“Insight psychotherapies’ were those historically called ‘psychoanalytic’ including Freudian, Jungian, Adlerian, et al. Despite the profound scientific work of Cameron proving their validity and superiority to several other modalities of psychiatric care, they are not generally publicly funded today. They are privately available and highly effective for certain patient groups.
The psychoanalysts in the American Psychoanalytic Association used to begin their therapy by advising the patient that the cost of therapy would be $100 an hour (now $200 to $400) and that therapy would be 5 hours a week and likely last for 2-3 years. During the first 6 months the analysand was not to change their job or their marriage without thorough discussion with the analyst. We used to joke that this was pragmatic in that it ensured the income that allowed for analysis but in fact it protected patients from the all too often destructive outcome of therapy, where in the individual makes geographical or relational changes with minimum insight only to fall into the trap of ‘repetition compulsion’. I argue strongly that the divorce rate in America is not only the product of hungry divorce lawyers and irresponsible self serving government courts who make the most by destruction of marriage and harm to children , but also . under trained therapists who contribute to ‘blaming’ rather than the gaining of wisdom and insight.
Insight therapies looked at the relationship of an individuals conflicts today, in relationship to conflicts in their earlier personal life. It was thought that unconsciously the past was being re-enacted in the present unconsciously and with insight the person could make healthier future choices. The classic example is the anti authoritarian person who has never addressed their own conflicts with their parents. This is the individual trapped unconsciously in adolescence unable to make their bed or be self supportive but certain as to how the world should be run. Alternatively it’s the man who marries his mother or the woman who marries her mother unable to move on from a ‘cathected’ relationship. The success of psychoanalysis and it’s relevance, and the truth in the ‘Freudian slip’ is mainstream knowledge. Once arcane the very notion of the unconscious with it’s drives is taken for granted to a large extent. Analysis of transference and countertransference, dreams and fantasies and free association are all technically part of this therapy.
I did this for years and continued to have some patients in which I was mostly doing insight therapy until very recently. Psychoanalytic psychotherapy was the first major variation of psychoanalysis and it involved the removal of the couch with the Analysand unable to see the analyst and because of cost reduced the frequency of visits to weekly or twice weekly. The next major variation was the introduction of ‘short term’ therapy versus traditional ‘long term’ therapy , the latter being open ended and often carrying on for years, sometimes decades. Short term therapy tended to be 6 months to 2 years of therapy. This conflicted greatly with insurance plans which began arbitrarily to offer only 10 to 20 or sometimes 20 to 40 sessions arguing that therapists would let the work expand to fill the time available. Today some ‘plans’ offer 4 sessions while others offer none, while claiming to be ‘medical insurance’, like the car insurance plan that ‘excludes’ collisions.
The conflict between public and private sector therapy, economics and science has profoundly damaged psychotherapy at the benefit of psychopharmacology which has historically been an inferior approach to the majority of psychiatric conditions except schizophrenia and classic manic depression. . Psychopharmacology has it’s strongest validity in psychotic disorders but not in the mood disorders and anxiety disorders. It’s benefit is really apparent in acute conditions but its value dwindles with recurrent and chronic conditions. This was a huge area of conflict in psychiatry and as psychiatrists made an unholy alliance with the pharmaceutical industry, the psychologists moved into compete with their psychotherapy. Often today it’s a psychologist who is a Freudian or Jungian psychoanalyst whereas originally only a psychiatrist could go onto be an analyst.
Historically, to the chagrin of psychologists and nurses the , psychologist to the psychiatrist was considered the same as the nurse to the doctor. Now everyone was to be leader but few want responsibility or accountability and a new class of administrator wants it all, except they don’t want to every be at the frontline and never came from there either. Their perfect knowledge and depends on their perfect ignorance
Meanwhile money and insurance funding and patients desires and the culture and society strongly influence the psychotherapies.
The patients who were best for Psychoanalytic Psychotherapy, those who gained the most were described with the acronym of YAFFI. These individuals remain to day the most desirable psychotherapy and counselling patients. The Y stands for Young. The young are more opened minded in general. The A stands for Attractive. If one was to sit for years of one’s life working with a patient one wanted to find them attractive. This counter transference factor was significant for therapy as well. The more ‘attractive’ the patient the more hopeful the therapist. F stood for Financially stable or affluent. The second F stood for focussed. The I stood for intelligence.
