The Academy Forum - Spring 2018, Volume 63, Number 1

The Academy Forum - Fall 2017, Volume 62, Number 2

The Academy Forum - Spring 2018, Volume 63, Number 1

The Academy Forum - Spring 2017, Volume 62, Number 1

The Academy Forum - Fall 2016, Volume 60, Number 2

The Academy Forum - Fall 2015, Volume 59, Number 2

The Academy Forum - Spring 2016, Volume 60, Number 1

The Academy Forum - Spring 2015, Volume 59, Number 1

The Academy Forum - Fall 2014, Volume 58, Number 2

The Academy Forum - Spring 2014, Volume 58, Number 1

The Academy Forum - Fall 2013, Volume 57, Number 2

The Academy Forum - Spring 2013, Volume 57, Number 1

The Academy Forum - Fall, 2012, Volume 56, Issue 2

The Academy Forum - Spring, 2012, Volume 56, Issue 1

The Academy Forum - Summer, 2011, Volume 55, Issue 2

The Academy Forum - Winter, 2010-2011, Volume 55, Issue 1

The Academy Forum - Summer, 2010, Volume 54, Issue 2

The Academy Forum- Winter, 2009-2010, Volume 54, Issue 1

The Academy Forum - Summer, 2009, Volume 53, Issue 2

The Academy Forum - Winter, 2008, Volume 53, Issue 1

The Academy Forum - Summer, 2008, Vol: 52, Issue: 2

The Academy Forum - Winter, 2008, Vol: 52, Issue: 1

The Academy Forum - Summer, 2007, Vol: 51, Issue: 2

My Mother's Work

By: Lillian Lesser, M.D.

The Psychological Effects of Movie and Television Sex and Violence on Adults: A Patient's Mother's Addiction to Television Violence

By: Peter Olsson, M.D.

The Business of Psychiatry: Marketing Your Practice

By: Gerald P. Perman, M.D.

Meet the Author of With a Woman’s Voice – A Writer’s Struggle for Emotional Freedom

By: Lucy Daniels, Ph.D.

The Analyst’s Analyst: From Judd Marmor’s Written Wisdom

By: Marianne Horney Eckardt M.D.

Dreams and Globalization: Far Away and Deep Within

By: James L. Peacock

The Fundamentalist Mentality and the Iraq War

By: Peter A. Olsson, M.D.

Aspects of Lilith: A Case Study from a South India Village

By: Hellen E. Ullrich, Ph.D., M.D.

Freudian Interpretation of Monster Movies

By: Scott C. Schwartz, M.D.

Words from My Heart: Presidential Address, May 2003

By: Ronald Turco, M.D.

The Complexities of the Term Hispanic

By: Efrain A. Gomez, MD and Gerda E. Gomez

Book Review: Irving Howe: A Life of Passionate Dissent , by Gerald Sorin

By: Richard D. Chessick, M.D., Ph.D.

The Academy Forum - Winter, 2003, Vol: 47, Issue: 1

The Academy Forum - Fall/Winter, 2002, Vol: 46, Issue: 2

Notes on September 11 and Afterwards

By: Leah Davidson M.D.

September.11, 2001, Riverdale ,New York, 6.30 a.m. I go to vote in the Democratic electoral primary. I had listened to the numerous candidates for mayor and decided that we need administrative experience in a city that caters to the corporations and their need for a cheap workforce, often under? or over?represented in the state and city budgets, according to political expediency.
9:15 a.m. My telephone rings while I am having breakfast. It is Eliot, who was coming to see me from Brooklyn at 10. “Do you have your radio or TV on?” he asks. “I cannot get over the Brooklyn bridge. The Trade Towers have just been hit by terrorist planes, and they are closing off access to the city.” Stunned, I rush to the television set just in time to witness the image of the first tower billowing out in a mushroom of fire and smoke, and the second tower being hit by a plane from the right. My TV is in front of my bed, and I collapse onto it immobilized. I do not feel like myself. I am both fascinated observer and wounded soul. It occurs to me that I have never liked those towers much as seen from the ground, but I remember eating and dancing at “Windows” and the “Brasserie.” I remember the Statue of Liberty seen from the observation deck on a glittery gold afternoon and the open vision of the horizon whence those immigrants came and still come to the piers and airports of New York. I wonder if the Museum of Jewish heritage is safe, housing our donated historical memorabilia brought to a safe rest and fruition here as nowhere else.

News comes of the Pentagon attack and the plane in Pennsylvania. My mind cannot hold or process what I am hearing. Filmed shots of people waving and jumping from the windows of the towers, followed people running away. Chaos. I am simultaneously numb and guilty for being so safe in my bed. It occurs to me that my patients may not be safe either. Even if I cannot cross the bridge into the office, I can make phone calls. Telephones are disrupted. It feels like an eternity before I reach anyone, some not at all. I have to contain my anxiety about them. A woman calls for a prescription of Klonopin. She has just returned from the site of the towers and fears she will not sleep tonight. It takes four hours to reach her pharmacy.

I watch the beginning of the attempt to clear the rubble at what is now called “ground zero.” My admiration goes out to the brave souls doing it. The sight of the twisted steel ribs of the huge towers sears itself into my retina. I see it whatever I try to do ?? which is not much. I too am immobilized. My sense of who I am has crumbled. How can this be, I wonder? I was never this identified with corporate America. Or was I? I feel stony, and I do not feel normal. I cannot eat. I do not want to go out of the house. All I want to do is lie in my bed and watch the horror unfold It occurs to me that I am an addict to grief. It occurs to me that most of the people in those towers were young, raised in a blue?collar world and moving into the lower echelons of the white?collar world. They believed in their futures.

It is night. I am exhausted from disbelief and detachment. I go to sleep by 10. having heard that the Democratic primary was a tie, and we have to have a run?off. What would have been important news now hardly seems to matter.

Septempber.12, 6.30a.m. I slept better than expected with no nightmares. I woke feeling more like myself with the thought that I needed to do something to contribute. The bridges are still mostly closed, and requests for donations of blood and money are not what I feel I can or want to respond to right now. Pictures of families seeking their loved ones in the rubble float by on the screen, tragic and repetitious. They too are numb and disbelieving. It will be weeks before the full impact of the horror hits us and them.

An irrational thought enters my mind. “There is going to be a war! Join the medical corps. Join the army.” I remind myself that I am a senior citizen and not eligible. This is not WWII, this is terrorism 2001. So what to do? I remember that the pharmacies were unreachable yesterday. People still need their medications. So I call a friendly drug representative and suggest that she and her colleagues from other drug companies deposit their samples at the Red Cross stations where people can get them. Later she tells me they gave out over 2700 of them. After doing this I feel better and more energetic.

I call the local police volunteer number and offer trauma counseling over the phone, but no one calls. They are not ready yet to deal with feelings. I call a patient who is a police officer on his cell phone. He tells me he is at the site on 24?hour duty sorting body parts. He says, “It’s awful. The families are in shock, and the smell is terrible.” Hearing this, I go back to bed. I still cannot go to work. Later I check my e?mail. Concerned friends from Poland, Israel, and Australia are asking if I am OK. My children and grandchildren have had difficulty reaching me by phone. I go to the supermarket to pick up groceries. People are mumbling and shaking their heads as they push their carts along. It is as if each person is in a bubble, processing what has happened alone. The bridges into New York are still on “restricted access” so it occurs to me to ask the check?out clerk if they are experiencing shortages of food. “Some,” she says without much concern. I remind myself again that this is not WWII. At home I turn on the radio and cook up a large pot of home?made soup, my comfort food in emergencies. I listen for further news, give up and go back to bed to watch the World Trade Towers go down over and over on the TV screen.

By evening I have managed to contact my patients and know they are all right. One or two are a concern, but I decide to wait till they reach me and they do. It is a great relief to know no one is lost. I am reminded of my emotional exhaustion only by the tension in my body. Usual remedies for this feeling like stretching or movement do not seem to work. Mind and body seem to be on hold. I remember a picture of a gopher someone once showed me, standing upright and vigilantly scanning the distance for danger. Right now, I think I am that gopher.

September 13 through November 25.

I do not know why I did not continue the daily documentation of this experience for all this time, maybe because I have felt so depersonalized and emptied of my life’s meaning. For about a month nothing has felt worthwhile or real. All goals and identifications seem to be on hold. I have had to keep reminding myself that I am a professional with obligations, that I have children and grandchildren who matter to me, that I must document what is happening. That life is important. Two days after the events I called a Muslim colleague in another town to express my sympathy about the anti Muslim riots in parts of Brooklyn. At the same time, my rage was unbounded when I saw pictures of Palestinians celebrating the event on TV.

My colleagues seem to be doing a lot of posturing and paperwork, organizing trauma centers which may or may not be useful. The emergency work was done by those brave souls at the hospitals who went down to “ground zero” and to the hospital pier immediately. My contribution to their effort was to hold two group sessions with some residents at a hospital I am affiliated with. They are all in the United States on temporary visas, from Rumania, Bulgaria, Israel, Singapore, Belgrade, India, and Australia. Concern about their own visa status was among their first reactions. Some had already lived through violent disruptive events and resented having their careers interrupted once more. Others missed the presence of loved ones and immediate family. One stressed her fear that she and her child would be mistaken for Arabs since they are brown?skinned. We shared their own reactions to patients from Islamic cultures as well as some of my own overreactions to what I perceived to be “Arabs” in the street. Some of the group were Islamic by birth and expressed discomfort about the extremist elements within their faith and about their differences from the rest of the group.

There is a poem by Mallarme’ written about WWI, called “Polpes,” French for “Octopi.” Mallarme’ speaks of the octopi at the bottom of the sea watching fearfully as aeroplanes fly overhead dropping bombs which the creatures experience as deadly eggs. The poet repeats a compassionate refrain while the octopi, confused, wonder about the boundaries of the sea and the edge of the land. I have felt exactly like those octopi. I did not want to spend time with anyone. I did not want to enjoy anything. I have needed a lot of sleep. Physical activity has been hard to initiate but routine tasks became almost a sacred duty and kept me from becoming totally paralysed. I realized that I had reverted to what I remembered to be my WWII mode. Slogans from that time surfaced in my mind. “Loose lips sink ships.” “Is your trip really necessary?” Needless to say, flying was out of the question.

The Jewish Holidays came and went. Many of us including myself were afraid to go to synagogue. I found myself angry at God, not wanting to observe the rituals. Reminding myself that personal spirituality was as important as ritual or temple religion helped, and I could restore my faith and hope that this too would find a resolution.

There is a story circulating around New York about a kindergarten child who said after the loss of the Towers, “It’s so sad. New York has lost its two front teeth.” Every time I look at images of the shore front I feel like that child. You cannot be pretty or social without front teeth. It’s also hard to feed yourself without them. Will our two front teeth ever grow back? I doubt it.

And then came the anthrax scare. People began to panic, buy gas masks, stock up on Cipro and to leave the city as much as possible. Going to the post office to buy stamps as well as opening letters became a hazard. I have faith that we will overcome and indeed we are doing better in Afghanistan and with the anthrax. However the silence from Iraq and bin Ladin feels ominous to me. I am prepared for more nasty surprises.

I am reviewing my life and documenting events as if my life is ending. I want to re?experience it all. I suffer from survivor guilt that manifests as anhedonia and procrastination on creative projects which might give me pleasure and satisfaction. I see this also now in patients as a delayed effect of PTSD. This must be fought against at all costs. Fortunately, some of my projects involve Holocaust memorial work, so two survivor guilt trigger factors come together in what I hope will be a final cure for a life?long misery of mine. There is a silver lining to every cloud they say. I hope so.

November 25 through December 16.

On December 11, New York celebrated the three?month anniversary of the attack. It was also Chanukah, a celebration of victory over oppression, also fought in the mountains. It is ironic that both wars were fought over religious issues, one about the freedom to worship as one believes, the other about the imposition of faith on others. Guilt is beginning to surface everywhere now. Patients have dreams about being and not being at the World Trade center to help. Those who were there have nightmares, flashbacks, anxiety, and depression. For many the recollections are so painful that they can not maintain themselves in therapy.

My housekeeper told me of a dream of her husband’s. He has been working on plumbing at “ground zero.” While she was out shopping he dreamt that “I came home from work, but you and the children are not there. The house is empty, and I am afraid. I choke with fear and pain.” At that moment their budgerigar began to sing and woke him. He saw this as an affirmation of life and love and went to feed the bird. A dream of my own mirrors his. I am on the observation deck of the World Trade Center, but instead of telescopes there are parking meters with large slots for money on the top and running scanners in the front. I put ten cents into the slot three times hoping to see the “outlook” in the scanner, but it is running by fast and blurred. I get more anxious with each insertion of the money. Then I become aware that there are people behind me waiting to do the same thing , so I give up and leave the line relieved. It is clear from this dream that I know there is no answer to our anxieties and that no one is clairvoyant, but I am not alone and I share these concerns with my community.

Patients bring me pins of jeweled American flags and glittering New York City apples with flags inside them as symbols of hope and renewal. I wear them proudly. Memories of 1976, when we celebrated our first 200 years as a nation come back to me. Memories of sitting at a concert in Central Park with the smell of dozens of ethnic foods all around me, and people of many different colors moving up to make room for one another happily, peacefully on the grass. Shared joy. Right now we share our vulnerabilities, our mourning, and a restrained enjoyment of life as it goes on quietly for each of us in the recesses of our souls. We are concerned for each other, and we are contained in our attitudes to one another. A brash, busy city has shown the world that we have a tender humanistic heart. We are praised for our politeness to each other right now. Many tell me to move out of the city, that it is too stressful, too economically vulnerable. I am not going anywhere. This is my city. I am proud to be a New Yorker. A time will come for fireworks, for celebrations, and for dancing. New York will rise again to glitter and shine like Joseph’s coat of many colors. I want to be there to see it and rejoice.

The World Trade Center Tragedy and the Experience of Disaster Psychiatry Outreach

By: Craig L. Katz, M.D.

In the fall of 1998 four senior psychiatry residents in the Columbia University Department of Psychiatry founded a charitable organization devoted to providing voluntary psychiatric services to all people affected by disasters. Disaster Psychiatry Outreach (DPO) grew out of their experiences responding to the crash of Swissair Flight 111 as part of a team of psychiatrists hastily assembled by the Office of the Mayor of New York. Struck by the work they did but unable to find an organization through which they could provide such psychiatric services in the future, they developed DPO in consultation with various experts, the New York City of Department of Mental Health (DMH), and the American Red Cross (ARC).
DPO has spent the last three years inching towards its ultimate goal of being able to respond to disasters at any time and in any place in the world. The September 11, 2001, terrorist attack on the World Trade Center struck on a scale, in a place, and a time always feared but never wholly envisioned by its founders and current directors - affecting many thousands if not millions of people in the organization’s own city when the organization itself still consisted of a devoted but small band of volunteers. DPO has since struggled mightily and seen much along the way of fulfilling its mission in its own backyard.

DPO previously grappled with a shortage of psychiatrists on its clinical staff. In the wake of September 11, however, close to two hundred psychiatrists have volunteered or offered to volunteer with the organization (up from a dozen). The clinical need and the inspired outpouring of volunteerism among our colleagues required the organization to expeditiously credential, orient, train, and coordinate an unprecedented number of staff in a uniquely brief time. To accomplish this and despite a shortage of funds adequate to the task, DPO’s half-time program administrator was upgraded to full time (really overtime), a full-time associate administrator was hired, and dozens of volunteer medical students and other non-psychiatrists from the Mount Sinai Medical School as well as other medical centers were recruited to work for DPO in the role of support staff.

Disaster psychiatry is unique in many respects, requiring close and easy relationships between psychiatrists and other relief agencies. DPO was able to deploy its psychiatrists into the community because of its collaborations with both the New York City Department of Mental Health and the American Red Cross, which permitted access to what were felt to be the primary sites for psychiatric outreach, the Family Assistance Center and so-called “Ground Zero.” These have been the central focus of DPO’s work, but other locales have included corporate settings, schools, and medical centers around the city, where both clinical and educational work was accomplished.

The Family Assistance Center (FAC) has been the central location for families to receive and provide information about missing loved ones. DPO was operating there within a day of the terrorist attack, making it possible for psychiatrists to participate in non-psychiatric roles where they could offer support, psycho-education, and psychiatry “on the fly” - reviewing hospital lists with families searching for loved ones in the days immediately after the disaster and initially assisting in the gruesome task of DNA collections. Many hundreds of people were seen in this informal capacity, with varying levels of emotional depth having been explored. DPO psychiatrists also provided individual consultations and group interventions and “de-briefings” from the outset. Up to forty such consultations have been done per day along with many more additional so-called “brief encounters.” A bustling “Children’s Corner” was also set up and supervised by DPO’s child and adolescent psychiatrists, working along with para-professionals to serve dozens of children and parents each day.

A sizable portion of what has been seen at the FAC is “normal” reactions to grief and trauma, including indifference, sadness, anxiety, inattentiveness, loss of appetite, nightmares, and insomnia. Similarly, among children, normal reactions on the order of regressive behaviors have been common. On the other hand, a considerable number of individuals have been seen who are experiencing depressive syndromes, of either recurrent or incipient nature. Some cases associated with suicidality were referred for hospitalization. A few individuals, mainly relief workers, have presented with hypomania and mania. Rarer cases of catatonia (mutism), new onset psychosis, and exacerbations of psychotic disorders have been assessed and treated.

