simplyt don't know that while Canada was at the height of world medicine 20 years ago Canadians limitted to the public care system are often getting only third world medicine.  Europeans and sometimes even Cubans are appalled by how limited our health care system is. The amount of administration and regulation that has arisen in the last 20 years is eating away all of what was once 'medical' care and now has become 'health' care.  Millions of dollars in 'advertising' are called 'health care' funding and people don't realize that. .
But I was talking about Hypnotherapy.Ooops!
Milton Erickson, MD is the psychiatrist who is the father of hypnotherapy.  He was a midwest American. He said Freud was wrong about the ID.  Jung had said Freud was afraid of the  Id and the 'irrational' as well.  It might have had something to do with Freud's  relationship his wife's sister and the experience of genital mutilation as a child.  Maybe it was just the residual effects of his cocaine abuse.  That said, Freud is still to my mind, perhaps the world's greatest psychotherapist and certainly to psychiatry what Einstein was to Physics.  He was a true adventurer.  I accept that I stand on the shoulders of those who went before and with the knowledge they gave us we can advance but we'd not be where we are were it not for them.  I sail and I see this in navigation and maps without having to listen to the petty political criticism of Columbus mistaking North America for India. If Columbus were a psychologist, boy would he be pilloried today for that. Freud unfortunately went astray when politically he got into the business of empire building.  That said, I save 'reverence' for God and tend to irreverence with myself and my  fellows, a fault that no end of therapy has been unable to eradicate. I can't help but think that Jung and Erickson would have enjoyed Monty Python and Seinfeld more than Freud despite Freud's intellectual support of laughter.  Now Anna Freud on the other hand would have loved even George Castansa and the Canadian Air Farce.
Milton Erickson said that it was the 'unconscious processes' that caused us to 'automatically' protect ourselves when we fell.  We didn't think about putting up our arms to 'block a blow'.  Milton Erickson believed in the 'child' within and felt that we had to 'free' the natural healing process of the human.  Jay Haley wrote the classic "Uncommon Therapy' describing best the work with Milton Erickson.  Though I was fortunate to know and train with Jay Haley and his wife Bianca Jenks I missed meeting Milton Erickson by a year or two when I began training in hypnosis and later in Structural and Strategic Family Therapy and Strategic Therapies in general. I even studied with the original Palo Alto group whose research gave rise to the mind body therapies that produced EMDR for instance.  "Mind Body Therapy" and other "Psychosomatic' therapies were foundational to hypnotherapy.
"Frogs into Princes' by Grinder and Bandler is a marvellous text teaching the basics of inducing a trance. These students of Milton Erickson went on to develop Neurolinguistic Programming which makes alot of Erickson's work more accessible to the lay public.   Milton Erickson was famous for saying everyone could be hypnotised. What he didn't say is that some took seconds to minutes while others could take hours to days.
I feel terribly guilty for not remembering the name of my original hypnosis teacher. He was the most extraordinary doctor whose job it was to hypnotize people for major elective surgery who were allergic to anethesia.  He told amazing stories about hypnotizing people for heart surgery and lung surgery.  Despite having learned and done extensive work using local anesthesia I was still impressed when I met a Russian doctor who'd removed a lung in the Urals because he had no anesthesetist.  This doctor who taught me hypnosis and wrote a classic book about his work   trumped us all.  I witnessed him hypnotise people stick them with needles and their showing no physical or psychological changes.   Having learned hypnosis from him I too went home and cut people under hypnosis was amazed.
Thanks to hypnosis and yoga I even learned the party trick of slowing my heart to where medical students couldn't feel it beating.  Those were halcyon days for learning about the mind and body in the early years of training before learning that the 'powers that be' were simply not interested in anything that was not 'orthodox'. Indeed the medical legal crisis was such that doctors who tried anything new were at the greatest risk for being punished royally. Adding lawyers and administrators to the healing equation guarateed mediocrity would reign.  That said, there have been major gains for all in the development of ethical research policies and advances again can be made but usually only by committee and with large financial funding.  It didn't surprise me to hear of a recent potential cure of cancer going unnoticed in Alberta because there was no likely profit from the development.  Business medicine reigns and with it comes pros and cons.
There are many ways to induce a trance. Later I'd even use amytal to do amytal interviews, injecting what has been called 'truth serum' into the veins of patients and then doing interviews and hypnotherapy with them. Most people who belittle pharmacology do so because they haven't learned it themselves, can't do it and don't have a license to do it.  It's called "cutting the heads off others to make yourself taller."  The "holistic' doctors often would be left with nothing to say if all their criticism of traditional medicine was removed from their repetoire.  And here I'm doing the same.