The key feature of psychoanalysis is that it was an ‘insight’ therapy not a ‘change’ therapy. The assumption was that with ‘insight’ change might follow. However, this wasn’t necessarily true. More often the outer aspects of the analysand’s life weren’t at issue. It was the inner world. In medicine people are described as having ‘symptons’ , or subjective complaints and ‘signs’ or objective complaints.
Freud said that Mental health was the ability to Work and Love. The WHO definition pretty much carried this forward with the addition that today we think of Mental Health in the broad sense as ‘the ability to love, work and play”. The reason word has been ‘ability’ as more and more people feel entitled to play and reward without work or relationship.
The original patients of analysis commonly were successful in their work, independently wealthy, often with intact loving families and perhaps some problems with play but mostly ‘dissatisfied’ with their lives. They were not happy. They often suffered greatly with what were described as ‘neurotic’ concerns. Neurotics were described as people who were rather likeable and successful but ‘got under their own skins’ whereas ‘personality disorders’ or those with ‘characterological disorder’ commonly lacked insight and ‘got under other people’s skins’. Developmentally the neurotics were overall considered ‘higher developmentally.’ Personality disorders were considered more primitive and prone to more ‘immature’ defences like ‘denial’.
Anna Freud described ‘lines of development” , that described the development of a child to an adult. The simplest was the movement from narcissism to altruism. Different defences or coping mechanisms were identified and seen in a developmental way, example ‘denial’ to ‘insight’. The psychoanalysts identified the unconscious mechanisms and in therapy would identify these in the free association and dreams of the patient. The classic and of especially important note today because of the lack of insight and development of judges collectively, as their world is the rather flat rational world of the 19th century while the rest of us must inhabit a 20 to 21st century reality, is ‘projection’. The court room has always been a theatre as some might argue all the world is a stage.
A person may say ‘you want to have sex with me’ when indeed they are the one who wants to have sex. The courts in their self serving rationalist archaic references, they are best in the written and video world but not the real world, ignored that women ‘show sex’ and ‘men say sex’. The demand of the male dominated courts for women to be masculine and ‘say consent’ and indeed ‘write contracts of consent’ is just one of the examples of the unscientific inhumaine and rediculously patriarchal court approach to the reality of human affairs.
Projection and projective identification were complicated defences identified mostly in narcissist and borderline personality disorders. They speak to the development of a mature ego with it’s ability to know where one’s self begins and leaves off. The courts often focus on the ‘individual’ when ‘individualism’ simply istn’ a developmental attainment of some cultures where the individual identifies with the family, tribe or gang. This results in the whole failure in court of the ‘alibi’ and yet the courts refuse to move from the 19th century rationalist world to the present day scientific world. Indeed judges and lawyers simply aren’t required to study little more than the same material 19th century arts students did while the world today has of course advances beyond the court along with a very sophisticated society with multi ethnic presentation and even multiple presentations of gender expression.
Obviously these are generalizations and the fact that we are at peace and the society muddles along reflects the individual and collective work of fine men and women who are judges and work with the broken nature of their profession.
Insight psychotherapy is normally set up on a weekly basis, so that every Tuesday at 10 am the person was in therapy. Because the basis of the insight therapy was ‘free association’ and ‘dreams’ the therapy required ‘no interruptiopns’. It was more like a ‘meditative space’ with therapists and patient engaged in a process much like hypnosis. Freud was a hypnotherapist and his techniques of therapy were based on hypnosis but with the patient in a lesser state of trance than formal induction. With the therapist sitting out of the view of the patient there was a level of partial sensory deprivation. In face to face insight therapy the therapist was completely neutral. If the patient said they wanted to kill themselves or the therapist, the insight therapist was ‘non reactive’ in even those extremes. They were in ‘observer’ mode and there to allow the patient to ‘explore their own unconscious’. Insight therapy was ‘analytical’ and not ‘emotional’ and indeed very much the opposite in many ways of ‘supportive therapy’ or ‘relationship therapies’ of today. The correct answer to questions regardless of the emotional state of the patient was usually, ‘how do you feel about that?’ And ‘do you recall another time in your life when you felt like that.”