The basis for DPO’s interventions has been a literature review conducted and written by its board over the last one and a half years entitled, “Disasters and Psychiatry” (submitted for publication, August, 2001). This review of the literature on trauma and disasters has established whatever empiric basis there is for acute interventions post-disaster. This academic work and DPO’s prior experience in responding to disasters was in the midst of being translated into a 17-page “Clinical Protocol” when the World Trade Center attack occurred. None-the-less the protocol has been reproduced with a notation that it is being revised and distributed widely in order to structure the practice of DPO psychiatrists in response to the events of September 11.

Talking treatments have varied from psycho-education to cognitive-behavioral and supportive psychotherapies. Basic but crucial interventions included advising families and workers alike to be sure to eat, sleep, and adhere to some measure of a routine. Perhaps the most needed and common intervention has been normalizing reactions and reassuring people that they are not “going crazy,” all the while educating them about what constitute “abnormal” reactions. Psychoeducational handouts have been helpful in supplementing this effort. An equally important role for psychiatrists has been one of advising parents about how to talk with and otherwise respond to their children in the face of the recent atrocities. Direct work with children has centered on drawings and play therapy. DPO psychiatrists were frequently asked to “de-brief” workers, an intervention which was practiced with the formal model of Critical Incident Stress De-briefing (CISD) in mind but tempered by a much broader model of psychoeducation and support. Massive donations of lorazepam and zaleplon have made it possible to provide these medications in either one-time only fashion or small supplies to people excessively burdened by their symptomatology, normal or otherwise.

Both full and brief encounter forms are available for recording all contacts with family members, children, and workers.

Medication logs and an on-site lock-box for the medications have ensured the safety and security of medication dispensation at the FAC.

Wherever possible, the FAC has been staffed with a mix of trainees and attendings, making it possible for supervision and teaching to be part of their experience (although everyone has learned something from their involvement, irrespective of their level of experience). Relationships with patients seen in these settings are not intended to extend beyond a single meeting or perhaps one follow-up meeting at the FAC; practitioners may see these patients in private follow-up only if no fee is charged. The National Alliance for the Mentally Ill has generously provided a continually revised list of local outpatient referrals for DPO psychiatrists to give to patients they have seen at the FAC or to use to provide them with a specific referral.

Work of an entirely different nature was begun with the workers at the site of the bombing in lower Manhattan, the so-called “secure zone.” Concern for the well-being of the thousands of law enforcement, fire, military, construction, and volunteers involved in the often grim work of search and rescue/recovery led to the eventual establishment of a team of DPO psychiatrists within that zone. This took over a week after the bombing to even begin to operationalize for a multitude of reasons. Initiation of this effort was especially hampered by the tight security at the site, which necessitated many discussions between DPO and government officials to work out a viable, sometimes convoluted, system for clearance of its psychiatrists to obtain the all-important red security passes needed to enter and move around in the zone. At the time of this writing, this clearance system has changed once again.

Once cleared to work at the site, DPO psychiatrists, outfitted with hard hats and respirator masks, could begin their work amid a scene that seemed like a horror movie come alive - the “pit” of mangled buildings, pungent odors, bright lights, and frantic activity surrounded by a perimeter of burnt-out storefronts occupied to support the operation with supplies and food. An initial team of psychiatrists from New York, Milwaukee, and St. Louis spent several days “scouting” the site in order to establish key locations at which to base operations. These were found to be several medical aid stations that lacked mental health support, a private gym that became a 24-hour rest stop for the workers, a Red Cross operated respite center for the workers, and “staging” areas at which workers congregated, watched the operation, and took brief breaks. Equally important during this phase was being visible and friendly so that workers could become familiar with the psychiatrists and the idea of their being there to talk and assist them.

The often roaming clinical work within the security zone has consisted of informal encounters begun over a meal, a cigarette, or even a security check that invariably lead to an outpouring of talk and some emotion from the rescue workers. Joking about being a “shrink” has been a creative and successful entry point as well. Sometimes a brief initial encounter has lead to a more intensive and frank discussion when the psychiatrist later re-visits a worker. These interactions have numbered in the hundreds already and center on themes such as the brutal conditions under which the work is being done, the horrific sights and smells, longings for missing co-workers, anger at the perpetrators of the atrocity, and the well-being of families not seen in days. No medications have been utilized as yet despite their availability. Currently these operations are being formalized through collaboration with federal medical teams dispatched to the site.

In brief, the days since the World Trade Center bombing have provided an unfortunate opportunity for psychiatrists to make a difference in a very profound way. DPO’s tireless and devoted psychiatrists have banded together in a special relief effort that transcends departmental affiliations and the walls of consultation rooms to be part of the greater outpouring of good that has followed the unparalleled bad of September 11. It is hoped that this work will bring some good to others’ lives now and even more so down the road of recovery. By being a part of the story from its outset, DPO’s psychiatrists and other mental health professionals can hope to be part of the many chapters certain to follow in the difficult emotional timeline of this event.

Psychiatrists who are interested in more information about the Disaster Psychiatry Outreach program may consult the website at or call 212-659-8733.

Dr. Katz is President, Disaster Psychiatry Outreach; Director, Psychiatric Emergency Services, Mount Sinai Hospital; and Clinical Assistant Professor in Psychiatry, Mount Sinai School of Medicine

Correspondence to: Dr. Katz at the Department of Psychiatry, Mount Sinai Medical School, One Gustave L. Levy Place, Box 1230, New York, NY 10029

Religious Conversion in Japanese Culture

By: Naoto Kawabata, Ph.D.

Japanese society has a peculiar nature in terms of religion. The majority of Japanese do not seem to take any specific interest in it. In an investigation of public opinion, about 70 percent replied that they did not believe in any particular religion. However, another statistic shows that about 80 percent of the Japanese population belongs to the religious organizations of Shinto and about 70 percent to those of Buddhism, suggesting that a large number of Japanese people belong to at least two religious organizations although most have no faith in them. This data reveals a truth about Japanese attitudes toward religion. They are indifferent to religion and very lenient about having different religious beliefs or customs at the same time.
In my own case, my family’s religion is Soto?shu, a sect of Zen Buddhism. If a family member dies, we ask a monk of that sect to direct worship at the funeral, and memorial services will be held every fixed number of years by a monk from the same sect. My parents’ home has a Buddhist altar, and I am supposed to pray before it at certain opportunities, such as New Year’s Day, during the Obon festival, or the first time I visit their house after a long time. It might sound as if I am very religious, and my religious life is organized in a Buddhist way. However, strangely enough, I have never learned Buddhism systematically, i.e., the teachings of the Buddha, and so on.

A further contradiction is the fact that I was occasionally taken to a Shinto shrine, for example, to celebrate a gala day for three? and five?year?old boys. New Year’s day is a popular occasion for going to Shinto shrines. We would stand in a long line waiting to come to a place where we would offer a ten?second prayer. If we have any special wish, such as health for our family, no car accidents, passing a difficult exam, or having a baby with an easy delivery, we would usually go to a shrine. Again, I don’t know what Shinto is and what Shinto teaches us.

Buddhism and Shinto are two traditional religious systems which are deeply rooted in Japanese ways of life. After World War Two Christian customs came to be widely accepted, although the number of adherents remains few. Celebrating Christmas by eating cake and giving presents to children and having a marriage ceremony at a Christian church have become a part of Japanese culture.

My academic background also reflects this polytheism. My parents sent me to a kindergarten run by another sect of Buddhism. They did not care that the sect was different from our family’s. My parents adopted a family custom of saying Namuamidabutsu before mealtime, which I learned at that school, even though none of us knew exactly what it meant. Upon finishing a public elementary school, I entered a Jesuit missionary junior high and high school. My parents seemed happy and satisfied with the school’s good reputation for academic teaching skill. They naively thought the religious atmosphere would be good for their adolescent son. Ironically, my soul started responding to the religious atmosphere. I joined a religious study group in school and started reading the bible. At one point a father teacher asked us to convert. I took this invitation seriously and asked myself whether I could make a commitment to Christianity. It was so appealing that I came close to converting, but I could not understand what the real existence of God meant. I thought it must be a kind of metaphor and asked the father teacher if it meant that God exists exactly in the same way a chair or a desk exists in front of me. He said, “Yes.” Then I gave up the idea of converting. I asked him whether I would go to hell. He said, “Yes.”

Since then, at the cost of being destined to go to hell, I have been content with the Japanese polytheistic secularism. My marriage celebration was held in Shinto style. I got a job in the university which was founded by Tenri?kyo, one of the new religions started about a hundred and forty years ago. Nothing appears contradictory, at least not on a surface level.

Historical Background:

The climate of Japanese polytheism is a historical product built up over a long period. Shinto is a naturalistic religion that developed out of the daily life of the Japanese people in a primitive era. Primitive Shinto centered on the animistic worship of natural phenomena, such as the sun, mountains, trees, water, rocks, and the whole process of fertility. Its mythology is concerned with many deities, reminiscent of early Greek mythology. Buddhism, which originated in India, was introduced into Japan in the sixth century. In contrast to Shinto, Buddhism is concerned with the afterlife and salvation and more concerned with theology. After its introduction Japanese Buddhism went through cultural transformations.

Amazingly, an imported foreign religion was accepted and harmoniously integrated with a religion indigenous to the country. Two religions came to coexist, making a two?layered structure. Neither Shinto nor Buddhism in Japan insisted on getting rid of the other, and they chose to live together in the same society. The two religions influenced, partially merged with, and adhered to each other. This fusion of two religions is called Shinbutsu?shugo.

In the 8th century, Shinto shrines started building Buddhist temples in their own precincts or remote places. They are called Jinguji, i.e. Shintoistic Buddhist temples. Some of them were built with the support of the dynasty along with a prayer for protection of the nation. Other temples were generated on a local level, independent of the central dynasty. In these cases many temples were set up on the basis of a prophecy made by Kami, a Shinto deity. For example, an ancient record about the foundation of Tado Jinguji in Ise district relates that in 763 the deity of Mt. Tado decided to convert to Buddhism in order to be delivered from karma of the deity of Kami. While reigning over the district for a long time, he had come to bear the burden of the sins, and he wished to escape from his position as Kami. Based on this prophesy, the Kami of Tado was renamed Tado Bodhisattva, and Tado Jinguji temple dedicated to him.

Another key concept to the fusion of Shinto and Buddhism is Honji?suijaku (True Nature manifestation) theory, in which Shinto deities are seen as incarnations of Buddha who came to this world to be the salvation of the people. This is an approach from the Buddhist side to incorporate Shintoism into it. It started in the 11th century, when Buddhism had been consolidated in Japan. There was a doctrine that Amaterasu, the central deity in dynastic mythology, is an incarnation of Dainichi Nyorai (Mahavairocana). These theories continued to have a strong influence until the end of Edo period. This type of fusion of two religions is unique in the world. In contrast to the strict repression of other religions, as when Christianity conquered the Germanic-Celtic religions and prohibited people from even reciting the names of indigenous dieties, Japanese Buddhism and Shinto chose a way to a peaceful coexistence.

Confucian philosophy has also had a great impact on Japanese secular ways of thinking. Beginning with Confucius, who lived around 500 BC, Confucianism accumulated the teachings of other scholars and took final shape in China during the twelfth century. Its religious aspect was not outstanding; rather it stressed a rational natural order, of which man was a harmonious element, and a social order based on strict ethical rules. The Confucian classics and system entered Japan between the sixth and ninth centuries but tended to be overshadowed by Buddhism until the seventeenth century. During the Edo period, its philosophy and attitudes pervaded society and contributed to the secularization of society along with the religious policies of the centralized Tokugawa system, such as the prohibition against Christianity, and the registry of all persons as parishioners of some Buddhist temple. In this period, Buddhism and Shinto became mere names, and Japanese rationalism was spread across the nation.

Polytheism and Japanese Mentality :

A Japanese religious scholar, Matsumoto, posited two ideal types of religion: paternal and maternal. In his view, a monotheistic religion, which has strict precepts and requires complete devotion, is categorized as paternal. For example, in Christianity, the contents of faith are defined ideologically, and each person’s faith must be examined consciously. Severance of affective bonds to secular people is a prerequisite for establishing the supremacy of the relationship to the monotheistic God. This kind of commitment seems to be consistent with the independent and autonomous ego of Western individuals. In contrast to paternal religion, the Japanese religious climate is striking in its tender, merciful, and lenient characteristics. Polytheistic Shinto does not have clear doctrines and does not require any conscious commitment to Kami. Widespread sects of Buddhism, like Jodo sects, emphasize salvation of all people. For example, in Jodo?shu (Pure Land sect), only reciting the name of Buddha is enough to be born in a pure land or heaven after worldly life. A founder of Jodoshin?shu (True Pure Land sect) advocated, “If even a good man can be born in a pure land, more so an evil man.” These doctrines were generated through the assiduous attempts of monks to find ways in which all human beings might be relieved.

This strong contrast between western religion and Japanese religion seems compatible with the psychoanalytic discussion of unique features of the Japanese mentality. A Japanese colloquial word, tutumu, which means to wrap or to envelop, is a key word for understanding self?image and interpersonal relationships in Japan. In the interpersonal situation, a person has to wrap up his individual thought or feeling and either conceal it or express it, if needed, tenderly and covertly. Another connotation of this word is to wrap up things and not make distinctions among them. Differential treatment of members of the group according to ability and merit tends to be seen as cold-hearted, sometimes even unfair.

Two types of ethics can be distinguished in Japanese culture, those based on the group or field (Ba no Rinri) and those based on the individual (Ko no Rinri). The former represents the predominance of the maternal principle in Japan. The Japanese word “ba” means “place” on the most concrete level but it also connotes a situation or relations among the people who are there. Ethics based on the field is usually not noticed explicitly but is shared implicitly or unconsciously by a group. If we assume that this ethic is rooted in a substratum of Japanese mentality and that it has supremacy over any other ethical elements, it is understandable that different religious beliefs and rituals coexist harmoniously in Japanese society. Differences among various religions and religious sects are not emphasized. Various Kami, Buddha, and God must keep equilibrium in a field. They all exist for people. Why should they fight each other?

Identity Formation of Japanese Christian Youth:

Sixteen years ago, I researched Japanese identity formation, comparing Christian and non?Christian youth and examining the characteristics of Japanese identity formation. I focused on Japanese Christian youth, who adhere to a paternal religion in a maternalistic society.

According to Erikson, psychosocial identity formation is a process by which one accepts a value system shared by the members of group and thus reorganizes one’s inner world. In this process, an ideology or an ideological image of the world is eagerly sought by young people. He emphasized the importance of selecting an ideology and committing oneself to it subjectively. We can see a prototype of this ideological commitment in the example of Christian faith, but it seems quite in discordance with Japanese mentality. The Japanese religious scholar Yoshida, himself a Christian, contrasted Japanese ego structure with that of a Christian. He designated a Christian who has a Japanese mentality as a marginal man, not only because he believes in a religion which is culturally different but also because in Japan it is unusual to believe in one particular religion.

In my study, 83 Christian and 177 non? Christian students were asked to fill out questionnaires such as the Ego Identity Scale, Ethics Scale, Commitment Scale, and Object Relation Scale.

Christian students were divided into three subgroups: those who were baptized as children; those who had Christian parents; and those who had non?Christian parents. The first group consisted of students baptized in childhood, at least one of whose parents are Catholic. Those belonging to the second group also had at least one Christian parent but were baptized after adolescence; in this case, the Christian parents were Protestant. The third group consisted of students who were baptized by their own decision without having a Christian parent. They encountered Christianity during adolescence, through a mission School, YMCA activities, or friends.

There were no differences in the Ethics scales between the second and third groups, but significant differences were found in one of Ethics subscales among subgroups of students with Christian parents. The third group (those with non-Christian parents) showed a significantly lower score in ethics based on the field than other two groups. This result is understandable if we take into account that the students in that group chose their position as the one and only believer in Christianity in their families. This study was originally derived from my interest in the difference in natures of religions, especially between paternal and maternal religions. Believers in paternal religions, like Christianity, have been supposed to show higher respect for individuality?based ethics than ordinary Japanese. It seems that the relevant factor here is not what they believe in, but how they come to believe in it. Above all, how the person is connected or disconnected to his family members seems to play a significant role.

Disruptive nature of religious conversion:

The religious scholar Lewis Rambo (Understanding Religions Conversion, Yale University Press, 1993) pointed out that the issue of conversion is controversial because quite often it does in fact disrupt people’s lives, and it does disrupt families. If we consider the secular character of Japanese society, this disruptive aspect of conversion can be a most salient issue. The magnitude of the disruption is dependent on the degree to which the religion is accepted in the society. The more the religion is radical or subversive to the society, the more conversion to it would be disruptive. However, whatever religion the person converts to, the process of conversion includes disconnection in two ways, internally and externally. Internally, the convert is disconnected from the old identity, and externally, from various human relationships in the secular world.

Dramatic examples of external disconnection include the seclusion from the secular world by many virtuous Buddhist monks. They are sometimes strongly idealized because of their success in religious life and their heroic appearances, but we must not forget the shadow entailed by light. The negative aspect of this type of behavior is clearly seen in the story of Sangi Saito, a modern Japanese haiku poet. He determined in his middle years to become a poet, having felt being touched by the elegant spirit of haiku. He deserted his family, who clung to him in tears, and started a vagabond life. For his family, even the most successful haiku poet was an irresponsible fugitive. More subtle and internal disruption can be seen in the Japanese Christian as a marginal man. In the process of becoming a Christian, the person has to acquire a new identity, and to lose some part of Japanese identity.