So hypnosis doesn't require pharmacology.  Hypnosis is done by joining with a person at their unconscious level using ritual and repetition.  It's really easy with children.  I ask a person to stare at something and this wil cause their eyes to tire and their eye lids to droop.  It's classic.  So I begin by using that 'tarot talk' , 'hypnotherapy' ' "mesmer voice' low and slow saying "I am observing you breathing, you are breathing in and out, your eye lids are fluttering and growing tired, you are breathing more slowly now, your eyes are drooping and as I count backwards from 10 to 1 your breathing will grow slower your eyes more tired and you will enter deeper and deeper into a relaxing calming pleasant thoroughly satisfied trance like state where you will be able to hear my voice and respond to my requests or commands but you may not remember anything that we say and do thereafter, I'm beginning now as I observe you breathing in and out, in and out, your eyes more and more tired, 10, 9, you are going deeper and deeper into that semiconscious realm, 8, deeper down deeper into the trance, where you will hear me and we will be able to communicate but your body will be so relaxed that you won't be able to move without my voice helping you 7, deeper now, your breathing in and......out, ....in and out....6, you are getting sleepy but not like sleep going into that twilight state, where you can hear me and respond to me but only as I ask you to where you won't remember what we have said because we will be so tired, 6 5 4 3 2 1....you are hypnotised now and your eyes are closed but your are able to hear me, can you hear me ....etc.

This 'induction of trance' is done in a whole variety of ways. It's used in marketting and advertising and commonly most adults aren't even aware when they are being manipulated and hypnotised.  Everyone should read 1984 and the Animal Farm.  These are dangerous times.  Especially with corporations like Abercrombie and Fitch marketting padded bikinis bras to baby girls.
That said any party animal should be able to hypnotise his friends to be clowns at a party.  What separates the professionals from the amateurs is if the patient lets you cut them open with a knife or tells you in horrifying detail about some memory that is frankly unbecoming and surprising.
The trouble with hypnotherapy is that alot of what one can learn using techniques such as reqression of a patient back through the ages is that for the benefit to be gained this 'unconscious' material must be 'learned' in the conscious.
Freud was probably one of the world's greatest hypnotists and hypnotherapists. His development of the technique of 'free association' and use of a couch was indeed a means of establishing a' partial trance' that faciltated the development of 'insight'.
Many is the time that I learned things about paitent's pasts in hypnotherapy but it did no good for the patient until they were subsequently 'ready' to 'learn' and 'accept' the material.
As every psychoanalyst and every psychoanalytic psychotherapist knows it's all albout the 'timing'.  Of course I know I want to go back in the womb and I want to be on another planet but telling me this is of little value and importance than if you tell me at exactly the right time I need to hear it.
Zen teachers call that the 'aha' moment and frankly amateurs are 'impatient'. I was lucky to have surgical training prior to psychotherapy training because I'd already learned to wait for an abscess to be ripe before cutting it or squeezing it.
Hypnotherapy is also all about association.  Being a poet before  learned hypnotherapy I found it easy to use allegory and metaphors in my work with patients. This allowed me to bring patients to get around 'blocks' without having to address them directly.  A famous Erickson metaphor was when he talked to a woman about growing tomatoes and her fear of sex left her. He never mentioned sex but he did talk about stroking ripe red tomatoes and the tall green stalk.
I don't think I could do hypnotherapy in another culture or as a second language.  Maybe if I was Joseph Conrad I could do hypnotherapy with English speaking people but despite my little knowledge of spanish and french I simply can't imagine doing hypnotherapy outside of my primary language of English and my culture.. I certainly couldn't see myself doing it with a translator. I've not tried but it seems foreign.
I did hypnotherapy extensively for anxiety disorders and mood disorders. Ironically people would want me to do it for quitting smoking and I'd not see it as that effective in that regard. But then in addiction psychaitry I wasn't doing forrmal hypnosis and hypnotherapy.
What I found was that I had to have a therapeutic setting for doing psychoanayltic psychotherapy and especially hypnotherapy.  It's been over a decade since I've had a practice in which I can guarantee that my sessions won't be interrupted by an emergency or in which I can guarantee silence in the room. Indeed most male psychiatrists and female psychiatrists as part of the organized destruction of the therapeutic process hardly feel safe with their door closed. Most doctors would like a lawyer in their office for all patients. And most doctors simply won't discuss sex or ask about sexual matters because of the risk of false accusation, or as is more often the case down right 'extortion'.
More pateints also have a 'secondary gain' issue when they see the doctor in a public setting. Their insurance company needs a report and often my role is 'illness recorder'.  In the mental health teams the psychiatrist is often told they're only there to prescribe and indeed if a psychiatrist does anything more than prescribe he or she will make less money.  I am paid most for recording illness and I can face severe penalties if I 'confront' a patient.  Indeed whereas 'confronting' illness was what we were trained to do in medicine, telling a person they have cancer, I found increasingly I was told that patients shouldn't be told anything they don't want to hear or they can 'sue' you.  We used to mock 'feelgood' medicine likening the valium prescriber and hand holding counsellor to the pusher and masseuse.  Now here we are terribly afraid of saying anything that might upset a patient for fear they might complain. Family physicians actually sometimes refer patients to me rather than tell them an unsavoury diagnosis for fear of retaliation.