The poor therapist who ‘rescued’ the patient or gave into what is commonly described in therapy as ‘emotional extortion’ failed in training and was told that they were best suit for the ‘lesser’ ‘inferior’ form of ‘supportive or relationship therapy’. The worst insult was such that a psychiatrist become a psychopharmacologie the who was seen as ‘giving medication’ like ‘breast milk’ to the patient and ‘infantilizing’ them. The hardest part of parenting a child was ‘letting them’ walk and ‘letting go’. Till this day I still remember with utter fear teaching children to drive, and am humbled by pilots and other heavy machine operators who teach others to manage this equipment. I was equally humbled when the surgeon teaching me said that I could take the scalpel and continue. That was psychoanalytic psychotherapy, not the watered down stuff of todays counselling which is equivalent to ‘massage’ versus surgery. It’s wonderful and feels good but is highly ineffective and in research showed little of the robust outcomes that traditional psychoanalytic therapies did.
Psychoanalytic psychotherapies were major ‘change’ therapies in the selected populations with which they were found to be highly suited. With ‘insight’ a YAFFI normally changed their behaviour to accommodate the new understandings they gained in therapy. They stopped acting ‘unconsciously’ and gained insight as to how their life was troubling because they were living a life their parents wanted or they wanted as a child but that today they did not see the merit of those actions. In insight therapies people made major changes slowly and went onto major successes.
Psychoanalysis was funded extensively as a ‘change therapy’ initially in the heyday of psychoanalysis, the 30’s to the 70’s. Consequently because it was tried everywhere, It was found to be not effective in a variety of settings. Counsellors persist in using ‘insight’ therapies in a variety of cases which were considered inappropriate for psychoanalytic or ‘insight’ approaches. Psychoanalysis and insight therapies are likened to surgery whereas counselling is likened to massage. The power of the insight therapy is in the knowledge of the symbols the individual has developed. The success is in the detail.
When I did psychoanalytic therapy it was common for me to a) have to teach patients ‘free association’ and resist their attempt to change this to ‘dialogue’. I had to remain aloof and this commonly took 5 to 10 sessions just to get the patient to the point of ‘free association’. I have tapes of therapy where I’m essentially silent as a therapist for weeks or even months. I begin the therapy by ‘hello’ and end it with ‘we’ll continue next session’. They free associated about their thoughts ,dreams and fantasies, usually beginning with the immediate week and then because of the weekly sessions picking up where they’d left off going deeper into understanding what R. D. Laing called the ‘knots’ in their past, those areas which seemed to keep cropping up to undermine one’s happiness. In time I’d then be able to help the patient with a sentence or a word to see a more present issue in the light of experience. ‘That sounds like how you described your first friend.” These ‘nudges’ resulted in the patient picking up the story.
The therapist in the psychoanalytic session is mostly ‘behaviourally’ “passive’ and ‘reflective’. The analysts by contrast to the surgeon was the least ‘active’. In Transactional Analysis the relationships were described along the spectrum of Parent, Adult, Child. In surgery the surgeon is the ‘active’ parent and the patient is the ‘unconscious’ child. By contrast in psychoanalysis the therapist remains the ‘parent’ but the analysand is the active one doing all the ‘work’ of therapy, the ‘talking’ and ‘reflecting’. The analysis makes ‘incisions’ as it were to assist in puncturing what have been described as ‘deep abscesses’ in the ‘unconscious’. The ‘interpretation’ was scalpel like. The classic one of humor, being, “you want to fuck your mother’, the therapist says when the patient describes their relationship with their spouse who is indeed uncannily like the mother. Portnoy’s Complaint is one of the best novels describing the insight process. Much of therapy is the patient trying to win you over, engage you, seeking reassurance and all the while the classic therapist remained aloof.
Having spent years in psychoanalytic psychotherapy in training to be an psychoanalytic psychotherapist I can honestly say I don’t know if my therapist ‘liked me’ or ‘didn’t like me’. He was as aloof as a surgeon in this regard technically. I knew he was a compassionate man but I didn’t know if he ‘liked’ me. He might well have ‘loved’ me in the general sense but despite my own attempts to be engaging and entertaining and ‘nice’ he remained the excellent technician he was, forcing me to look at my desires rather than changing the externals of the relationships.