Here, we need to think about what kind of psychological meaning this disruption has to each individual. The adolescent period coincides with the time of the youngster’s identity formation. Religious commitment may play a critical role in this process. It may facilitate the second individuation process by providing these young people with extra?familial social networks and new relationships with a transcendental authority. However, these perspectives seem to have a missing part, which has to do with the development of continuity. Gaines (Detachment and continuity: The two tasks of mourning, Contemporary Psychoanalysis 33:549-571, 1997) in a discussion of the mourning process of children who lost a parent, says,

Emphasis on the need to detach from the lost object has obscured another aspect of the work of mourning, which is to repair the disruption to the inner self?other relationship caused by the actual loss. The individual needs to reconnect the severed bond, now on an exclusively internal basis, and to maintain the availability of a sustaining inner relationship. This is the task I call “creating continuity”. (p. 549)

The same task could be posited in the process of conversion. How the convert creates continuity for the former unreligious self and his human relationships in the secular world has not been given enough attention. On the contrary, these attachments to the old relationships and identity are regarded as a hindrance to religious commitment. Contemporary religious studies point out that converting is a complex process rather than a one?time event. Rambo breaks down the conversion process into seven steps: context, crisis, quest, encounter, interaction, commitment, and consequences. In this process, the converter creates new identities and consolidates a new spiritual orientation. This model, however, lacks a complementary part of transition, that is, the re?creation of the old connections. In order to shed some light on this aspect of conversion, we might examine the life course that Japanese Shinto Kami chose, becoming Buddhist while remaining Shinto Kami. This unique way of conversion might tell us something important about the conversion process, something that has been neglected in Western culture, and which may become more meaningful in our time of religious globalization.

Dr. Kawabata is a graduate of the William Alanson White Institute and will be teaching at the Kyoto Bunkyo University in Japan.

Correspondence to: Dr. Naoto Kawabata, Nanbu-cho 43-1-701, Fushimi-ku, Kyoto 601-8059, Japan.

Psychosis and Religious Conversion

By: Tony Stern, M.D.

Psychosis and conversion are closely related, as the following abbreviated case study illustrates. A seventeen-year-old youth loses all interest in doing his schoolwork. He is unable to concentrate. For the last two or three months he becomes withdrawn, indifferent to family and friends. Family members grow worried and angry. Teachers give extra homework assignments to discipline him. One Sunday afternoon he is trying to do a lesson, but his mind wanders. His older brother walks in, sees his inattentiveness, and scolds him. The next morning the boy runs away from home. Immediately, previous habits of sleeping and eating go by the wayside. He sleeps rarely and erratically. He eats only if fed by concerned strangers. He stops speaking. In fact, he talks to no one for the next four years. He becomes disheveled, oblivious. He never bathes. Insects bite him, leaving pus-filled sores on his back and legs. He hardly notices. This process in its most acute form continues for about a year.
What has happened here? Perhaps it would help to know that the boy’s father died when he was twelve years old, and that one day around the time his schoolwork began slipping he suddenly felt gripped by a fear of death and a sense of certainty that he himself would die imminently. Even with only this information, there can be little doubt that we are dealing here with a severe psychotic break. What kind of treatment would be indicated? Supportive psychotherapy? Antipsychotic medication, perhaps mood stabilizers? Adjunctive family therapy, perhaps?

This boy never received professional help. He never returned home. When an uncle and then his mother and brother first found him years later, he all but entirely ignored them. In his subsequent long life he never worked at a job, never married, never developed normal relationships. Instead, this young man, born Venkaturamana Iyer, grew older, settled down considerably, and came to be known as Sri Ramana Maharshi, one of the most deeply and universally admired saints in the history of India. For almost anyone looking to the East for inspiration, Maharshi represents a phenomenal pinnacle of spirituality and wisdom. While he lived all his life, from 1879 to 1950, in or around two small villages in southern India, he attracted an international following. Among Western visitors to his cave were the author W. Somerset Maugham, who later wrote The Razor’s Edge. The psychiatrist C.G. Jung, wrote of the sage: “In India he is the whitest spot in a white space. What we find in the life and teachings of Sri Ramana is the purest of India” (Forward, in The Spiritual Teaching of Ramana Maharshi, Shambhala: Boston, 1972).

Without the case’s unexpected end—“the rest of the story”—it is simply a sad glimpse at the life of a teenager with a major mental illness. With its conclusion, however, it is a challenge to basic assumptions about psychosis and conversion. Are they separate entities? Is it possible to distinguish between a profound mystical conversion experience and a psychotic episode? Sri Ramana’s transformation is one type of conversion, in which a person “converts” to a deeper form of his or her own tradition rather than turning to another sect or religion. In any conversion experience, as in a psychotic episode, the world is suddenly seen with different eyes—through a rearranged belief system.

Henri Ellenberger’s idea of creative illness may be useful here, which is one way of talking about “regression in the service of the ego.” Stanislav Grof provided a recent version of this concept with his diagnostic category of “spiritual emergency.” Yet both thinkers run the risk of over-romanticizing and prematurely clarifying a gray area. This same risk applies to Ken Wilber’s important work. At the core of his efforts (in books like The Spectrum of Consciousness and The Atman Project) is his simple yet brilliant explication of the distinction between regression and transcendence—between pre-egoic psychopathology and trans-egoic spirituality. Wilber has indicated that true spiritual practice transcends the ego; it is a mistake to dismiss it as narcissistic withdrawal or oceanic regression. Genuine spirituality lies above and beyond and builds upon a healthy ego; don’t reduce it to regression or equate it with emotional disturbance. (See Walsh, R., and Vaughan, F, Eds., Paths Beyond Ego, Jeremy P. Tarcher: Putnam, NY, 1993, and Wilber, K., Engler, J., and Brown, D.P., Transformations of Consciousness, Shambhala: Boston, 1986)

In this light, how shall we understand Ramana Maharshi? Was he disturbed or inspired? Was he pulled into his flight from home by regressive tendencies? Or was he pushed from home by a divine process? My own answer to these questions is “yes” and “yes;” both are true. One can discern a mixture of pre-egoic and trans-egoic elements in the unfolding of his early life, but more importantly either interpretation becomes compelling depending on how one views the story. Seen from a psychiatric standpoint, Maharshi was clearly regressed and obviously ill, at least in his late teen-age and early adult years. Seen from a spiritual orientation, he was undergoing a salutary transformation—extreme in its manifestations yet tremendously positive in its end result.

However one might clarify and understand Maharshi’s transitional period, it poses a challenge to any vision of spirituality as supreme or higher psychologic health and of development as proceeding from the stage of childhood conflicts to normal mature functioning and then ascending into spiritual realization and mastery. It is helpful to re-consider the situation without the benefit of historical hindsight. Forget “the rest of the story” and all the spiritual definitions and categories (samadhi, kundalini, or the like) that go with it. If you saw a patient with the behaviors described above, what would you think? What should your way of looking at it and responding to it be? Despite the possibility of distortion, imaginative reconstruction with oneself in the picture is necessary. To explore the interface between spiritual realization and madness and shed light on both, highlighting the hidden story of madness in the saint is a vital task, and it carries with it the requirement to intentionally forget and then remember again that the person under consideration was a religious pioneer and a spiritual giant. Equally important, though beyond the focus of this article, is uncovering the urge toward transcendence in madness. Of course, in the sketch of the saint’s adolescent years above, I have purposely been selective. I have given a thumbnail history close to what would probably be culled at the average mental health clinic or psychiatric hospital. Most of the recorded details we have left unmentioned would be summarily characterized as “hyper-religiosity” and therefore further evidence of a psychotic illness at any conventional treatment facility. Our protagonist had religious longings beginning rather suddenly at age sixteen. A year or so before his departure from home he read a devotional book that stirred him to his depths. Thereafter he visited the local temple every day for hours at a time, tears in his eyes, fervently praying to be made a true devotee of God. Upon fleeing home he left a note that read, “I have started from this place in search of my Father in accordance with His command….”

A further issue should be touched upon, though it is beyond the scope of the present discussion. In describing the young Maharshi, I mentioned in passing that he had an experience of abruptly feeling certain of his own imminent death. This occurred about two months before he left home. I neglected to add that he then lay down for a half hour and calmly and rather spontaneously inquired into the matter of who was dying. According to the spiritually oriented biographical sources about the sage, at the end of that half hour he had fully awakened to That which is deathless, That which can never die. The Absolute. From that time on he was, they say, completely liberated. All this occurred some weeks before the saint’s rapid downslide into months and years of a shockingly deteriorated level of functioning!

Sri Ramana’s story is one of those instances where life eludes our best efforts at categorization. More specifically, he exemplifies the reality that psychosis and conversion cannot always be cleanly separated, nor can psychopathology and transcendence. Differentiation between regression (pre-egoic experience) and spirituality (trans-egoic existence) remains a preliminary and useful theoretical construct, but it does not seem to hold up terribly well in many real life situations. It is tempting to resolve the problem of explaining Maharshi’s behavior by saying that the human struggle and perhaps the spiritual journey in particular contains a mixture of regressive and transcendent elements. After all, even spiritual teachers have their human side. While this may shed some light, it does not come to grips with the important finding that in this story and similar ones the times that are most worrisome psychologically are the very transitions of deepest spiritual unfolding. It is no accident that Maharshi recalled the period of apparent psychosis as the transformative turning point of his life. Such paradoxical logic applies to the specific behaviors under scrutiny as well. For instance, is a person’s sudden and dramatic drop of interest in his customary routine a sign of illness or of health? In terms of current psychiatric diagnosis, it can only be appreciated as an expression of illness. From the spiritual perspective, however, it sometimes implies an upsurge of profound health.

Ramana Maharshi may be an exception in some important ways, but the difficulty his story presents is encountered to one degree or another in the histories of most individuals of significant spiritual realization about whom there is adequate personal data. The people in this category whose biographical or autobiographical writings I know include Ramakrishna, who along with Sri Ramana has been generally considered one of the brightest spiritual lights of modern Hinduism; the great Zen Buddhist teacher Hakuin; the well-known philosopher J. Krishnamurti; the 19th-century Hasidic rabbis Nahman of Bratzlav and Mendel of Kotzk; many of the Catholic saints, including St. Anthony, the third-century Christian recluse known as “the father of monks,” and St. Francis of Assisi; and George Fox, the founder of Quakerism, who was scrutinized by William James in The Varieties of Religious Experience. This list is incomplete, but perhaps it gives some sense of the range of individuals under view. The figures who have led to major religious traditions might also be mentioned in this connection, even though much less is clearly known about their lives. For instance, according to Christian scripture, in the early days of Jesus’s mission his own family thought he was “out of his mind” (Mark 3:21).

Let us return to Ramana Maharshi and the central unresolved question we have been asking about him. How are his flight from home and subsequent disruption of previous functioning to be best understood? Psychosis or conversion? Regression or transcendence? Was it an expression of sickness or a part of a process of realization? The conventional psychologic view would see Maharshi as an example of unhealthy regression, whereas an Eastern vantage point would essentially claim that his apparent psychosis was a pseudo-psychosis involving the adjustment of his physical body to the profound spiritual energies released by awakening. Fortunately, spiritual heroes like Ramana Maharshi save us by defying the categories we have decided are real. Was he regressed or not? The idea of regression (or for that matter suppression or repression) does not make quite so much sense in this case, however, as something we might call compression. The magnitude of Sri Ramana’s spiritual life compressed other aspects of his life to the periphery for a period of years. Our psychiatric and spiritual categories soften in the face of a phenomenon like this. Any good solution to the dilemma posed by this saint will be found not through maintaining our old logic but through seeing how it has misled us. The dilemma remains, and as we walk a fine line into the ambiguity here, as reductionism and romanticism both fall away, the dilemma heightens.

One of the issues here is the never-ceasing challenge of selectivity in constructing a “history of present illness.” Inevitably a multitude of suggestive data presents itself, each bit clamoring for recognition as “significant” or “central.” For example, was Maharshi’s brother’s scolding him important? What if that two-minute incident had been bypassed in the narrative? Suddenly the seeker leaving home now seems a little less like an average teenager or a troubled youth, and therefore a touch more like a newly converted religious man off to meet his destiny. Psychoanalysis today offers a meaningful starting point for moving more fully into the dilemma. As a fundamental psychoanalytic view, all human experience and behavior is adaptation. Psychosis and conversion are both adaptations to the realities of loss, separation, change, and death—and these realities surely affected the young Ramana deeply. This is only a starting point. It leaves much unresolved, but it is a good place to begin. It is also where Buddha’s First Noble Truth (the central fact of suffering) and the living symbol of Christ on the cross join modern psychotherapeutic thought.

(I am indebted to Jeffrey Rubin, Ph.D., who co-authored an earlier version of this paper.)

Tony Stern, M.D. is in private practice and on the faculty of New York Medical College. He is also an attending psychiatriston the Westchester Medical Center’s mobile crisis team and at Abbott House,a foster care agency.

Correspondence to: Dr. Tony Stern, 7 Ravine Drive, Hastings-on-Hudson, NY 10706

Ghosts: Living with the Aftermath of Managed Care

By: James Bozzuto M.D.

Presented at The American Academy of Psychoanalysis Winter Meeting, December 2000, Miami, FL

If you practice medicine or psychiatry in the year 2000, as you listen to patients, you are witness to a plethora of concerns in your patients concerning “alternative therapies.” Naturopaths administer herbal medicines to my schizophrenic patients; depressed patients pay high fees to spiritualists who will help them communicate with their dead loved ones; manic patients “channel” spirits from distant ages; various psychosomatic ailments are “cured” by non?touch laying on of hands; and EMDR “cures” childhood traumas in a few sessions. The spiritual has penetrated the consulting room, but I find myself somewhat secure in my scientific training, even if it is the scientific study of emotions, behavior, mind?body interfaces and psychotherapy. It is in this rigorous discipline that I find guideposts and consensual validity that help me right myself and assist my patients.
So imagine my surprise when I found myself haunted, plagued by ghosts, tormented by forces that I am still not sure I understand.

In 1993 I had been involved in resisting the abuses of managed care in psychiatry for three or four years. I had received the Distinguished Service Award from the Hartford Psychiatric Society for my opposition to MCC’s takeover of a local HMO; I had been quoted in the Hartford newspapers as stating that managed care in psychiatry was the “rape of the mentally ill.” I then became aware of a 35-year-old woman, hospitalized at a large general hospital, who had died after a postpartum psychosis. She had been treated by a colleague of mine and coincidentally was a friend of my next-door neighbors. I attended the hospital’s Mortality and Morbidity conference. The patient was a prominent executive who became depressed after the birth of her first child. She was hospitalized for a short stay. During her hospitalization she was characterized by the nursing staff as quiet, and many nursing staff felt uneasy about her because she shared so little. Quickly the attending psychiatrist was besieged by three different reviewers demanding her discharge. These included the hospital reviewers, HMO reviewers, and out-of-town managed care physician reviewers. Each day the attending physician spoke to each of the three reviewers, answered the same question, “Is she suicidal?” and was threatened with the same refusal to authorize further days in the hospital. He discharged her after ten days against his better judgment. She was transferred to a partial hospital program, which she attended for a few days, and then she quietly drowned herself in her bathtub.

As I listened to the case, I felt a mixture of anger, disillusionment, helplessness, and disgust. I had just read Robert Lifton’s book, The Nazi Doctors, and I felt it was unfolding before my eyes—physicians concerned with other issues rather than patient care. My neighbors, who were unaware that I knew details of the case, lamented the loss of this fine colleague and mother and pondered the fate of her infant. Could the father raise the child alone? What would he tell his child of the mother’s fate? My general knowledge was that postpartum psychosis was definitely a treatable illness, requiring careful monitoring, and support, and I was sure that if more time had been given to this patient, she would probably be alive today. After listening to the M&M conference, I believed this patient died because of managed care pressure to discharge her prematurely.

I imagined that the review physicians would have told the husband, “We have decided to take a risk with your wife because we wish to maximize profits for ourselves and our company. We will, with your permission, roll the dice, not take the maximum precautions, and gamble with your wife’s life so we can minimize our financial risks and increase our bonuses based on cost savings. This is the policy you bought, so now live with it.” It was at this point that I knew managed care died. No one would want anything but the safest course for their loved ones. Witness the case of the Firestone tires. They killed only 125 people, but who would buy these tires and take the risk? Even shipping them to third-world countries has proved difficult. I felt helpless in this overwhelming stampede by managed care. How do we educate the public to understand the risks involved? What was going through the minds of those review physicians who I felt were responsible for the death of this woman? I resolved to do my utmost to reverse this system.

Weeks later I awoke in a sweat. A woman who I had never known appeared in my dreams as the woman who drowned in the bathtub. She asked me to make sure she had not died in vain. I was mystified. The dream recurred every night for weeks and months, sometimes with her child, sometimes with her husband, but always with the command entreating me to not let her death be in vain. This went on for months and continues intermittently to this day.

In 1997 I read a front page article about a father whose 13-year-old daughter died from leukemia. His 15-year-old son became depressed and suicidal and was hospitalized. Over the father’s objections, his son was discharged after five days. He pleaded with the hospital not to discharge his son as he felt the boy was extremely suicidal. On the day of discharge the boy hanged himself. Here were two children’s deaths, one who received the most advanced treatment in the world for her leukemia, with no holds barred and no financial restraints, and the second with depression and the shoddiest of care.

More ghosts appeared, still the woman’s. I waited for a couple of months. It seemed awkward, but after one of the harder decisions of my life, I called the father and asked if I could help. To my surprise he was very receptive. He said that nothing could bring back his son, but he did not want him to have died in vain. If it would help others in the future, he would cooperate in any way he could. He eventually filed a lawsuit that is pending today. I was able to facilitate finding a forensic psychiatrist for the family who could assist his case.