I heard one doctor afraid of telling his patient he had cancer because he was afraid this very 'litiginous' patient would blame them.  The stress that doctors work under just going to work and making diagnosis is such that many colleagues have taken to calling everything 'bipolar II" because it's a diagnosis which actually has no clear specificity and if anyone doubts it the doctor can say its because the patient 'rapidly cycled'.  Epidemiologically there's been epidemics of 'bipolar II " diagnosis breaking out everywhere without the World Health Organization even investigating it. It's terribly infectious to say the least.  The most cowardly of doctors and lowest of doctors flee the frontlines of patient contact and hide in administrative office or worse police doctors acting out their own unresolved 'identification with the aggressors'.
The only treatment I've read for Bipolar II is pharmacalogical.
A pharmacalogical psychiatrist can see 6 to 10 patients in an hour billing for visits every 5 to 10 minutes whereas a hypnotherapist takes usually an hour and a half.  The provincial plans pay at most for 50 minutes of therapy wiht any one patient but will pay ad infinitum for 5 minute visits weekly ad infinitum. The richest most relaxed and satisfied of pscyhiatrists are the pharmacological psychiatrists.  Their frequent trips to Hawaii  providing by drug companies revive them.
Psychotherapists don't make anyone any money and the payment for psychotherapy is the least that a doctor can receive despite the fact that psychoanylitic pscyhotherapy and hypnotherapies and couple and family therapies are the most intensive of work.
So I don't do much hypnotherapy.  As I've got older I've learned that I'm stupider than alot of my colleagues. Rather than criticize them for doing those things that are remunerated I've come to realize that the 'market system' repays those things that people want.  I get great satisfaction personally from alot of the successes that I've had as a result of my training and the exdellent teachers I've had. I use the lessons of  hypnotherapy in my day to day language and in the way I talk to patients and do therapy itself.
One of my favourite hypnotherapy techniques is to 'seed' conversations and by 'story telling'.  I talk about 'irrelevant' matters and 'seed' this material with whatever it is I'm 'selling " the patient.  So I may talk about my dog and comment on how the young are constantly exercising. It's no surprise that all my obese patients have heard these stories but none of my athletic patients would hear about my dogs constant exercise.  I tell a story about a patient who recoverd from cancer giving up smoking and indirectly I'm telling my patient who I've already told to stop smoking because of her cancer, to stop smoking in another way.  I never do 'nocebos'. I never undermine a person's work on their wellness or suggest they can't.
I've dozens of students in my practice whose grades have gone any where from failing to passing or from c's to A's and I take that as evidence of the effectiveness of therapy.  Naturally I have all manner of psychiatric disorders improve or get better but take even more pleasure in seein my patients with somatic illnesses and addictions get better because these have more obvious 'markers' for the success of the interventions I'm using.  Some of my patients are just living a lot longer than their doctors predicted and I like that too. I actually take great pleasure in my patients getting better and leaving practice where I had a locally famous pharmacological psychiatrist say his patients never got better and always had to see him. He didn't see any irony in this because frankly he's a fairly stupid rich thug and gives pharmacalogical psychiatry a bad name by his barbarianism.
These days I enjoy working with addicts and take every success to heart because the life expectance of a downtown eastside addict is maybe 30 years of age or so.  I love seeing alcoholics and addicts achieve sobriety or needle users get off needles.
Alot of my work with somatic illness is to get patients otherwise dying to adhere to their medical regimen. I work with some of the finest endocrinologists, cardiologists, neurologists, gastorenterologists and internists who every once in a while phone me and tell me that they realize that their patient is alive and following medical regimen since seeing me and that before that they didn't think they were going to live out the year. I am blessed to work with some of the finest of family physicians as well and so often together with a motley team of community resources manage the most difficult of patients watching them go from the dregs of life to whatever passes for normal living.
I had alot of fun working with a pediatric endocrinologist getting teen agers to accept their diabetes and take their insulin. She was great to work with and together we had tremendous succes with this really tough crowd.  Overdoses and diabetic catastrophes literally stopped the year we worked together.
Trauma interests me now. When I worked with the military and police what  I learned in hypnotherapy helped me walk people through the trauma that had given rise to often chronic ptsd.  It's one thing to remember but remembering can re traumatize. So how one does this is really tricky and I enjoyed honing my skills with these amazing heros of our society.  I loved having them tell me their nightmares were gone but mostly I had a great deal of fun working with a military captain and his secretary who truly loved the vets who had been in the front lines. Often these were the ones who were most stoic and least likely to talk about their experinces. This beautiful captain doctor would send these amazing men to me and over time they'd tell me stories that I was truly priviledged to hear, often stories that had never been told.  Not only would Veteran Affairs be able to help these individuals then but also we could get psychologists trained specifically in the treatment of ptds to help these folk regain their lost lives.
Oh well, that's about all I'm going to say about hypnotherapy.  I did regress a guy in hypnotherapy once by saying "I want you to go back to when you were happy' and he told me he was surrounded by blue and felt warm and there was this loud comforting drum beating.  He was back in the womb.  He had chronic depression and never had a happy day in his life as far as I could see so my task went from restoring a sick man to health to teaching a blind man to see. All the failed therapies he'd had hadn't taken into acount that he simply had nothing to build on.  Hypnotherapy certainly helped him.  His telling me he actually felt what he understood to be happy one day, really did make my day.