By contrast ‘supportive psychotherapy’ and ‘counselling’ is a relationship in which the therapist is the ‘caring parent’. There is never any investigation of the ‘negative transference’. Change in psychoanalytic therapy came mostly when the ‘negative transference’ was being analyzed. This is where the therapist works through the ‘idealization devaluation’ phase which is normal in adolescent development and is always a stage in ‘good insight therapy’, but avoided in ‘supportive therapy’. Most of counselling never matures to this ‘adolescent phase’. The patient rarely ‘leaves home’ fully. Counselor and client work busilily together addressing ‘industry’ level conflicts but never go to the dark nether reaches of the ‘adolescent’ attachment issues and ‘alienation’ and such.
Psychoanalysis did not appear to work with prison populations. It had very limited value in addicted populations. It was not particularly good either in helping people who had not matured to the ability of being independent and having work and relationships. It required the therapist to do their own therapy formally which was costly and demanding. Few counselors want to go to that rather ugly place where you work through your ‘caring ‘neediness’ and address the anger at the mother rather than persisting in being ‘pleasing ‘ and sucking on the tit of the patient by being a ‘liked’ mommy rather than the much tougher and more mature ‘good mother’. The fact remains that psychoanalytic therapy was an apprenticeship like surgery and can’t be learned from books or weekend retreats. It required a therapist to change themselves and have insight themselves and to know their ‘counter transference’ issues. Most counselors are ‘needy’ compared to the surgeon and the psychoanalyst who is increasingly most interested in technique and outcome. The drama is far less interesting.
Presently I’m seeing a very few people for insight psychotherapy. The College of Physicians and Surgeons being dominated by the Consumer Health Care Model and the Communist Health Care Worker model demand that the psychiatrist be ‘popular’. The very nature of ‘working through’ negative transference is that the patient like the adolescent goes through a process of not liking the therapist or therapy and indeed sees the problem as the ‘therapist’. Today even our culture is celebrating the angry destructive adolescent and those who say ‘okay boomer’. The political’ leadership’ has indeed lost it’s compass and is often directionist but always hedonist. If a patients grandiosity and egotism is sufficient they will want to destroy the therapist for the sake of the world. They are not just helping themselves remain in denial but now are on a crusade.
The administrative doctors because of their own developmental delays and grandiosity, have themselves left patient care for the aloof ivory tower of authoritarian governmental parentalism. They are glad to collude with the unhealthy patients and ‘police’ the psychiatrists who are a threat to them because collectively administrator are the most immature and least ‘psychologically minded’ of doctors. Administration is safe authoritarianism. Administrative doctors today make surgeons collectively look humble. Administrative doctors are police.
Psychotherapy was a ‘therapeutic alliance’ and required ‘selection’ as so few patients were ‘appropriate’ for that therapy. The Communist Model of Canadian Health Care with it’s affirmative action components demands that psychiatrists not ‘choose’. Everyone is ‘entitled’ to the same therapy’. Patients demand ‘insight therapies’ because they like the television image of what is essentially ‘counselling’ in which the person waxes poetic and the understanding counselor listens adoringly. It sadly reinforces negative behaviour in those who are not sufficiently development to use insight. It’s an aberration of modern times.
My favourite patients were the addicts who had some counselling variation or aberration of ‘insight psychotherapy’ who would later always tell me they ‘loved’ the counselor all the while they were drinking more and losing their jobs and marriage. That counselor taught me ‘I drank because my mother did’t love me. ». More reason to drink. Serial murderers would love those ‘counsellor’s. The counselor was doing classic Carl Rogers relationship therapy with some Mennigerian elements of Insight therapy to keep the counselling pseudo cerebral and the patient was drinking more telling their buddies that the counsellors helped them see their mother didn’t love them. Imagine serial murderers and pedophiles. History forgotten repeats. There is an extensive history of research from the 50’s showing this but today’s counsellors get the 6 month or 4 years shake and back instant preparation and are little different than the ‘quick back’ surgeon with a few months of training. Better than nothing and indeed social workers more than psychologists having humility and immense frontline experience were able to rather quickly overcome the deficiencies of their academic models.