A few months later I attended the funeral of a neighbor’s 15-year-old daughter, whom I had seen only a few days before. She had become depressed and was hospitalized for just a few days at a local hospital. It was decided, under pressure, that she was not suicidal, and she was discharged. I knew the parents well. Had they bought an insurance policy that stated they would gamble with their daughter’s life so that an insurance company could post stronger quarterly reports?

In some of the many capacities physicians perform, I am also Chairman of a large Physician Health Committee which oversees licensure and assists physicians with problems. One case seemed particularly relevant. We received complaints from patients of a pediatric endocrinologist who had molested children 20 years ago. After confrontation he relinquished his license. Is sexual molestation worse than death? His injured patients were traumatized but alive. Are the physicians who discharged my neigbor’s friend and the 15-year-old boy without guilt or responsibility? Have they rationalized their actions, believing that “We are preserving the system. That’s what employers want. Rationing health care is necessary”? What if the surviving family members were to ask for their licenses? Would the experimentation on the population by the managed care experiment parallel the Tuskeegee experiment? Are patients and families due compensation? These questions are not answered and remain part of the current debate on managed care.

What of the Chairman of the Department of Psychiatry at a large community-based general hospital, who boasted that his was the “most managed care friendly system in the region,” with low rates, short stays, managed?care friendly physicians, and reduced nurse?patient ratios. A state investigative unit concluded that the strangulation death of a 12-year-old patient resulted because of inadequate staffing, inadequate training of staff, and inappropriate response times. Did that chairman talk to the mother and apologize, explaining he was only trying to remain profitable. “only adapting to the system.” One year later, at the same institution, a second death occurred when multiple drugs were dispensed in the hospital under improper supervision by staff physicians. The chairman was quickly removed from his job. Did he practice with “skill and safety?” Did he have his patient’s health as his highest priority? Did he tell patients hospitalized there that “We are the low-ball provider in the state, and if a few of you die because of that, that is the risk involved?” What does he think of now? Does he have guilt and remorse? Is he still proud of being managed care friendly? Should he be allowed to continue to practice when the state cited his institution for improper care twice?

What of the reviewers of one large managed care organization who, acting on orders, mandated in 1994 that all patients who requested outpatient mental health care be “screened” first. Screening meant identifying yourself as a patient and presenting to a managed care office to be told by a physician that “You aree not as seriously ill as some patients and because there are only limited mental health resources, if you used services, think of all the more seriously ill people who would go without care.” This physician was cited for “inappropriate behavior” by a county medical society (not his APA district branch) and continued to practice HMO medicine for another five to six years.

What of the medical directors of Magellan and United Health Care, who are permanent members of the Managed Care Committee of the APA? Under their direction mental health costs have significantly declined. Do they feel responsible? They blame employers. “They don’t want to spend on mental health care. We push until we get a push back.” None of the patients described here pushed back. The managed care directors continually tell me they are advocates for quality care. When discussing “phantom networks” and patients’ inability to find a psychiatrist willing to see them, one recently stated that his dreams would be answered if every patient could see a psychiatrist within 72 hours of request. Are his dreams different from mine? His plans reimburse physicians at such a low rate that the majority of psychiatrists will not see these patients. This same physician was the medical director of a managed care company that routinely denied psychiatric treatment to a couple whose 19-year-old son was murdered. The father went through five sets of reviewers over a course of one year who all denied his requests for care. After one year the review process involved the medical director, who was generally hostile but finally approved a few outpatient visits. How many patients are so persistent? The father pursued the appeal process for over a year, knowing he was doing this only so that the next person might have an easier time. Did the father have dreams of his son? Did he want his son’s short life to mean something for the mental health system in the future. Maybe the mind cannot fully contemplate its own death or the death of a child, who is experienced as part of the self, but it can understand the forces that attempt to extinguish us. Mmanaged care in psychiatry has significantly put our patients’ health and lives at risk.

And what now? Are there still ghosts? I still have similar dreams, eight years later. As “managed care as we know it” dissolves under the weight of innumerable lawsuits and unprofitability, not by the increasing actions of responsible physicians who operate these systems, do we hold these physicians responsible? Should they be reported to their physician health committees? Should their licenses to practice medicine with skill and safety be reviewed? Are administrators who are responsible for the deaths of patients in their institutions to be held accountable? What will replace managed care? Will we return to a fee?for-service system? Will mental health patients be treated with respect and not criminalized and incarcerated? Will the forty psychiatric beds for adolescents that were closed reappear in my community? Will reasonable lengths of stays return? Will the cost of an hour of psychiatric care continue to be substantially less than my wife’s appointment with a hairdresser? Will my dreams cease? Do I have to contact the husband and child of the woman who drowned herself and tell them that she was treated by an experiment in medicine that reduced costs but killed their wife and mother? Maybe then, and maybe when the patient with depression is treated like the patient with leukemia, and when the physicians who are responsible are held accountable, will my dreams cease.

Dr. Bozzuto is Assistant Clinical Professor Of Psychiatry, University Of Connecticut Department of Psychiatry

Book Review: Freud: Darkness in the Midst of Vision

By: Richard D. Chessick, M.D., Ph.D.

The author of this book is a psychotherapist and psychoanalyst who holds a Ph.D. in clinical psychology from Ohio State University and became a training and supervising analyst at the Southern California Psychoanalytic Institute. He was the founding president of the Institute of Contemporary Psychoanalysis and is now Professor of Psychoanalytic Studies, Emeritus, at the California Institute of Technology. Therefore, his book deserves to be taken seriously and he is clearly not one of that group of obtrusive crack-pots who lose no opportunity to take a shot at Sigmund Freud.
Breger’s book is a pleasant one to read; it is well organized, and he has an easy-going expository style, in contrast to the usual style of biographies produced by professional historians, of which he is not. Unfortunately, there is one major flaw in the book, and it happens to be the central premise of his entire study. According to Breger, Freud “invented” (p. 3) the Oedipus complex “which he instantly promoted to a universal law” (p. 3). Breger complains in his excellently written introduction that Freud’s overblown theories and sweeping generalizations were fueled by Freud’s desire for greatness, his attempt to be a powerful scientist-hero. There was never any convincing evidence for these ideas, says Breger; they arose primarily from Freud’s needs and personal blind spots: “The version of Freud’s own childhood that emerged from his self-analysis . . . that sexuality was at the root of his fears and symptoms—and that he later extrapolated into psychoanalytic orthodoxy—was an invention, a self-interpretation that served to cover up the unbearable losses and traumas of his own life” (p. 4). Throughout the book Breger depicts not only Freud but a number of his followers as suffering essentially from a post-traumatic stress disorder due to traumatic and unhappy childhoods. He demonstrates how Freud in sweeping generalizations attributed the Oedipus complex and sexual conflicts as etiological in all sorts of emotional illnesses and disorders. What Breger seems not to realize is that he is doing the same thing with his sweeping generalizations about the role of trauma in childhood as producing all sorts of emotional disorders. The continual attribution of the various personality characteristics and neuroses of individuals mentioned in the book, especially those of Freud, to traumatic experiences or deficit parenting in childhood becomes repetitive and should have been altered by an astute editor. It seems that Breger has the same failing as the one he attributes to Freud, except he concentrates on a different assumed etiologic agent. To me his orientation seems more Adlerian than Freudian, and one only wishes to know why he seems to need to reinterpret the entire corpus of Freud’s work and attribute it unfailingly to various derogatory characteristics of Freud’s personality.

If the reader can get by this fault, Breger’s work is worth reading. He brings out the dark side of Freud in a persuasive manner and accomplishes a de-idealization of the man Freud which perhaps serves as a counterweight to the early idealizations of Freud by his original followers. In nunce, this book represents an honest effort to portray Freud as a flawed individual and to replace Freud’s sex-based formulations with Breger’s trauma-based formulations.

Breger’s formulations are based on the same sort of speculative suggestions, bearing such phrases as “It is almost certain,” “in all probability,” or “It is a good guess,” and so on. He claims that “As a very young child, Freud could do nothing about the painful realities that engulfed him; he almost certainly felt frightened, helpless, shunted aside, and overcome with longing for love and care” (p. 17). He concludes that “Freud created his oedipal theory because his traumatic losses aroused overwhelming emotions that were impossible to manage alone, in a self-analysis. By turning to the oedipal story, he created a comforting myth, one which allowed him to think that what most disturbed him was his adult-like sexual desire for his mother, and also promoted his weak father to a position of kingly power” (p. 19). He re-analyzes many of Freud’s famous cases, invariably changing Freud’s formulations, and makes it clear that in his opinion most of Freud’s clinical work was simply wrong and based on Freud’s neurotic difficulties arising out of Freud’s deprived and frightening childhood. Freud’s main interest in life, according to Breger, was to become famous by discovering a single theoretical principle. We are told, “He needed to produce ‘cures’ to prove his theories, and this overrode both the welfare of his patients and a careful assessment of the results of his treatment” (p. 121). These are harsh accusations indeed.

We are introduced to Breger’s theory of the interpretation of dreams: Freud’s “focus on wish fulfillment shifted attention away from one of the most important functions of dreaming—attempting to master the disruptive emotions associated with traumatic and other threatening and distressing events” (p. 144). Breger concludes that Freud’s “dread of giving in to his infantile yearnings was transformed, in his theories, into the image of a menacing sexual instinct” (p. 168).

Breger repeatedly and almost obsessively criticizes Freud for making speculative generalizations about his patients. He presents us with the following explanation of why Freud said, when he came to after he fainted in the presence of Jung, “How sweet it must be to die.” Breger tells us that Freud’s statement “expressed both his wish to be the passive recipient of love and care and the deathlike fear associated with the disappointment of this longing” (p. 229). No explanation is given as to how Breger arrived at this interpretation. We are also told that “Because Freud, intensely competitive and rivalrous with his former colleague, could not credit Adler with a theory of aggression, he needed to derive his theory from what had the appearance of ‘biological-scientific’ principles” (p. 267). Here Freud’s postulation of the death instinct is attributed to Freud’s allegedly unfortunate personality characteristics. There is no hint that perhaps Adler’s theory was inadequate and superficial or that adopting it would have led to a major change in the focus of psychoanalytic treatment from the patient’s sexual conflicts and fantasies to struggles for power with the parents, much more compatible to both Adler and Breger.

In summary, Breger’s “new vision of Freud” (p. 376) is a highly debatable vision, and, remarkably, he attributes his findings to the same kind of procedure that Freud used to justify his findings of the ubiquity of sexual conflicts in the etiology of the neuroses. Breger writes, “I felt like a scientist who stumbles on a theory and finds that it reorders a mass of data into a new and more coherent form. As I did more and more research I kept coming across additional pieces of information that fit into the puzzle and enriched the account” (p. 377). This could have easily been written by Freud!

Dr. Chessick is Professor of Psychiatry and Behavioral Sciences, Northwestern University, and Senior Attending Psychiatrist, Evanston Hospital., and Training and Supervising Analyst, Chicago Center for Psychoanalytic Study

Correspondence to: Richard Chessick, MD, PhD, 9400 Drake Ave., Evanston, IL. 60203-1106

Briefer Psychoanalysis across the Ocean

By: Ferruccio Osimo, M.D.

A Memory from my Training:

For some reason one of the most vivid memories from the time of my training in dynamic psychotherapy in London (1981-83) is the following. Every other Wednesday, after having lunch at the Tavistock Clinic “restaurant,” or after skipping it, I would sneak away from the side entrance of the clinic, near the library and, after crossing one road, sight the Hampstead Clinic. I must say that every time I left the Tavi, this was always with some feeling of guilt. “What else are you looking for? Aren’t you happy with us? You are in the cradle of psychoanalysis. Is what you’re given not enough? How greedy of you!” I experienced the pervasive Kleinian atmosphere at the Tavi in a highly schizo-paranoid way, and this anxiety about my greediness might therefore be regarded as the result of an identification with the aggressor (Sorry, this is an Anna Freud favorite!).

When, three minutes after leaving the Tavi, I entered the Hampstead front door, a sense of awe took the place of my guilt. I was getting into Freud’s home (almost so) and hopefully about to meet his daughter! That was really a sacred temple. Moreover my analyst, whom I had to leave in Milan to go to the Tavi, was enthusiastic about Anna Freud, which made my transference feelings to him and Anna even more oedipally charged. You will imagine the intensity of my emotion then, the day Anne Hayman, in recognition of my assiduous and faithful attendance to the Clinic’s Wednesdays for the last months, asked me if I would like to be introduced to Ms Freud. Adrenaline is a poor word to describe my accelerated heartbeat and the upsurge of heat coming from the depth of my body and filling my cheeks, face, and ears, my wobbling gait toward Anna, and my almost complete inability to articulate a dignified speech.

I will spare you the dialogue that followed which, in any event, meant really little compared to the physical experience I was going through. This intensified even further when we shook hands, and I confusedly felt I was actually touching what for a few seconds was to me nothing else but Freud’s incarnation. I would not write this, which may sound disrespectful of Anna, had it not been my sheer experience, for which I cannot be held responsible. Even though that day was one of the last times Anna Freud took part in a Wednesday open meeting (she was to die only a few months later), she proved to be thoroughly lucid in her careful discussion and extremely bright in the comments she made at the end of the research report presented by two American colleagues.

Brief Psychotherapy and Long Psychoanalysis:

Why mention all this? What has it got to do with brief psychotherapy (Short-Term Dynamic Psychotherapy on the American side of the ocean)?

At the Tavi I was on David Malan’s Psychotherapy Unit, specializing in brief psychotherapy and doing outcome research studies under his direction. This contrasted with the remarkably long-term Kleinian atmosphere which we breathed all around. Analyses with Kleinian analysts tended to last longer than analyses with Freudian or more Independent analysts. Historically, a gradual increase in the length of treatments started with Freud himself and characterized the first fifty years of the development of psychoanalysis. The early treatments by Freud were, however, brief, and by crossing that road to see Anna Freud I was in a way returning to where it all started and symbolically uniting what had been divided. Why, in fact, call analysts Freudian, Kleinian, or ...? Apart from the obvious cacophony of Winnicottian, Sullivanian, or Frommian, and the tongue problems posed by Ferenczian (of which he was aware, considering his 1933 “confusion of tongues” paper), do these definitions say anything relevant to what analyst and analysand actually do? About the way they relate with each other? Or is it just a way to divert our attention from all this, ennobling our ignorance with a respected label? Finally, why do we use different names for long-term psychoanalysis and short-term psychotherapy? Is treatment length per sé a meaningful index? If it is, what does it measure?

These and other thoughts and question marks populated my mind at the time of my training, and they still do.

The Malan-Davanloo Connection: Chemistry and Surgery:

At the Tavi, it goes without saying, I attended Malan’s Brief Psychotherapy Workshop every Friday afternoon. We discussed sessions and viewed tapes within the group, and Malan emphasized the “Davanloo technique.” This name sounded rather exotic at the time, and hearing Malan say that Davanloo was Persian, lived and taught at Montreal General Hospital, and was a genius of STDP, infused his image with a mysterious, fascinating halo. The British, as a heritage of their colonial empire, tend to turn up their noses to most of the other cultures, but Malan is a leading and highly respected clinician, and since he saw revolutionary elements in Davanloo’s approach, it was impossible to ignore them. It must be said, in total honesty, that Malan’s hammering on this made us trainees feel uncomfortable, first because it seemed to detract from the “Tavistock tradition,” and second because learning this revolutionary method turned out to be horribly difficult.

Once I met Malan in the fourth floor corridor, and he handed me manuscripts of four articles he was writing for Davanloo on the subject of “Intensive Short-Term Dynamic Psychotherapy” (IS-TDP). That represented the best that was available to make theoretical sense of what Davanloo was capable of doing in his spectacular videotapes of defense-dissolving interaction with the patients. Considering that Malan graduated in chemistry before becoming a Doctor Medicinae at Oxford and that Davanloo’s career in general surgery preceded his devoting himself to psychiatry, one may well conclude metaphorically that Malan was able to identify the molecules and to describe the chemical process behind Davanloo’s deeply incisive interventions and remarkably cutting stance. The two of them made up a very special and highly specialized team and a unique example of co-operation between two outstanding researchers. Davanloo’s volume Unlocking the Unconscious (John Wiley and Sons, 1991) describing the principles of IS-TDP was made possible by their conjoint efforts. Both Malan and Davanloo proved to be the midwives of STDP therapists, since legions of trainees attended Malan’s Brief Psychotherapy Workshop over the years, and many others attended Davanloo’s symposia and the “Immersion Courses” he held in Canada, the United States, and Europe.

Family Trees:

Even though Freud and the other early analysts published some accounts of notable brief cases, the goal of brevity as such was never in their dreams. The historical birth of STDP dates back to the 1940s and took place on the American side of the ocean, when Alexander and French made systematic efforts to make psychoanalysis “briefer and more effective,” providing patients with a corrective emotional experience. Leigh McCullough (Changing Character. Basic Books,1997, p.8) observed that,

Unfortunately Alexander and French were strongly criticized by the analytic establishment because there was active manipulation of the transference. In practice, however, the transference is inadvertently “manipulated” by whatever therapists do, and no less so when neutrality or passivity are maintained in the analytic technique. The point is that we must acknowledge and specify [...what we do…] so that the effects can be experimentally examined.

Another major source of STDP research endeavors sprang up in the Boston area. A tragic fire occurred at the Coconut Grove Restaurant in Boston in 1942. Many customers were killed either from the fire or while trying to escape, since they found the doors locked. The survivors of this fire, whose friends and loved ones died beside them, were rushed to Massachusetts General Hospital, where Eric Lindemann and his staff provided treatment. Lindemann observed that these survivor victims improved more rapidly than his long-term patients and surmised that the crisis raised anxiety levels, resulting in their defenses being more responsive to intervention. Two of Lindemann’s residents were Peter Sifneos and Habib Davanloo, who developed their respective STDP models, both of which have a notable anxiety-raising component.

On the European side of the ocean, in the early 1950s Michael Balint experimented with brief forms of therapy. He was personally acquainted with Alexander but ignored his work and did his own investigations from the beginning. He founded the Brief Psychotherapy Workshop at the Tavistock Clinic, consisting of a group of selected and gifted clinicians, one of whom was Malan. Their initial idea was to circumscribe a conflict area on which to concentrate dynamic work, and Balint coined the term “focus.” I was told by Malan that the therapies supervised within the BPW were never really focal since interpretations actually addressed all the meaningful material and not only the parts of it connecting to the focal conflict. The term “focal,” applied to brief therapy, became widespread and was mistakenly thought to be almost equivalent to “brief.” This term also appears in the title of Balint’s posthumous book, written with his wife Enid and his disciple Peter Ornstein (Focal Psychotherapy: An Example of Applied Psychoanalysis, Tavistock, 1972). Basically, I regard “focal” as a reassuring concept, in that brevity makes it easier to accept focality, and the latter seemingly explains brevity. This view is, however, simplistic because even a dynamically simple case with a single and highly meaningful focus, is not guaranteed to be effectively dealt with in a short time. In other cases using an effective approach a relatively short time may allow for the resolution of dynamically more complex, thus “multi-focal,” disturbances. Since there are other factors involved, the term “focal” as a label for brief psychotherapy, is as misleading as it would be to use “couch” or “free-association” as a label for psychoanalysis. To quote Balint himself, “I used to think that the essence of analysis was five times a week on the couch, free association, etc., but now I realise that the essence of analysis lies in the attitude of the therapist” (Malan, personal communication).

With the help of Marco Bacciagaluppi, the President of OPIFER, I tried to sketch a family tree of present-day STDP therapists (figure 1). On the second line there are a few of Freud’s analysees plus Federn, who was never analysed by him but was his devoted disciple. Federn analysed Weiss, who analysed Italo Svevo, the famous Italian writer and the author of La Coscienza di Zeno (Zeno’s Conscience). Weiss then emigrated to the United States, because of the fascist anti-Semitic legislation in Italy (1938), and co-authored Psychoanalytic Therapy (1946), with Alexander, French and others (1946), hence his link to STDP. What is meant here by “last generation STDP therapists” is that they trained with Malan, Davanloo, or both even though they were not (at least not all of them) analysed by either Malan or Davanloo.

A Transitional Phase:

In the mid 1960s David Malan started his own Brief Psychotherapy Workshop for trainees at the Tavistock Clinic. This was quite different from Balint’s, since the original one was entirely for experienced therapists. Malan postulated the unavoidable connection among selection criteria, therapeutic technique used, and the quality of results obtained. His elucidation of the dynamic process and of change factors in dynamic psychotherapy and psychoanalysis is invaluable. His well-known books contain a rich harvest of clinical material, providing evidence on which the “science of psychodynamics” is based. In this respect they represent an ideal continuation of the book by Alexander and French. Malan was actually able to disprove the “hypothesis of superficiality” according to which brief psychotherapy is a superficial treatment, applicable to superficially ill patients, and bringing about superficial results. He spelled out that, “The aim of every moment of every session is to put the patient in touch with as much of his true feelings as he can bear” (Individual Psychotherapy and the Science of Psychodynamics. Oxford, 1979, p.74). This simple statement actually has two major practical consequences: Firstly, a therapist should be able to detect what “as much [...] as he/she can bear means when applied to a specific moment of the interaction with a specific patient, and, secondly, it would be good to have effective ways to regulate the intensity of emotional experiencing as indicated. Thus Alexander’s original intuition of how crucial is the actual experiencing, was strengthened by Malan’s clinical research, but what was still lacking was an adequate clinical methodology effective enough to facilitate and handle intense emotions in the patient and also in the therapist. This is certainly the main reason why Davanloo’s advent was immediately felt by Malan to be the “missing link,” eventually making it possible to connect together the therapeutic and the theoretical sides of psychoanalysis.

Two remarkable research studies evaluating the relevance of emotional experiencing to therapeutic outcome were carried out in New York at the Beth Israel Research Program. The correlation between three types of intervention by the therapist and the frequency with which they were followed by an emotional response by the patient was investigated (McCullough, L., Winston, A., et al., ...., The relationship of patient-therapist interaction to outcome in brief psychotherapy, Psychotherapy 28:525-533). Research results indicate that transference interpretations followed by an emotional response bear a significant correlation to improvement at termination, whereas an intervention followed by a defensive response correlates negatively to outcome. In another study (Winston A., Pollack, J., et al., Efficacy of brief adaptational psychotherapy, Journal of Personality Disorders, 4, 244-250, 1990), 32 patients with personality disorder were randomly assigned to Davanloo’s IS-TDP or Brief Adaptational Psychotherapy (BAP), a more cognitive approach developed at Beth Israel. Significant improvement took place in both groups as compared to controls.

The Last Generation of STDPers:

The confirmation of the positive correlation between emotional experiencing in response to therapist’s intervention and outcome gave further thrust to the clinical investigation of the ways to actually facilitate this experiencing and make it more easily attainable. This was repeatedly confirmed using video technology and mutual supervision and proved to be a crucial factor accelerating dynamic processes within the patient-therapist relationship. A number of former trainees of Davanloo and of Malan contributed their own creativity and their personal research endeavors, laying equal emphasis on the psychodynamic and the experiential aspects. Diana Fosha (The Transforming Power of Affect, Basic Books, 2000) proposed to call this approach “Experiential Short-Term Dynamic Psychotherapy” or E-STDP.

I have described some aspects of the historical evolution of STDP, and it is not possible to go into the theoretical or operational framework of E-STDP more deeply. E-STDP especially draws on Malan’s work for the emphasis given to the deepening of feelings in the therapeutic rapport and on Davanloo regarding the handling of defenses and the quality and intensity of human feelings. A number of colleagues who, like myself, received training from one or both of them base their clinical work and research endeavors along these main guidelines. A new association of psychotherapists, the International Experiential STDP Association, (IESA, was recently founded in New York. E-STDP is basically a relational psychotherapy firmly rooted in the patient-therapist relationship, seen as a genuine, personal, and respectful human interchange. It is psychodynamic—that is, it uses the basic dynamic theory of conflict and transference phenomena,—and it is experiential, promoting and valuing the actual physical (through the body) and mental (related mental representations, thoughts and fantasies) experience of feelings, affects, emotions, impulses and desires. A first international conference centered around E-STDP was held in Milano, Italy, on May 10-12, 2001, with the conjoint efforts of IESA, OPIFER (Italian Psychoanalytic Association and Federation), and the Niguarda Mental Health Department.

Dr. Osimo is Associate Professor of Short-Term Dynamic Psychotherapy at Università Statale di Milano,Italy, President of IESA: International Experiential STDP Association, and Treasurer of OPIFER: Organizzazione di Psicoanalisti Italiani, Federazione e Registro.

Correspondence to: Dr. F. Osimo, Via P. da Volpedo, 12, 20149 Milano, Italy

Linguistic Aspects in the Treatment of Schizophrenic Patients

By: Scott C. Schwartz, M.D.

The importance of language cannot be overestimated in the practice of psychiatry. It is our stethoscope, our thermometer, our MRI. Language, including body language and non-verbal communication, is our primary method of assessing improvement, change, and, on a psychodynamic level, meanings in the therapeutic relationship. We must accept that words have meaning, sound and a flow that is unique to every individual.
In dealing with more severe forms of psychiatric illness, we have become accustomed to use psychotropic medications that can reduce the intensity of the symptomatology. Many recent books and articles emphasize the controversial qualities of these agents and their use and may even sensationalize their effects and precautions. I am a strong supporter of the intelligent use of psychotropics. My issue is with the our excessive reliance on medications as the only way of approaching severe pathology. The art of entering the patient’s world, so common and necessary in doing empathic psychotherapy with neurotic or personality disordered patients, is a valuable way of understanding and treating the world of psychotic pathology as well. Understanding the autistic meanings of words, symbols, delusions, hallucinations, and referential ideas in conjunction with patient motivation and a trusting therapeutic alliance clears the road for deep change of defensive structures and realignment of psychic functioning. It is also an avenue for deeper exploration of actual or perceived trauma and adaptation mechanisms. None of this need be seen as antagonistic to neurobiological views of schizophrenia or affective disorders. The art of processing and storing perception, is refined and evolved through therapy, learning, experiencing, and realizing, as it promotes recompensation. Awareness can always be deepened, and the struggle for a harmonious psychological balance with the environment is constant and enduring.

As a linguistic expedition into the mind of a schizophrenic, which ultimately resulted in a successful outcome, I want to present a case I treated starting in the second week of my residency in July 1975. Barraged with learning to differentiate TD from EPS, FOI from LOA, and where on the sheet to write admission diet orders, I met Dana, a 30-year-old Caucasian female admitted during the night after she was picked up for “bizarre behavior” in the ladies’ room at Port Authority Bus Terminal where she lived. Before going to interview her, I was cautioned by the ward chief to approach her slowly and observe a classic but now rare sign. I walked into the room and saw a seemingly attractive woman, old before her time, her long brown hair messily hanging over an amorphous gown, slowly turning around in place, her absent stare not fixing on any point in the room. Introducing myself, I asked if she would be willing to speak with me. She continued to turn and responded, “Can’t talk, but will try… the voices are talking to…. Don’t know why they are talking to like that. Not normal, am not normal.” I thought, “Oh my God, maybe I can still land that pediatric residency. What the hell is this crazy field I got into.” The rare sign of course, was the posturing, and in addition she showed waxy flexibility. I asked her to come over to the table, have a seat, and talk to me, and she walked over backwards. She never walked forwards. Her speech entirely lacked “I” or “me.” She was clearly hallucinating and was guarded about what turned out to be a complex delusional system. There was no drug or alcohol abuse history, no medical pathology and a past history of one admission elsewhere about two years before with no ostensible follow-up. In spite of this seemingly fragmented and almost hopeless level of psychosis, I was very moved by the fact that she could see all this as “not normal.” This shred of intact reality testing was the basis of the treatment done over the next ten years. She was started on low doses of perphenazine and integrated into ward activities. Nobody told me at the time that I shouldn’t try to understand delusional thinking so I went ahead with trying to figure out why Dana decompensated. I decided to work on the delusional ideas first to see if these could be connected to the posturing. The rotating related to “fighting the voices” which were sent by the government to control all thoughts. By constantly facing all directions “vigilance would be a protection.” Walking backwards aimed to confuse them into going away. The government, it seemed, had made her into a robot as a punishment for having caused the war in Vietnam. In trying to make sense out of this symbolic material, I needed to define the terms and parameters and see how they related to her life history. In Dana’s delusion, the government represented an incomprehensible force that makes things happen, influencing people to do things, and dehumanizing them. A robot was a depersonalized human substitute that could imitate but never be a human because it lacked feelings. Due to the external controls, the robot also lacked choice. The war in Vietnam symbolized a world war, one that ultimately destroyed all countries. The delusion could be reworded as follows: Dana had been made into a feelingless human substitute, devoid of choice by some incomprehensible powerful governing force as a punishment for creating a world war that destroyed the nations of the world. I am not a Freudian analyst and would perhaps now seek out the effects of this on her life today, but at the time, I wanted to connect the belief system with trauma in childhood.

Dana was born in New York to working-class Irish parents, devoutly Catholic. She was an only child and could recall no extended family and no socialization outside the home with neighbors or schoolmates. Her parents fought a lot, physically and verbally, because her father drank excessively and womanized. They were strictly religiously observant, so no divorce or separation was possible. She recalled fearing for her mother’s life and felt she needed to be around for whatever protection she might provide. Though she tried to intervene in the fights, she was rebuked with “You stay out of this! Don’t you get into this! Everything was fine until you were born! You can’t fix what you destroyed!” It should be mentioned that Dana, prior to her decompensation, worked for an airline as a reservation agent and as such, had been able to travel throughout the world. My attempt to understand the delusion lead me to infer that in her family she was made to have felt responsible for causing the whole world to fight and that as a result, the governing force, her parents, had ostracized her from the world. Therefore Dana was not truly human. For a five-year-old, your home and family is your world; for a ten-year-old, your neighborhood and school and friends are your world; for a twenty-five-year-old travel agent, the world becomes your world. The conflict is constant; the battlefield expands. Though her affect up to this point had been completely flat, her eyes showed some evidence of tears. We explored the reality of this idea, that whether the birth of a child could truly create such problems. She was able to note that there had to have been deep problems from before that could not have been her fault. Within two days she stopped posturing, began to walk forwards, albeit slowly and somewhat machine-like, and started to integrate “I” and “me” into her conversation. I was omnipotent! She continued to improve. The perphenazine was lowered to 4 mg a day. She was accepted by a residence, and a discharge date was set up. Against the ward chief’s wishes, I wanted her as an intensive patient and took her on. My first supervisor, though an analyst with an interest in the symbols of dream interpretation, felt that she could not be treated in an interpretive way. I was to see to it that she took her meds, bathed, paid her rent, and got a date from time to time. It didn’t matter. I was unstoppable! I was going for the gold, the ultimate interpretation.

The next delusional system we encountered was her belief that Hitler was secretly living in the White House. Once again I needed to figure out the language. Hitler symbolized the embodiment of tyrannical evil, though not in her mind connected with the world war spoken of earlier. No specific relation to Nazis, persecution, genocide, or Germany could be elicited, only that he was supremely evil. The White House was of course the central seat of government. Evilness lurked in the powers that run the nation! On one level I thought that this could be interpreted as more symbolic referents to her parents, but I off target. The belief remained unchanged, and the affect still was the same. So, more history. What emerged was that when she had just finished high school and turned eighteen, her mother died from unknown causes, possibly suicide; Dana wasn’t sure. Her father had for some time been involved with a lover and, soon after the mother’s death, moved the woman into their home. This made Dana completely redundant, and since she was eighteen, he threw her out. “Life has to begin again! She’s dead and now you’re out of here too!”

Dana moved from apartment to apartment of high school friends in exchange for cleaning, baby-sitting, and dog walking. Later she lived in a room and supported herself cleaning houses. She took a course in making reservations for airlines and got a job making phone bookings for an airline. All the while, she felt rage at her father for throwing her out, being non-supportive and unavailable to her. This took the form of fantasies of “him getting his” and his being afflicted with misfortune. As it happened, she learned later that he had in fact died from alcoholic liver disease, but she was not contacted at the time.

The high school she attended, a strict parochial school, had inculcated a teaching (which I am told is no longer taught but which was at that time prevalent), namely that from God’s viewpoint, fantasizing an act was no different from actually doing it on an external level. So much for psychodynamics! Catholic friends of mine corroborated that they too had been taught this concept. Since the intensity of any feeling is experienced through the associated fantasy, it appeared that the feelings themselves were being stifled. Dana was, justifiably in my opinion, furious at her father, but her fantasy, to her, was the wish that caused his demise. In her delusion then, the White House represented not the parents but the government of her own life, her psyche, and Hitler represented the evilness of her anger killing her father in fantasy and, therefore, in truth. Though she could see how his drinking in fact caused his death rather than her anger, it was not apparent to her that a fantasy is merely a metaphorical way of experiencing the intensity of a feeling, and not the same as an action.

To concretize this concept, I devised a chart, written on a notecard for her to keep, which we called “The Circle of Feelings.” It was completely improvised and may seem rudimentary by therapeutic standards of today, but it clarified otherwise difficult and confusing words. It begins with the idea of a cause, specific to every person, based on ones tastes, ones beliefs, or ones background. What makes you happy might well differ from what makes me happy. We get turned on, ecstatic, furious, or soothed by specific stimuli related to our own emotional hierarchy. This cause leads to the feeling itself, whose major characteristic is that it cannot be controlled except by controlling the cause, accomplished on the internal and external level. Someone steps on your toe on the bus and creates the feelings of pain and anger. The pain does not begin to subside until the person gets off your foot. The anger, based largely on that person’s clumsiness, could be dissipated by the person apologizing (external) or by your noticing that he is blind and could not help it (internal), or by simply deciding after a time that there is no point to remaining angry (internal). The feeling would then lead to a responsive action. This is completely controllable, based on one’s resources (Am I able to do this action?) and consequences (What would happen if I did this action? What would likely happen if I did not do it?). We would like to tell the man who is stepping on our toe to get the heck off. Can we? Would he understand and respond appropriately? What would be the consequences? If he were, for example, Mike Tyson and in a very bad mood, the benefit of keeping silent would far outweigh the consequences of telling him to get the heck off our toe. Finally, we judge the consequences. Did I do well? Did I accomplish satisfactorily what I wanted to? These judgements become in and of themselves causes of new feelings that then start the cycle again. It is noteworthy that this judgement should best be directed at the choice of behavior, which is always changeable. However, judgement is usually directed at the validity of the feeling itself, which one cannot control. We try to extinguish, suppress, or eclipse a feeling when the associated behavior is the real source of fear. I cannot be angry at my father because disrespecting him would be unacceptable to my moral beliefs. The anger exists and cannot be pushed away. How you handle anger—by direct confrontation, by redirecting your energy, by choosing to remain quiet, or by proving your value by believing in yourself—is within your control and, therefore, can be reasonably judged. Additionally, between the feeling itself and the resultant behavior, is the notion of a fantasy. In the “Circle of Feelings” fantasies play two roles: They are substantive ways of measuring the intensity of a feeling, and they “rehearse” the concomitant behavior as a way of arriving at the optimal solution. Schwartz’s third law of psychiatry states “A fantasy is a fantasy because it is a fantasy. If it were a reality, it could not be called a fantasy.” A fantasy need engender no fear.