As a hypnotist doing hypnotherapy as when I did sodium Amytal interviews and therapy I needed to be thoroughly focussed on the session. It is very demanding and focused. You can’t be taking anything other than ‘process’ notes and you can’t be considering that an Insurance Company or College or Lawyer is going to be reading the ‘notes’. Today administrative doctors don’t really care if the patient lives or dies, what matters is the chart. So today some of the worst doctors, therapists and surgeons get the greatest awards and advancement because of their immense success writing fictitious accounts of their work. Much like politicians.
Many of the analysts and whole schools of analysis did not allow the therapist to engage with any outsider, didn’t talk with parents, didn’t talk with partners, didn’t talk with insurance agents, or lawyers or college. If the patient asked that, that request was indication that therapy was ‘ended’. The patient had as much called ‘uncle’ in the therapy which has sometimes been called the ‘struggle with the patients demons’. In Kleinian schools of psychoanalytic and insight psychotherapy there is an ‘administrator’ who is assigned to deal with all aspects of therapy other than the actual therapy. Even ‘paying for therapy’ become a ‘transference’ issue. Patients commonly would express their hostility like adolescents who refuse to make their beds, by refusing to pay for services.
When a patient refused to pay for the services the College of Physicians and Surgeon colluded with the patient and said that the therapist was being unreasonable to expect the patient to ‘pay for the cost of photocopying’. Administrative doctors commonly developmentally mired in adolescence defences themselves with ‘identification with the aggressor’ and ‘splitting’ as their weapons of choice, ‘lick and kick’ their own way to the ‘top’.
The College of Physicians and Surgeons always like more and more of the judges wants to be ‘the good mother ‘ and forces the therapist and other adults in the community to be the ‘bad father’. The patient thereby ‘punished’ the therapist with the collusion of the College. Splitting is central to the ‘politics of today’. Whenever I’ve been called into the College of Physicians and Surgeons , the administrative doctor and ‘brought shamefully before the ‘august’ authorities’ I have never had a psychiatrist present when commonly a 19th century rationalist administrative burnt out low brow arrogantGP and a 19th century rationalist lawyer have punished me for challenging patients to reflect or even change psychopathic behaviour. On a half dozen occasions patients with DUI’s and bosses and wives on ‘my side’ have ‘objected by being ‘diagnosed ‘ as ‘suffering ‘alcoholism’ or ‘addiction’. Therapists have shot out my window and threatened my life and killed my dog for ‘making the diagnosis’. Meanwhile I’m a good therapist and the government and it’s representatives makes money as ‘drug dealers’ and ‘alcohol peddlars’. Sociopaths and psychopaths would rather ‘kill the messengers’ , lie and say ‘fuck you’ rather than reflect on their characterological defects. The final straw was when I refused a wheel chair to a ‘malingerer’ who didn’t ‘need’ a wheel chair and could walk perfectly and did so as captured repeatedly on camera went to the Minister of Health, the Minister of Health of the government required me to give the patient back the wheel chair. He was using it in his management work in sex trade. The Minister of Health no longer supported the doctors as the Attorney General no longer supported the police. The front line workers found quickly they were alone and increasingly no one wants to deal with ‘negative transference’. Euthanasia and « MAid » are the rising industries today. Indeed therapy studies show that the patients ability today to ‘recovery’ is greater than the ‘therapists’ belief in their ability. But then the therapists today have no support.
I’m surprised anyone does psychoanalysis in Canada today and really figure it’s probably no longer something that can be done in the public system. Ineffecutal very popular counselling is far more attractive in the same way that the government is increasingly telling addicts and alcoholics that the therapists who seek abstinence are uncaring whereas they the loving mother therapists will give them their alcohol and drugs .
It’s always been said in insight therapy that therapy begins when the therapist says ‘no’. Don’t say ‘no’.
Why change when ‘being offended’ is so much more lucrative. The cornerstone of therapy was that the patient saw their need to change and that the role of therapy was not for the doctor to change. Today there is even Dr. Google who would have in the day told Freud and Jung to go stuff themselves as all they were wanted for was to agree with the patient and sign the chit.
Indeed most of psychiatry and psychiatrists have been co opted by insurance companies , pharmaceutical companies, laboratory services.. the STATE and by the Courts. Indeed the least paid activity for psychiatrists is psychotherapy of any kind.