My aims were to generate more trust in the basic logic of her thought content and, second, to urge her to bring the delusional material to the sessions so we could examine and analyze the underlying feelings. I also felt it might be beneficial to give her a “souvenir” of our discussion to refer to and to keep in her wallet. We often referred to the “Circle of Feelings,” and it has been helpful for other confused or regressed patients. As Dana became more comfortable with these truths, the presence of Hitler in the White House subsided.

As the therapy continued over the ensuing months, the focus gradually shifted to “life issues” and less interpretation of schizophrenic delusional ideas. Questions of improving communication with her boyfriend, how to negotiate for a raise at work, and how to deal with demanding or obnoxious clients became more common than symbolic interpretation of autistic ideas. Occasional delusions did emerge in the form of strong word puns. The 1976 presidential election, as an example, caused her fear that she could not vote without a driver’s license since the candidates were a Ford and a Carter. In 1977 the news focused much attention on congressional approval for the funding of the B-1 tactical bomber. Dana had by that time gotten more confident in her airline ticket sales job, had met a new boyfriend, and had become friendly with people from work and from her residence. She seemed happy, but one day she announced to me that the government was experimenting with the B-1 not just for defense but as the mediator of all future foreign policy for the rest of eternity. Here the government referred to the self, the psyche. B-1 meant being one (person), being whole, complete. Foreign policy denotes the way that one’s government (i.e. self) interacts with other governments (i.e. people), and eternity means forever, for the rest of ones life. Thus translated, “being whole is more than simply a defense, but becomes a means of successful interpersonal socialization for the rest of your life.” The concept was completely congruent with her external experience and accurately described, albeit in a symbolic fashion, a universal truth. Despite the interpretation, she had a lot of difficulty seeing her fantasy as a projection of her internal issues and tended to maintain her view of certain government activities. Related statements at the time included the idea that Egypt built the “As one” dam to stop “denial,” and that Henry was “kissing her.”

The whole notion of the undercover inner workings of secret politics and clandestine activities in government is a source of mystery to most people, from Nixon’s Watergate enemy hit list, through Oliver North and the Iran-Contra affair, through the KGB, the CIA, the Secret Service. These mysteries are the meat of delusional ideas, and while we can attempt to relate it to internal emotional churning, it is not possible to “prove” that on a governmental level it does not exist. One could even create a pun suggesting that “governmental” is a way to “cover mental” issues. I conceptualized a kind of boundary line onto which is placed a see-through mirror. On the far side, we place the government, the world, and international politics. On the near side is the self, the feelings, the psyche. There could be reflections of world events from the outside in, but since world events can be so inexplicable, perhaps we could stay with the explicable, understandable, internal events. These internal realities may be then projected out, but for them to remain on the near side of the line would be much more beneficial. Admittedly, I liked my metaphor of the line and mirror, but it got only smiling, passive acceptance from Dana.

Since I was not going to get her to cross the line to the internal self, I decided to approach the level of understanding by crossing to the outside. It was time to study history, in this case (of course knowing me) medieval history. I devised the following “historical” analogy. A tiny nation was surrounded by two powerful, warlike countries that constantly bombarded each other and the tiny nation. To protect itself from this ongoing attack, its government built a huge wall, completely sealed off, thick and impenetrable, to guarantee the safety of its citizens. No hostile forces could invade; nobody could even see inside. Of necessity, the inhabitants could not see or go outside either. After a time the neighboring governments were overthrown and replaced by more benevolent rulers, but these changes were of course unknown to the walled-in tiny nation. No more bombs were falling. No more banging on the wall. Was this a trick, or had peace finally been declared? People began to peek between the bricks and saw no soldiers outside, and the neighbors peeked in but caused no damage. The neighboring nations perhaps could even be of help by providing resources or technical support. Gradually, the walls, which were no longer necessary, were dismantled, and free exchange was implemented. Dana responded, “Gosh that sounds a lot like my life, don’t you think?”

An extended period of respite followed with discussions about leisure time, work, and social life. Her affect was full range, and her relatedness was on a level that belied the pathology we had explored. This was interrupted by a slight increase in paranoid thinking and double meanings, largely government-connected, like “The government makes Indian reservations to fly them away.” For the first time she told me that, in fact, I was an agent of the government. I! Part of the forces of possession and oppression! I was shocked, even a bit insulted, given all the effort and time I had put into the treatment, with every intention of freeing up, rather than oppressing her life. I told her that I was absolutely sure I was in no way linked-up with the government, and that I wanted to know what evidence would make her think such a thing. She attempted to calm me and said that unbeknownst to me the government was working through me and could program me to say certain words that had special control issues, but that I, of course, had no awareness of all this. Figuring that this related to certain authoritarian expressions or words I might have used, I asked what these magical words were.

Her response was one word, “which.” “The voices on the street always told me I was a witch and so whenever you use that word, I know that the government is talking through you.” I asked if either usage of the word was an issue, either spelling, and was told “That’s how the government works. Any way you use that word, it is their way of attacking me, humiliating me.” Apparently, this did not occur with other words incorporating “which” such as, “switch,” “twitch,” or “sandwich.” Needless to say, I did not want to be part of the “bad guys,” even unknowingly, and I had trouble figuring out what this was all about: Negative transference? A way of moving away in therapy? A form of testing? I discussed it with a psychoanalyst friend who suggested that she was testing my own strength to tolerate her crazy ideas and that the best way to proceed would be to try to eliminate “whiching” from my sessions. I disagreed with the tolerating part, since I had tolerated much stranger ideas in the past. My own neurotic needs to please did, however, gel with the idea of talking without using the word. To speak without the noun “witch,” as in “on a broom,” was easy, but “which” to introduce an explanatory phrase happened to be very much a part of my speech pattern. I found my ... self ... speaking ... slowly ... with ... hesitation ... to plan ...every upcoming ... phase. All spontaneity was lost. Every sentence was a challenge fraught with the fear of accidentally using “which.”

Within a few weeks of this, I was feeling increasingly upset with the entire process, and I told her so. She asked me what I meant and why I was doing that. I explained that if I were a government tool giving secret messages, she would leave treatment and we would lose all the gains we had made. She assured me that there was nothing to worry about, that I had said the word “which” hundreds of times over the years and that she had never walked out or left treatment. After so much time, she assured me that I certainly had nothing to fear. True as that was, I still thought that now that I knew about this, I could no longer trust that reassurance, and that she would not tolerate a government agent being her therapist. I came to realize that I had developed a fixed belief, completely impervious to the most reasonable, gentle experiential convincing, that was causing my entire communication process to become stiff, rigid and inexpressive. I had developed a paranoid delusional response with verbally catatonic features. Dana saw my dilemma and commented that “Now you have a deeper understanding of what it’s like for me.” I surely did. I could see my process as a massive defense against the potential loss of goals, purpose, validity, and alliance. I could not trust the fact that, even with her promise not to walk out, the fact that she had never done so up to then, and that great strides had been made, she would not abandon our journey.

So I maintained my route of compulsive avoidance, practiced intensely, and improved at speaking proficiently without using the word “which.” I taught myself to substitute words like “that” or “whatever” or break the sentence into shorter sentences. I also observed that she could speak fluently without using the word. The outlook improved for both of us. One day Dana told me about two men who liked her, but she was not sure which one she liked more. In the same session she mentioned an interest in visiting one of two islands in the Caribbean on vacation, but she could not decide which one to travel to. I realized that the only place where there can be no substitute for “which” is when a choice is made between two objects. I asked her to talk about what it meant for her to make choices. Dana said it was the worst thing imaginable, that she hated to make choices. Choosing was tantamount to selecting one and rejecting the other, feeding one and starving the other, nurturing one and killing the other. It was always better to do both options since you would be creating pain and death for one of the choices. She felt this dilemma since her childhood, and it was always a source of anxiety, based on her apparent need to establish an alliance with one or the other parent. What kind of person could inflict such a degree of pain so easily? A witch. The entire delusion was referable to the trouble caused by making a choice, with the concomitant rejection of certain options.

This was the climactic point of therapy. The rage that Dana had felt through virtually all of her life had combined with her fear of any form of fantasy, based on the learned doctrine of mortal sin. This combination made it necessary to suppress the conflict out of consciousness. Any semblance of choice risked opening the gates to an emotional turmoil she felt was unmanageable and uncontrollable. By displacing the entire conflict into an out-of-reach government place, she attempted to do away with her fears of being an evil murderess. She was, however, stuck with her ever-present rage fantasy, likening herself to a witch. The government can be interpreted on many levels. Obviously, it represented her psyche. It also represented a projected father, an embodiment of humiliation, that addressed her despised self, the portion of the internal image that can never be good enough and made her unable to be a part of the world. The government also was an idealization of the guilt she felt at having the power to choose an attitude, as a choice-making witch. On a larger level it represented the whole worldview, the inexplicable lack of control over her existence, with the strong ambivalence of needing the control, yet relinquishing it, and yet resenting no longer having it. The result was a figurative and literal inability to move, causing a belief system that exuded grandiosity and at the same time horror, through persecutory delusional ideas. The balancing act of my trying to communicate without using the word “which” was a reflection of her balancing act between the desired loss of homicidal potential and the inevitable feelings of rage she had always suffered.

Dana did well in therapy, never exceeding the low dose of perphenazine, eventually working as the assistant to the director of a well-known museum. I did well in therapy too. I developed some strong personal insight into what may have been a tiny piece of paranoid-catatonic process. More importantly, I came to a tremendous respect for human creativity, even in the context of schizophrenic thought disorder. One of my supervisors, who was more sensitive than others to my explorations, told me that I would never have this sort of therapeutic encounter again. I was furious! I had found the cure for schizophrenia, and the world was full of jaded old “shrinks” who knew everything and did nothing! Years later my supervisor’s statement proved right, at least in part, and I came to an understanding of what she meant. First, Dana truly hated being schizophrenic. Her illness had ceased to function as a defense against an unaccepting and humiliating world, becoming in and of itself a source of humiliation and rage.

Many other patients remain less comfortable with returning to the external reality of the actual world and manage to balance their lives in a way she no longer would do. Secondly, and far more apparent to me now, is that the effort I made throughout the treatment to reframe and understand her delusional system may have meant more to her than the specific meaning of my interpretations. The active interest and participation of a stranger, for the purpose of making sense out of one’s emotional chaos, are powerful messages for the lost soul. The idea of a strong entity becoming available to our presence and willing to help us is a central concept in religion, education, and therapy. Saints, teachers, and therapists all extend lifelines to worlds unattainable to us without them, and they help us to achieve those solutions with dignity and awareness. It is likely that the lifeline I extended to Dana did not require that degree of interpretation, and I could have maintained the effect without the vast expenditure of emotional and intellectual energy.

While treating Dana, I started analytic training. Students at school and colleagues at work all had strong opinions about what I should have done, what would have been more effective, more stimulating, or less self-effacing for me. Many of the approaches I had used were pure improvisation. The whole direction was uncharted territory for me.

At a distance of twenty-five years from the treatment, I admit that the interpretations were at times sophomoric, perhaps heavy-handed, maybe too limiting. There are those who oppose using psychodynamic interpretations to comprehend schizophrenic symbols or those who would reframe them in other ways. In fact, my own dynamic framework is far less retrospective now than it was prior to my formal training. Perhaps my youthful grandiosity made me too headstrong about the validity of my efforts. However, I was able to avoid the whole cookbook, complacent therapeutic approach all too common today. This case cannot be used as a model of how treatment should be done. Rather, I use it as an example of the importance of seeking meaning, of communicating, of penetrating into what someone really is talking about, trying to help a person at that level. Not long ago, a group of medical students asked me how does one “do therapy.” I wanted to avoid a dismissive answer like, “It takes years to learn,” or “It cannot be done on an inpatient unit.” I thought about their question and gave them three basic rules: First, seek out the intrinsic strength of the individual as the main bulwark against the pathology. Second, think carefully how you yourself would want to be spoken to. Offer what you can deliver, and never promise or threaten what you cannot or will not do. Third, be aware that there is always more to learn about a patient, and keep digging.

A few months ago, I was talking with a woman from Minnesota about a fascinating project with which she was involved. She and a group of investors had put together a “health center.” After programming Harrison’s textbook of medicine and the equivalent textbooks of pediatrics, gynecology, pharmacology, psychiatry, and therapeutics into a large computer, they set it up so that people (for a small fee) could input their symptoms into this computer, day or night. They would be given a diagnosis, a treatment plan replete with prescriptions, possible side effects, and a series of return appointments to report their progress. The woman excitedly told me that this would effectively eliminate the need for doctors altogether, thus saving tremendous cost and time and putting tons of money into the investor’s pockets. This idea appalls me and frightens me. The business of medicine and psychiatry has all but killed psychodynamic therapy and has crippled cognitive and behavioral models. This plan would eliminate all individual treatment in favor of a few group psycho-educational sessions to bolster the need for lifetime medication, prescribed by a primary care “gatekeeper.” It is not a long jump to the next step of eliminating us psychiatrists completely. Ironically, the administrators and the captains of industry comfortably place blame for their takeover of our work on the need to control our excessive greed! Too many of us are burned-out and cynical about the inevitability of this phenomenon. Among the things that humans do better than machines are thinking, feeling, and caring. As a psychiatric community, we can offer understanding, pain-reducing medications, and the redirection of destructive perceptions or impulses. People surely have impairments of neural pathways and chemical imbalances, but they also need the support, the communication, the belief, and the reality of empathic warmth to reconstruct their lives. Let us never sacrifice either direction in our work.

Scott Schwartz, MD, is a Fellow and Trustee of the American Academy of Psychoanalysis, Assistant Professor at the New York Medical College Department of Psychiatry, and Attending Psychiatrist at Metropolitan Hospital Center, New York.

Correspondence to: Dr. Scott Schwartz, 829 Park Avenue, Apt. 10B, New York, NY 1021

Book Review: Of Two Minds: The Growing Disorder in American Psychiatry

By: Richard D. Chessick, M.D., Ph.D.

This is a long and thorough anthropological study by a professor of anthropology at the University of California, San Diego. The target audience of such a book is the generally educated public who may be interested in medical affairs and in problems in the mental health field. Psychiatrists and psychoanalysts reading this book will find little that is new in it, but they will find that Luhrmann has done an excellent job in describing the current status of psychiatry and psychoanalysis. That status can only be described as a disaster, and more of a disaster for the mentally ill than for the practitioners in the mental health field.
There is no need for me to review what Luhrmann experienced in her studies of various psychiatric hospitals, psychiatric treatment programs, and psychiatric residents in training, as it is all quite familiar to those of us who are in the field. The book has a somewhat polemical and at times repetitive tone because it is frankly aimed at making the public aware of the calamity that managed care has imposed upon the mentally ill in our country. When I tell my European colleagues about this situation they are aghast and convinced that we Americans are insane. At the same time they worry that the general Americanization of the world that is going on today will be spreading away from our shores and encompassing and ruining medical practice in the rest of the world including their own countries.

The book begins with an introduction that leaves the author open to some question regarding her capacity to bring about her investigative field work, but as the book moves on it becomes apparent that she certainly has done a respectable job; as for her motivations in doing such a study, this is not relevant to the results of the study in this case. She states that since 1989 she did four years of field work “including more than sixteen months of full-time intensive immersion” (p. 9) involving local hospitals, attending lectures, visiting at length with residents, and sitting in on medical meetings. She spent time at various kinds of private hospitals and traveled around the country “speaking with hospital administrators, psychiatry residency program directors, and young psychiatrists” (p. 9). She shadowed residents during their days of work, watched patients interviewed, and received twice-a-week psychotherapy “with a senior psychoanalyst for more than three years” (p. 10). She does not explain why she received this psychotherapy, and she also tells us “I have followed eight individual patients for psychotherapy under the supervision of a senior psychoanalyst” (p. 10), which makes one wonder how this came about and raises concern about the ethics involved.

In the first two hundred or so pages of the book Lurhmann tries to paint a balanced picture of psychiatric training as it was when she started her research over ten years ago, when residents were given instruction in both psychodynamics and psychopharmacology. As time passed it became clear that under the influence of managed care there was going to be no time for psychodynamics and no time to spend trying to understand patients; psychopharmacology became the predominant treatment. So psychiatrists increasingly spend their time prescribing medication, doing extensive paper work, and arguing with managed care to get authorization for treatment and payment. There is a general demoralization in the profession. At one extreme there are the biological psychiatrists and at the other extreme the psychoanalysts, an unfortunate split since it is increasingly clear that a combination of biological understanding and treatment, along with psychoanalysis or psychodynamic psychotherapy, is the optimal approach to people with mental illness.

Her description of the annual American Psychiatric Association meetings is impressive, She points out the “air of carnival” (p. 55) and it is clear that the gigantic multinational pharmaceutical industry has now totally dominated the field of psychiatry. Psychoanalysis is increasingly shoved onto the periphery, and of course this position is used by managed care as an excuse to deny payment for such treatment. Training in psychodynamic and depth psychotherapy has largely been eliminated and rightly so, since it is almost impossible for young psychiatrists starting out to find patients who are able to pay for this by themselves. The net result is a calamitous medical malpractice situation in which the psychiatrist is held responsible and yet manipulated into situations where clearly inferior treatment is provided. This is especially true of hospital psychiatry, as documented at great length by Luhrmann. Luhrmann reviews some of the extreme positions of psychoanalysts in the middle of the twentieth century, such as the attempt to explain manic-depressive disorder on the basis of family dynamics, and so on. The deep psychoanalytic interpretations of peptic ulcer that I learned in the 1950’s now look rather strange next to the discovery that this disorder is caused by bacteria. So, describing the meeting of the American Psychoanalytic Association, she tells us that a young analytic candidate described it as “watching dinosaurs deliberate over their own extinction” (p. 183).