In psychoanalytic therapy we used to call ‘insight therapy’ and other ‘change therapies’ as ‘therapy’ whereas ‘medication therapy’ and ‘supportive therapy ‘ were ‘management. “Management’ is mostly what doctors do and the greatest money to be made as a psychiatrist indicating what the College, Government and the society at large want from them is to sign prescriptions and write notes for insurance, occupation or court. Management demands in their inadequacy that psychiatrists and all physicians indeed ‘manage’ their patients since ‘cure’ is a higher level of comprehension and requires a greater level of hands on experience.
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The following is another story. I don’t know how to outline and cut or cut and paste on this blog program. I’d like to keep this rough draft.The one above I’ve reviewed and as usual watched how I was writing fine and informational material until I mentioned the ‘College of Physicians and Surgeons’. I have PTSD from being held hostage, threatened, shot and physically attacked in my work in offices and prisons and asylums. Nothing is more ‘abusive’ though than dealing with the Borg of the Beurocracy. This is Kafka’s Castle and they have caused me untold pain and suffering simply with their belief that they don’t cause untold pain and suffering and see themselves as ‘good tits’. All the evidence of history especially Nuremberg Trials suggests otherwise but anyone who questions ‘authority’ in this society is punished still by the totalitarian government models and as malingres, addicts, borderlines, sociopaths and psychopaths know the power of and ‘use’ spliting’ the present ‘authorities’ are doing untold damage to patients by supporting the malingerers, sociopaths etc to the detriment of the health care which is now coopted by anything but health care. This hijacking of essential services has it’s own history and was best done by Hitler, Lenin, Trotsky. The US today has been ‘split’ into a ‘democratic majority house’ and a ‘republican majority’ house and yet no one will accept the historic interpretation of the war of ‘good and evil’. Freud described the drives as ‘life force’ and ‘death force’. The history of health care has been in Canada and other communist countries the destruction of the power and autonomy of the middle class and the ‘guilds in general’. There is a return to the elite and peasant or king and peasant or ‘communist committee and peasant model and the use of the brown shirt, the antifida and the mafia and borderlines to this end along with the ‘illegals’, ‘illegal migrants’ , ‘illegal addicts’, ‘illegal protestros’ makes the model of psychoanalysis with the idea of the ‘doctor’ and ‘health care’ precarious. Death is preferred. There is always more money in killing than healing. There was more money offered to me for doing abortions than delivering babies.
So I get derailed. I think someday I’ll ‘purify’ my history and discussion of practice and write a book without the despair and sadness I experienced dealing with the sociopaths, borderlines and narcissists in government who were at times far more disturbed and dangerous than my sometimes dangerous patients. I think I’ll be removed from the trauma of work without support and with all the promises broken and I’ll talk about just how to put a thumb in a damn to save the wall. But today I see that I get derailed. I see the Pope defending Pedophiles. I see Judge Curry . I see a stoned prime minister paying a terrorist 10 million dollars to kill a good American soldier. I’m in despair and struggle each day to help patietns who continue to come to me and want to ‘do the right thing’ and want help ‘being good’. And want ‘symptom relief’ mostly because they’re struggling in todays toxicity where more and more shit is coming down on all but the elite.
When I began in psychiatrist it was said psychotherapy wasn’t needed if a vacation or a raise could solve the problem. The normal complaint I see today is « I’m homeless’.... »I can’t pay the rent’.... » I can’t afford school’...I can’t find a job’.....People break into my apartment every day......I was robbed three times and the police just recorded it.....I was raped and it’s the second time and nothing is done....all the girls in my neighbourhood have been raped.....the ‘problems’ are ‘social work’ problems and I’m reduced to ‘supportive therapy’ and ‘writing letters to get funding, housing, mediation and health care’. I’m no longer asked to be a ‘neutral’ psychiatrist but a ‘street worker advocate and social worker’. Given the shortages I’m irritated by colleagues who don’t work in the field but increasingly doctors are avoiding the ‘front line’s because they have no back up. Police told me they are afraid to be first to shootings because of the same. No wonder there was 20 minute delay the last time I phoned 911. Of course administration is afraid too.
One day I’ll ‘edit’ the blog and cull the ‘good news’ and leave the negativity in the basket. Editing is a summer time job. Not now when I’m looking outside and grey and should be writing gratitude lists because despite all the shit life goes on and things really improve and patietns are benefitted great élu by the hodge lodge and the Minister of Health is a good enough guy and the College of Physician and Surgeosn like the Judges and Coursts are mostly doing good. There are less homicides in Canadia. People live longer. There’s generally so much good and I personally have to write stuff which reflects that ....focus on the positives of psychotherapy and address the benefits of ‘insight’ without the ‘snide’ comments or the criticism of the ‘other’ guy. I have been in volves the last couple of years in ‘politics’ which is outwardly focussed. We criticize the other guy and secondarily improve our ‘brand’ or ‘product’. It’s like hockey. I am in a ‘war’ with the other team and ‘call them down’ and ‘psyche ourselves up’ but I need to focus on the positive. This is better. In my work I do. In my personal life I flog myself and see the negative and flaws rather than seeing the sacred and holy. The world is beautiful. God is good. There is good in everyone. I have to be that way inclined. But I’m a novice. So for now that’s the parallel in psychotherapy. The struggle.
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To be edited for typos etc.
With that said the next therapy form was Cognitive Behaviour Therapy. I was formally trained and supervised for 6 months in CBT in 1986 by one of Canada’s first proponents and leaders in this therapy which derived from Dr. Beck. CBT was a parental education model with the patient as ‘student’ and homework assignments being given and the role of the therapist not as ‘listener’ but as ‘teacher’. The therapist was ‘active’ and the nature of the work was always in the conscious realm. “Negative transference’ was never addressed. The therapist didn’t say ‘no’ and mostly this was coupled with psychopharmacology so the ‘good mother’ not only taught the child ‘good thinking’ but also gave her the tit with ‘good drugs’.
My interest had been ‘non compliance’ or ‘non adherence with medical regimen.’ At the time morbidity and mortality were the model of care. Doctors were compensated for restoring patients health and returned them to work and relationships and extending their lives. In CAnada today the health care system has introduced Maid which means that the role of the doctor is no longer quality and quantity of life but may simply been to assist with ‘quality of life.’ I thought I was a good boy doctor because I’d stopped hundreds of patients from killing themselves , got thousands back to work and in relationships with much active work on my part. Today if a person wants to kill them selves government psychiatrists are offering them Medicall Assisted suicide or ‘feel good’ drugs. It’s fairly dumbed down. There’s certainly no ‘struggling with the demons’ ,or need to keep patients alive,. You get paid whether they live or die. It’s kind of like Climate Change or Bipolar Disorder .You win heads or tails. You get paid regardless of what you say or predict. Very nice for the therapist but not so good for the patient perhaps. The key though is there is longer an agreement of outcome. The doctor whose patients all die or all remain drunk may well be elevated and paid the most whereas the doctor whose patients live and change might not be liked. It’s all politics and popularity now.
The key to psychoanalytic psychotherapy was that it indeed viewed competing drives. Freud saw individuals as having within the unconscious an Eros or life with and ‘thanatos’ or death wish’.
CBT works very well with compliant patients. The trouble is that ‘education’ as a model has major limitations as evidenced in studies when seatbelt ‘education’ resulted in only a few percent wearing them whereas a ‘fine ‘ resulted in 90 % compliance.
Psychoanalysis began with motivated patients.
Today there has been a whole focus on ‘Change’. Dr. Watsylwalek out of the Palo Alto group wrote a book and began to assess therapy relative to change. It wasn’t about ‘feeling good’ but ‘doing good’. In CBT you felt what you thought. But in Change Behaviour feelings were thought to follow from changed behaviour. The whole concept of ‘Secondary Gain’ which was central to Psychoanalysis was again addressed.
Motivation Therapy which assesses first the ‘Willingness to Change’before assigning resources specifically works on changing behaviour. STory Telling therapy is another ‘change behaviour’ which works on ‘changing behaviour’. 12 step facilitation therapy works on changing behaviour. Indeed there are a variety of new models of therapy which use ‘change of behaviour ‘ as the point of outcome. Not ‘feeling good’. These are advanced in Occupational Therapy schools.
Somewhere back there I typically began to wander. If I were to actually be writing a paper I’d stop with the discussion of psychoanalysis, avoid mentioning the Borg College which invariably throws me off thinking rationally about therapy. It’s as bad as mentioning politics today. Like most of my patietns I’m in Existential Fog. ‘What the fuck happened.”