Because the power of the pharmaceutical corporations and the insurance corporations with managed care is “pushing the psychodynamic approach out of psychiatry with a nearly irresistible force” (p. 203), many individuals needing long-term treatment are deprived of a chance to have at least a passable existence during their short span on this earth. So ...

The real crisis for psychodynamic psychiatry has been not the new psychiatric science but managed care. . .. It isn’t that psychiatrists think that psychotherapy isn’t important . . . but the more time they spend on the phone with insurance agents negotiating for a six-day admission to be extended to nine days because a patient is still suicidal, the more admissions interviews they need to do, the more discharge summaries they need to type, the less the ways of thought and experience of psychodynamic psychiatry fit in. (p. 238)

Luhrmann concludes, “Then, at the end of my field work, I saw the balance tilt irrevocably” (p. 238), and she is told by one of the residents that “They’ve decided to ax the psychoanaltyic journals from the library” (p. 239). The disaster that managed care has caused to the mental hospitals is described in detail, with the firing of staff, the demoralization of those who remain, and the change in orientation toward patients from humans with problems to biological things that have to be patched back together and sent out to the environment that precipitated their illness in the first place. A lot of anxiety occurs because some of these patients still seem to be suicidal, and it is very difficult to be the psychiatrist caught in the middle. Most of the analysts in these hospital settings have either left or have been fired, and I am sure the readers of Academy Forum are aware that the chairmen of departments of psychiatry today are all administrators and pharmacologists, whereas fifty years ago they were mostly psychoanalysts.

So, as Luhrmann quotes an eminent psychiatrist, we are “seeing our profession in the beauty of its great sunset” (p. 252). In the whole area of psychiatry and psychoanalysis, as well as in the rest of the medical field, we are enduring the demise of the doctor-patient relationship. Those who wish to practice psychoanalysis have to accept a very substantial financial drop in their income. Given the exigencies of modern life in corporate America, few of us are in a position to accept such a drop, and the result is a migration toward once or twice a week therapy for patients who at least can afford to pay for their therapy on a much less frequent basis. The great age of the flowering and expansion of psychoanalysis is over; the enormous gains in understanding the human mind and how it functions from the depth psychodynamic exploration of patients in four and five times a week treatment is a matter of history except in the hands of those few who are willing to make the sacrifices entailed to continue this exciting and worthwhile journey. The side effect of this loss of the psychoanalytic orientation is a loss of empathy and compassion for suffering human beings, what Heidegger referred to in the age of technicity as “enframing,” a viewing of people as objects to be manipulated, controlled, medicated, with the implication that they are also objects that may be liquidated and erased.

By writing this book Luhrmann apparently hopes that somehow she can influence the American public to put a check on this disaster, but I think in that hope she is underestimating the power of the insurance and pharmaceutical industries. The reader merely has to examine the amounts of money that are given to political campaigns and lobbying efforts by these giant corporations and the total control of the media by their conglomerates to see how the situation has progressed to a state of what Marx called mystification or “ideology,” in which the predominant economic powers of a country inculcate what they wish to be known as “truths” in the mind of the public and enable those who challenge these “truths” to be labeled as “bad” or “mad.”

In summary, Luhrmann has done a great service by this anthropologic study. She is a clear although rather verbose writer and one can only hope that her book catches on. Let us not forget that it has to compete in the bookstore with the enormously popular appeal of the fantastic twists and turns of the imaginative “better than reality” Harry Potter works and the well-written and long chilling horror that is the fictional reality of Steven King’s novels.

Dr. Chessick is Professor of Psychiatry and Behavioral Sciences, Northwestern University, and Senior Attending Psychiatrist, Evanston Hospital., and Training and Supervising Analyst, Chicago Center for Psychoanalytic Study

Correspondence to: Richard Chessick, MD, PhD, 9400 Drake Ave., Evanston, IL. 60203-1106

Useful Fictions in Psychoanalysis and Psychotherapy

By: Harold R. Galef, M.D.

There is a version of what used to begin or end many psychoanalytic papers in the past, the unequivocal statement that Sigmund Freud was a genius and that “he got there first.” Besides his many other formidable gifts, his genius was expressed in leaping from few data to an organizing principle of sweeping depth and extraordinary explanatory power. This aspect of his work has resulted in many of his conclusions remaining valid, while others have been more or less discarded. I am well aware that he himself swept many of his ideas under the rug in favor of later propositions of his own construction. The uncertainty of several of the more hallowed principles allows me to refer to them as fictions. They may be true some of the time. It is highly unlikely that they are true all of the time, but it is useful to at least think of them as if they are always true. Hence, the term of “fictions” in the service of analysis. I do not refer here to such concepts as Thanatos, which has been more or less disregarded by contemporary psychoanalysis. Rather, I will emphasize certain clinical concepts which are still stressed, although I question the all or none aspect of their validity.
Psychoanalysis is not a science in the usually accepted definition. This point has been endlessly debated, often terminating in the cheerfully optimistic statement that psychoanalysis is a hermeneutic science, even if it does not meet the rigid criteria of a natural science. This area of contention does not interest me. I leave the matter to the Poppers and Gruenbaums of the world and to some Freudians who continue to debate this contentious area.

Even if certain basic theories of psychoanalysis are not universally true and can never be proved to be so, they may be eminently useful in clinical work. We need not apologize for this view, even if it is short of what we might like. Even in physics, the “hard science” to which we are often unfavorably held to in comparison, the situation bears some similarity. The theories of Newton and Maxwell, once regarded as universal truths, have long since been shown to fall short of the mark. Nonetheless, they remain of remarkable utility for contemporary functional scientific work because they are true in the huge majority of situations.

Here are a few examples of clinical situations in which it is extremely useful to listen as if certain truths always hold, even if we cannot, or do not choose to, view them as universals. In working with dreams we still follow the Freudian tenet that we must not settle for the manifest content but rather must listen to associations that will bring us to the latent content, where the “real” meaning lies. Also, we were taught that a dream always represents the fulfillment of an unconscious wish. It has become clear to me that in the dream work process, in which latent meanings are changed into the manifest, recalled content, we are dealing with a very uneven process. There are times when the manifest content has been altered only to a small degree, if at all, and other situations in which much work of displacement, condensation, and so forth requires analysis before a meaningful understanding can be reached. There do appear to be dreams in which a wish is not of paramount interest. There clearly are dreams in which great attention must be paid to the relatively undisturbed manifest content. This approach will often lead us to at least a partial interpretation of the dream, if not to the idealized “complete interpretation” so desired by students in our field. It is certainly useful to “think” in idealized terms, even if we know that the reality will often be otherwise. Here we have an example, more often stated than observed, where we must not force the patient’s clinical material to fit the Procrustean bed of theory. We must be prepared to shift our attention to more reasonable views when the idealized picture does not exist in a given clinical situation, although our initial attention often focuses on the theoretical model.

A second area concerns the matter of transference. So many comments of the patient may refer to disguised feelings about the analyst, but they certainly do not necessarily have this value. Nonetheless, it is always useful to consider that possibility and to interpret it if other material is suggestive. Just as it is foolhardy to force a transference interpretation on all presented content and affects, it is careless not to think of such a case as a distinct possibility. The situation may represent a truth or a fiction, but we are usually better served if we consider transference to exist at all times. That is precisely what I refer to as a useful fiction, begging the question on each occasion as to whether we are dealing with an absolute truth.

The last example I would like to present is more equivocal. It concerns free association. If associative material is continually presented in this fashion, I do believe that one can follow the material in that mode of working. However, patient’s productions are never presented in that way without significant gaps. In spite of the inability to prove the case, the use of free association represents an enormously significant aspect of psychoanalytic practice. We must always maintain the stance that it is an ongoing truth, even if, on reflection, we know that there are frequent and significant gaps in the process, gaps which we cannot elucidate. This is a useful fiction, even if there is a space of a day or more between sessions.

In essence, then, I feel it is more prudent to think of such clinical ideas as representing universal truths, even if we come to the conclusion that they may be fictions in a given clinical situation. The alternative, as we well know, is to let too many opportunities pass by outside of our awareness. It always seems better to follow our clinical precepts first, and then be prepared to alter them, as necessary.

Harold R. Galef, M.D., is Clinical Associate Professor of Psychiatry, Albert Einstein College of Medicine, New York, NY; Faculty, Westchester Center for the Study of Psychoanalysis and Pschotherapy, White Plains, NY.

Correspondence to: Dr. Harold R. Galef, 15 Roosevelt Place, Scarsdale, NY 10583

The Popularity of Harry Potter

By: Ildiko Mohacsy, M.D.

Why is Harry Potter so popular among children? The very existence of the series is itself a kind of magic story. Harry Potter books are written by J.K. Rowling. She herself is in her 50s, Scottish, and a single mother. She did not expect to abruptly become one of the world’s most popular authors. Rowling began the first book on scraps of paper, sitting in a café.
Rowling writes fantasy. Harry Potter, an oppressed little boy, discovers he has great powers. The stories are, in a sense, collections of modernized and sophisticated fairy tales. The question is why today’s sophisticated children love Harry so. Bettelheim comments in The Uses of Enchantment: The Meaning and Importance of Fairy Tales: “The fairy tale ...conforms to the way a child ...experiences the world…. He can gain ... better solace from a fairy tale than he can from ... comfort ... based on adult reasoning…. A child trusts what the fairy story tells ... its world view accords with his own.”

Children explore both pleasurable and frightening scenarios from the safety of fairy tales. Fraiberg concurs in The Magic Years: “... a magic world is an unstable world ... a spooky world…. As the child gropes his way toward reason ... he must wrestle with the dangerous creatures of his imagination and the real and imagined dangers of the outer world.”

Fairy tales involve more than magic. Familiar figures, from the outside world, guest star garbed in any number of guises. Characters, both villains and heroes, are rewarded or punished for their actions. Reward or punishment is often determined by how well or badly a character copes with the unexpected. As Freud wrote in “Creative Writers and Daydreaming” (1908, SE, Vol. 9, pp. 141-154), literature and fantasy are tangibly intertwined.

Children like reading Rowling just for this reason. She spins fantasies about coping. The Harry Potter series concerns dualistic feelings of being despised and being admired. Harry experiences the pain of being a despised minority among the Muggles - the ordinary people. And he experiences celebrity. In Rowling’s books, Muggles constitute the ordinary world.

A Muggle is a person who has no flare for the magic of life. He has neither curiosity, nor sense of surprise, nor of beauty in any sensory modality. Muggles never experience any sensations of serendipity or epiphany. They are boring, normal English people. Harry starts out experiencing terrible deprivation among the Muggles. The world he escapes to, though, is filled with wonder. There are wondrous animals, unicorns, dragons, griffins. Harry finds himself in a puckish world full of Pucks, as if dropping into Shakespeare’s A Midsummer Night’s Dream. It is a world, however, where Harry and his friends must learn to confront human evil, jealousy, envy, revenge.

Nothing in the wizard-world is ordinary. The wizards are the lucky few who possess inspiration, creativity. This gives them power. They find “miraculous solutions” to frightening problems - a common fantasy. The wizards turn bad situations into good. In school, Harry has to deal with a problem many children wish to have - without knowing the consequences - of being a celebrity. Harry has to bear the consequences of being admired, as well as being feared and despised.

A fascinating thing is how Rowling’s books are a combination of Grimm fairy tales and the Hauff fairy tales, in which violent and horrible things happen to children. Harry Potter’s struggle between evil and good, light and darkness, is also a reminder of Zoroastrian mythology, e.g. The Magic Flute, with the Queen of Night. Zoroastrian battles are always fought between forces of dark and light. Even in Harry’s wizard school there are two parties. There are good and evil forces. The evil want nothing more than to kill Harry. The good, in the personage of the giant Hagrid and the teacher Dumbledore, saves him.

Who is young Harry? He is the hero of all myth, legends, fairy tales. In the first volume, Harry Potter and the Sorcerer’s Stone, it is clear that he doesn’t know his parents. He is maltreated by strangers. The secret that he is of famous royal descent is kept from him. Harry’s self-discovery follows the pattern of Freud’s family romance. His self-discovery partly follows a mélange of folk legends: orphaned Oedipus, the Nibelungen Ring’s Siegfried, the Norwegian Edda cycle, the English King Arthur. Harry likewise resembles Moses, who is miraculously found floating down the Nile by a princess.

Harry has something else in common with figures from legend. After being struck on the forehead by a wizard, Harry is marked, like any number of stigmatized saints - notably Joan of Arc - immortals, the exiled Cain, and the Golem. The Golem, a creature from Jewish folk legend, actually bears a mark signifying truth, emes, on its forehead.

How else is Harry a figure from folk legend? Harry starts out by being enslaved and tortured by the Muggles. His sufferings may remind readers of themes of enslavement and torture, the labors of Hercules, of Jason searching for the Golden Fleece, or of biblical-scale victimization, Jacob working for Laban, Joseph the dreamer being victimized by his own Muggle brothers. Harry himself is modest, like any good hero. He doesn’t fight evil to gain fame, but because it’s the right thing to do. He seizes opportunities as they arise.

Harry has much in common with earlier heroes from children’s literature: the four siblings from C.S. Lewis’ Narnia chronicles, who have no clue they are kings and queens of Narnia, until they are transported via a wardrobe from a British country house, during World War II. Harry may remind readers of Mark Twain’s little boys in The Prince and the Pauper, who swap birthrights with disastrous consequences. He resembles Charles Dickens’ heroes David Copperfield, horribly exiled to a life of pasting labels on wine bottles among the proletariat, and Oliver Twist, surviving among the thieves though he has a rich grandfather. Harry resembles Frank Baum’s Dorothy, marooned in the Land of Oz - in Hebrew the word Oz means courage - coping with good and evil witches. Harry is like Kipling’s Mowgli from the Jungle Book, a parentless child who learns the language of animals.

Like its predecessors, Rowling’s books are parables about mental mechanisms for defense, adaptation and integration. I asked one little girl why she is fascinated with Harry Potter. She said, “Something unexpected happens all the time.” Rowling’s characters cope with happenings, whether expected or unexpected. Harry copes with being disliked by the Muggles, even with being disliked in the ideal world of the Hogwart wizard school by teachers like Snape or by his schoolmates Malfoy and Crabbe.

What else does Harry cope with? It is his tenacity, his endurance, his life instinct, his patience, his ingenuity, which so appeal to children. First, Harry confronts his state of being different. A child always feels different from grown-ups. Every child has to cope with his differences from the Muggle or grown-up world. Harry Potter shows us how to endure immense difficulties imposed on him by Muggles. He is cold and doesn’t get food. He is locked in the dark in a closet. Yet despite his fright at being closed in, Harry overcomes any number of claustrophobic situations, even his early fear of being annihilated. He deals with what Fraiberg calls “anticipatory anxiety.”

Secondly, Harry shows how one can overcome difficulties with wit and skill more than with strength. Harry is himself a weak boy. He is as innocent and helpless as a human being can be. Children often feel helpless, cheated, frustrated. Consigned to his little cubbyhole when there was a big party, Harry coped. Even when his own birthday went uncelebrated, Harry gathered enough self-solace to protect himself from pain.

These narratives appeal to girls as much as boys. Both male and female characters represent good and evil forces, virtues and vices, intellectual strength - particularly personified by the schoolgirl Hermione - of loyalty, friendship. Hermione represents brilliance, consistency, reliability. Harry’s female teacher McGonagall represents brightness and kindness; she is the closest thing in the books to a good mother.

Rowling’s avoidance of superficiality is equally appealing. The books contradict the clichéd, modern-Hollywood ideal that bright and beautiful go together. Harry’s fatherly Professor Dumbledore and ever-present Hagrid demonstrate how physical beauty and spiritual greatness can go separately. Harry himself is hardly described as a picture-perfect boy from TV commercials. He is thin, small, has untidy hair. He wears eyeglasses. He is described as an ungainly child. Only his shiny, green eyes are beautiful.

The popularity of the series also illustrates how much children prefer imaginative and fantasy reading to reality-based classics like Susie Goes to the Grocery Store or Fun With Dick and Jane. Writing in The Boston Sunday Globe (July 9, 2000), Susan Linn notes Winnicott’s belief “that children thrive in environments that have safe boundaries, but do not impinge on their ability to think and act spontaneously.” Fantasy stories are as important a formative influence as reality-oriented books. One interesting feature of the Harry Potter series is how wishes and fears, of the future and past, are reflected in a magical mirror called “Erised” - meaning desire. Every child who looks into Erised can see something. Harry’s wish to glimpse his parents is fulfilled; his mother cries as she waves to him. Some wicked characters look into Erised. It shows them how they can take revenge on Harry. Yet just because the mirror shows wishes, it doesn’t mean that it will grant them.

Here again, Rowling is using literary riches from the past. Mirrors have a long history in folk legends. They are dualistic objects of good and evil. The power of a reflection can be frightening. Gazing at themselves was fatal for both Narcissus, and unlucky men who looked at Medusa. The magic mirror in Snow White answered the stepmother’s question: “Mirror, Mirror, on the wall/who’s the fairest one of all?” It also incited the stepmother to attempt homicide. Mirrors, though, are sometimes saviors, as when Jason borrowed Athena the Goddess of Wisdom’s reflecting shield in order to slay Medusa.