When I began in psychiatry and did psychotherapy for decades it was an old adage if a person ‘s problem could be solved with a raise or a vacation it wasn’t a psychiatric problem. Thanks to government mismanagement and society change and the rise of the black market and delusional processes, the majority of my patients have principally ‘sociological’ issues. As one psychiatrist said, “I feel I should stand in the office with three signs and hold up which every one applies. His signs were ‘GET A JOB!” “GET MARRIED” or “GET A LIFE”. Most of his patients wanted to feel good but without eating vegetables. Their lives were so socially unbalanced that there was little expectation psychological change would help. Half or more of my patients are physically severely limited. Increasingly my psychiatric role is ‘advocate’ whereas the government saying they want to help patietns punish those who actually are on the frontlines. The wealth of medicine is now far removed from the patient doctor interface. The patients ‘depression’ is increasingly tied to their financial problem and the health care system doesn’t pay for the therapy they ‘need’. There are ‘cures’ for ‘cancer’ but their ‘government health care plan’ doesn’t cover that.
Patients are no longer depressed because they’re psychotic but indeed the ‘system’ is psychotic. The lunatics are out and the normals are in the asylum. There’s all manner of ways of saying it but mostly my patients would get a whole lot better with a raise or a vacation and what they’re told they get is another as like antidepressant when what they need in their work is cocaine because they’re being asked to do the job of ten people for less a and less compensation Mostly they can’t afford to live in Vancouver. Those aren’t traditional psychotherapy issues. Increasingly I’ve been ‘teaching’ people how to hire a lawyer, access advocacy groups, get into an education program, get funding. I’m doing ‘social work’ because they don’t have social workers. I’m increasingly doing general practice medicine because 50% of patient don’t have a family physician and 80% of psychiatric patients don’t. So rather than thinking of what’ unconscious issues or drives are involved in the patients presentation’ I’m actually ‘rescuing’ the patient by writing a prescription for an antibiotic. I’m constantly fighting for patients to have what the government insurance policies promised them but has refused to provide them. I am waiting 2 years for sleep disorder consults and 6 months for MRI’s. Increasingly patients are asking me about euthanasia because of the delays and beurocracy and their negative social situation. Many of my patients are living out of plastic bags because of the cockroaches and bed bug infestations.
When a patient is bleeding the psychiatrist puts finger in the hole or applies a tourniquet. The Canadian Health Care System is so broken with massive interfering micromanagement and lack of communication and ‘divide and conqueur’ ‘splitting’ tactics of communist administration that doctors are doing little more than emergency care in general. Going to work for the last decade has felt more like being in a war zone psychologically than the golden years of psychotherapy when patients were not angry with all the broken promises and the general difficulties of ‘just getting by’. Now most of my patients have no money, no time and are utterly frustrated and want a quick fix and have read all the promises and fantasies on google and see the doctor as a threat because the alternative health care people ‘care’ whereas the ‘government physicians’ are just interested in money’.
Oh well. That’s the way it is. I miss doing insight psychotherapy , weekly seeing the same person, getting to know them in depth, not talking, sitting in my reclining chair, listening and watching the patient ‘change’. No medication. No ‘feeding’ the patient. No third party person demanding centre stage. I miss the drama of the two people in therapy. My friend went to jail because she refused to breach patient confidence. Nothing we say is sacrosanct. Everyone is watched. The paranoids are right. But I miss that nearly meditative experience in the quiet room. I miss hypnotizing people and seeing them go on to have surgery without anesthetic. I miss a lot of the past therapy eras, the power of group therapy and marriage therapy when I did it. But now I just do ‘walk in clinic psychiatry’. Like the ‘walk in ‘ doctors in general I miss the ‘relationships’ we had as physicians when we didn’t have to always be fighting for resources for patietns and when the patients were not so socially desperate. We could treat illness not this beaurocratic abortion with the black market and less and less communication and time. I miss the monthly meetings with psychiatrists and getting together weekly with colleagues to discuss cases. I miss the days when the administrators served the people but today we all serve the new masters and they are hard task masters and the problems are mostly ‘social’. When a person has food we can talk about dreams and fantasies. But insight psychotherapy has no place when people are starving.
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