Dualisms and monstrosities run rampant throughout Harry Potter books. Such fantasized wild things, as Bettelheim suggests, come from children themselves, from their desires, fears, and projected wishes. Wild things come from children’s realizations that the outside world is dangerous. Wild things thrive in many classics of children’s literature. Maurice Sendak’s classic story Where the Wild Things Are has its hero falling into a wild, dark world at night, clad in pajamas. In Doctor Seuss’s Horton Hears A Who, nasty adult animals run around threatening baby elephant Horton’s tiny, magic world, yelling, “Boil that dust-speck!” The Last of the Mohicans, Treasure Island, Kidnapped, Robinson Crusoe, The Swiss Family Robinson, even the satiric Gulliver’s Travels, all deal with the conquering of wild surroundings - with the conquering of the uncontrollable.

Harry himself copes not just with the wild, but with ultimate evil. His greatest, most terrifying enemy, Lord Voldemort - whose name we are warned, cannot be mentioned - of course reminds us of God, whose name cannot be mentioned either. The name Voldemort, too, as Joan Accocella points out in The New Yorker, may come from a combination of two languages, vol-ful, de-of, mort-death. So the God-like Voldemort also resembles the Angel of Death, or Lucifer.

Concealing himself, Voldemort may remind readers of any number of monsters, Batman’s foe Scarface, the scarred and masked Phantom of the Opera’s Phantom, the eye-patched Captain Hook in Peter Pan. Voldemort is like the boogie man, the wolf in Hansel and Grettel. He serves the same function as Hagen from the Nibelungen legend, who betrays Siegfried to his enemies. All these monsters appear in destructuralized form.

How does a small child cope with fear of the monstrous? Fraiberg gives an example in The Magic Years. A five-year-old says, “My Daddy is so strong. If there were two tigers in my room? My Daddy would kill them immediately.” What is this statement but the child’s omnipotent, magic, animistic belief in his adored father’s strength?

So in a child’s life, the good wizards are the good parents when they prove to be good. His parents are evil wizards when they prove to be bad, denying pleasure, when being punitive or unreliable. In such circumstances the parents’ names cannot be mentioned, any more than Voldemort’s. The child cannot call his parents insulting names, nor say the curses in his head.

Fraiberg even suggests that a child’s future mental health “depends upon ...[his] solution to the ogre problem.” She adds: “... Even the most loving and dedicated parents discover that in a child’s world a good fairy is easily transformed into a witch, the friendly lion turns into a ferocious beast, the benevolent king becomes a monster….” Denied his way, a child transmogrifies his parent into something horrid, a monster for the duration of his rage.

Other negative qualities are incorporated in certain animals or represented by certain human figures. Names hide foibles. In the first Harry Potter book there is Professor Snape - whose name could stand for snake - and the nasty schoolboy Malfoy - whose name could imply bad fable. Other nasty schoolboys, Crabbe and Goyle, remind one of crabs and gargoyles, the stone menagerie clinging to Notre Dame cathedral.

There are interesting twists. Sometimes Rowling’s wit is that the names characterize the opposite. There is a three-headed dog who acts ferocious, but whose name is Fluffy. Fluffy is the keeper of a secret place, like Cerebrus. In Rowling’s magic kingdom, a child’s inner helpless fears and frightening views of the “ordinary,” Muggle, grown-up world are mirrored.

Why do many grown-ups like Harry Potter? According to Freud, scratch a grown-up and find a child underneath. Ferenczi’s famous article, Child Analysis in the Grown Up discusses how ongoing prejudices, fears, hopes, all have their roots in human development. We know that any grown-up person can regress under internal or external stresses; the essence of post-traumatic stress disorder is well-known.

One thing that may especially appeal to adults is how miracles save Harry. He survives with unexpected help. Early in the first volume, the good, kind, giant Hagrid flies in on a motorcycle to rescue Harry after many years of suffering. Likewise, many adults believe in magic, in divine intervention. A patient of mine mentioned a great miracle. He survived after being knocked 200 meters, while on his own motorcycle, by a truck. He said this shows there is a god. He did not stop to ask, “Who sent the truck?”

Grown-ups frequently feel helpless as children. They want miracles to change unfortunate situations. Rowling’s books resonate with what may be termed a Cinderella complex - the ever-present inferiority complex most people suffer from.

At the mercy of the Muggles, Harry lives miserably. Harry slaves when guests come. He is left out. He doesn’t get any cake or goodies. He has to clean up like Cinderella and is starved like Cinderella. Many grown ups suspect that they, too, are living in Cinderella-type situations. Reading about Harry’s exclusion can kick off feelings of displacement, of not being accepted into a club. “Harry,” remarks author Stephen King in The New York Times (July 23, 1000), “is a male Cinderella, waiting for someone to invite him to the ball.”

Children, too, identify with Cinderella. A child’s inner resources in Harry Potter are externalized. Hagrid and Dumbledore are good, ever-present parents. The Muggles represent the mean, unreasonable parents, who in the child’s conception, are treating him like a slave. Often in a child’s imagination or experience, he feels he is being taken advantage of. A child may be angry when not being given coffee or alcohol, while grown-ups drink it, being sent to bed while grown-ups stay up. In response a child can perceive life as a series of unexpected rewards and punishments by his powerful parents.

Fraiberg explains the relationship between childish fantasy and primitive thought: “These are ‘magic’ years because the child in his early years is a magician - in the psychological sense.” Bettelheim concurs, describing children’s thinking as “animistic.” He agrees with Piaget’s suggestion that children think animistically until puberty. “To the eight year old ... the sun is alive because it gives light ... the stone is alive ... as it rolls down a hill ... it is believable that man can change into an animal….”

Bettelheim emphasizes the connection between fantasy and fairy tale. Children identify with characters in fairy tales in order to wrestle with their questions of identity: “‘Who am I? Where did I come from? How did the world come into being? Who created man and ... animals?’ ...Fairy tales provide answers.” Because parents guard children, children believe that some guardian angel will also “do so out in the world.” Bettelheim suggests, as well, that adolescents deprived prematurely in childhood of imaginings, may continue believing in magic for years.

Walter Kendrick notes in Writing the Unconscious, that Freud found correlation between the creation of “literature ...and ... the clinical experience of psychoanalysis.” Freud believed that some “imaginative writers ... anticipated the discoveries of psychoanalysis,” citing Hoffman’s tales as a particular example. According to Freud, Hoffman - author of “The Nutcracker and the Mouse King” - “intuited the importance of early-childhood experiences.” Freud concluded that “Literary artists ... already plumbed the mind’s depths long before….”

J.K. Rowling’s popularity invites a final question. Why are some people afraid of letting children read Harry Potter and The Goblet of Fire or Harry Potter and the Chamber of Secrets? Why fear these books? Not all grown-ups admire Harry, nor what he represents. Rowling’s writing is considered among the most controversial literature in the United States these days. According to Laurie Sydell of National Public Radio (“Weekend Edition,” November 14, 1999), some groups “advocate banning” Harry from schoolbook shelves - along with Winnie the Pooh and Little Women. Other groups are demanding for more parental screening of libraries. Do these people fear imaginary monsters? Mirrors named Erised? Strong female characters? Do they fear Lord Voldemort himself? Children engaging in fantasy? Perhaps their fears are to be expected. The Muggles never did like Harry Potter.

Ildiko Mohacsy, M.D., is Assistant Clinical Professor of Psychiatry, Department of Child Psychiatry, Mount Sinai Medical School and Adjunct Assistant Clinical Professor of Psychiatry, Cornell Medical Center

Correspondence to: Dr. Ildiko Mohacsy, 1065 Park Avenue, New York, NY 10128

Four Poems

By: Jane Simon, M.D.


To stand on one corner of the world (In this case Madison) Watch the sun bed down over fancy buildings

The crowd: handsome couples, high-heeled singles anticipating, The miscellaneous marching, simultaneously converse on phones;

How elegantly the white-haired lady Clad in white flows by In time-defying motion

Some sense me, with pencil set to paper, and wonder if I am an agent under cover

A dog passing by sleek and amber: needs only his nose to inform, I am nothing more or less than ‘lover’


A worn, yellow paper cup Agitated, extended by bare arms

Her back propped against the street lamp and around her breast

a brown, plastic bag Her eyes, glazed over don’t register our dollars

But our voices over cell phones (about her) Startle: set her bare shoulders suddenly in motion

down the street, rattling this red herring of a yellow cup neither filled nor filling


The rarity of a pair (of socks)


Dreams of riding under the stars in my motor home

Dashed by reality: rotting tires, leaky gasket.

My dreams roll: their own volition carries them faster.

day and night traffic doesn’t matter

The ‘motor home dream’ is the ‘bag lady fear’ in reverse

Are we mobile or homeless?

One rolls into another as fatefully as True West brothers

(Austin and Lee) turn in a jiffy between criminal and writer

our bodies haul heads and tails of the coin

We are both: mobile and homeless

Jane Simon, M.D., is the past editor of the Academy Forum.

Correspondence to: Dr. Jane Simon, 145 Central Park West, #1A, New York, NY 10023

Film Review: Male and Female Relationships in Stanley Kubrick's "Eyes Wide Shut"

By: Richard D. Chessick, M.D., Ph.D.

I am not posing as a movie critic in this paper, so I will not dwell on the technical aspects of the movie. Suffice it to say that the camera work is, as usual in a Kubrick movie, magnificent and without peer. There is a grainy high contrast style to the photography with lots of backlighting and many primary colors. He sets the film at Christmas, taking advantage of holiday lights, and makes it all deliberately kitsch. The overpowering use especially of red and blue—with the marital wife bathed in red and death and danger in blue—and the progressive juxtaposition of these colors adds to the underlying tension; there is also a peculiar music that includes a pinging on the piano that some critics found unpleasantly repetitious. The movie itself has functioned almost as a Rorschach test among critics, with reviewers ranging from those who call it a great masterpiece to those who consider it an abject dismal failure and suspect that Kubrick never finished it in spite of the studio’s insistence that he did.
“Eyes Wide Shut” attempts to be a mystery movie; the possibilities of conspiracies and murders are lurking throughout. It has a nightmarish quality, and the hero (or anti-hero, named Bill) remains puzzled and confused almost to the end. In my opinion, he should have been confused even at the ambiguous end. When Bill wanders the streets of Manhattan at night, one is reminded of the section in James Joyce’s Ulysses, titled “Ulysses in Nighttown”.

Briefly, the story is of Bill, an affluent doctor married to a very beautiful young woman, but it is clear that their marriage is not going well. When his wife, named Alice, admits to an intense sexual fantasy about another man, Bill seems unable to accept that fact and ends up wandering the streets of Manhattan at night in a somewhat unbelievable sequence. He is constantly identifying himself as a doctor in a way one usually sees in movies by the detective who pulls out his wallet and flashes his identification wherever he goes. Clearly the doctor’s self cohesion has become fragmented by the narcissistic wound inflicted by his wife. Later, in another unbelievable scene in which his wife is laughing in her sleep and he wakens her to tell her that she has had a nightmare, the wife astonishingly confirms this (laughing during a nightmare?) and relates a second intense sexual fantasy which is again demeaning to Bill.

In his wanderings, the doctor is knocked aside in a quasi-homosexual manner by a group of punks who offer him their behinds to kiss, is picked up by a prostitute who initiates a sexual relation that is interrupted by a telephone call from Bill’s wife, and wanders into a bizarre orgy scene in which he is told that his life is threatened. The orgy scene is also strange because apparently the rich men at the orgy require some kind of anti-Pope ritual involving a group of almost naked women at first covered in monk-like habits before they can be turned on sexually.

There is a scene in a morgue where a completely naked woman is laid out uncovered on a slab in a storage locker, a procedure different from that in any morgue that I have seen in my medical experience. In the opening scene of the movie, while his wife is flirting with a Hungarian roué, Bill is called upstairs to see a naked prostitute who has overdosed on heroin or cocaine. In a totally unprofessional way, the patient is left completely naked throughout the medical examination, and Bill does not even seem to notice her nudity. In general, the camera work on the numerous naked women in the movie gives them almost a waxy retail-store dummy kind of appearance. This I think is important in understanding what Kubrick is attempting to do.

“Eyes Wide Shut” is based on a novella by Arthur Schnitzler, a contemporary of Freud, who praised Schnitzler a great deal and felt that he had an intuitive insight into the unconscious. Schnitzler, describing Bill in the novella, wrote that “Everything seemed unreal: his home, his wife, his child, his profession, and even he himself, mechanically walking along through the nocturnal streets with his thoughts roaming through space” (reference). So, as a fragmentation of the self developed, the symptom of derealization became manifest.

Schnitzler’s erotic stories, bursting with sweet young women, often offer a mordant critique of the cruelty, callousness, and hypocrisy of Vienna (see Freud: A Life for Our Time, by Peter Gay, p. 511). Schnitzler “secured Freud’s unequivocal applause for his penetrating psychological studies of sexuality in contemporary Viennese society” (p. 166). Freud wrote him a letter stating that he envied him his “secret knowledge” of the human heart. Schnitzler wrote of dreams as cravings without courage which, chased back into the corners of our minds, dare to creep out only at night. He might have added “or when we are stoned on marijuana or high on alcohol,” as in this movie.

There is a scene in a costume rental shop where the proprietor offers to also rent his daughter, and the movie follows Schnitzler’s novel faithfully except for the introduction of a rich man who is Bill’s facilitator but who manipulates him continually. Kubrick is clearly offering what one critic called a “Hobbesian theory of life” as short, nasty and brutish, and portraying the human as a deeply flawed creature decidedly closer to barbaric apes. Plato said that in our dreams we are all savages.

The title of Schnitzler’s novella is “Rhapsody: A Dream Novel,” but it is set in Vienna and occurs before the time of the author, indicating that it is already somewhat dated; when it is set in New York in Manhattan it becomes grotesque. What is important is Kubrick’s deeply cynical view of the world, as I have described it in my paper “Archaic Sadism” (Journal of the American Academy of Psychoanalysis 24:605-618, 1996), ruled by a human species driven by greed and violence and its own delusions. It is even hard to believe that the couple has been married for nine years and has a seven-year-old daughter, because there is so little love between them; even their sex is mechanical and more like a scene in a pornographic movie.

We know that Kubrick was interested in the concept of man as a machine, a philosophical position known as eliminative materialism; he was even working on a possible movie called AI (for Artificial Intelligence). He replaces Schnitzler’s sensual psychological story with a formally stilted approach that was obviously composed of numerous obsessive photographic takes and retakes, which results in a very rational cold almost inhuman series of events that one can either believe or not believe. As Heidegger might put it, Kubrick in his male fantasy is presenting to us his experience of being-in-the-world. As Kohut might put it, this is the empty mechanical world experienced by the fragmenting self.

Neither Bill nor Alice are believable characters. Bill seems to be highly irrational and devoid of basic character unless one can imagine him in a state of semi-fragmentation after two narcissistic wounds. He is a kind of as-if personality, and it is doubtful whether, as in the movie, rich and successful people would employ him as their physician. Alice is more interesting, although all we know about her is that she once managed an art gallery in SoHo but now spends all her time caring for a school-age daughter, a transition hard to believe considering the magnitude of that career change and the fact that this is 2000 A.D. in Manhattan and not 19th-century Vienna. The pictures on the wall of their apartment, allegedly painted by Mrs. Kubrick, would never be found in SoHo.

What is fascinating to psychoanalytic clinicians is that Alice has confessed to her husband that she has had two very intense sexual fantasies and that he is unprepared to accept the possibility that women have such extreme aggressive and archaic dreams and fantasies. Regardless of the quality of the acting, which critics disagree about, this is an important point because it is not uncommon for men to delude themselves that their wives, like their children, are without lust or aggression, and are unerringly faithful, whereas men are allowed to wander and play around like Bloom in Ulysses, and even Jimmy Carter is allowed to have lust in his heart.

The actress playing Alice is smashingly beautiful and could easily pass as an angel, so Kubrick achieves his aim when he reveals what is actually going on in her mind and when he puts gutter language in her mouth. One is reminded of St. Augustine’s famous saying that a woman is a temple built on a sewer. What Augustine did not realize is that all of us are built on sewers, commonly called the id today. Thus each married person has within himself or herself all kinds of sexual imaginings, longings, fantasies, lusts, and hatreds, and the actual marital life of a husband and wife involves only the expression of derivatives of this, as Schnitzler was aware and Freud developed in his psychoanalysis. Shakespeare, the greatest of all psychologists, portrayed this by introducing the monstrous Caliban in the underground caves of the beautiful island in The Tempest.

As mentioned above, the music for the orgy (composed by Jocelyn Pook) is performed on a piano repeatedly struck very hard, and the dialogue of the movie also has a weird repetitiveness in which one character makes a statement and the next character repeats it with a question mark. This adds to the mechanical atmosphere of the whole film. Kubrick’s insistence on showing as many naked female bodies as he can possibly crowd into the movie destroys the erotic aspect and introduces an ambience of almost clinical coldness, which is augmented by the deliberately slow pace and development of the story.

Actually “Eyes Wide Shut” is also a moralistic tale because, whether by accident or design, neither partner is unfaithful to the other regardless of many opportunities that present themselves. As Holden wrote in the New York Times (Tuesday, July 20, 1999, pages B1-B2), this serious major studio film “is a sternly anti-erotic movie that regards its sexual license with a cold Puritanical hauteur. . .nothing so much as grim ritualized necrophilia.” There is no doubt that the sexual chemistry between the husband and wife in the movie is at most lukewarm, and the picture of New York is that of a city where sexual predators threaten the rather confused doctor and his wife from all sides. Holden concludes, “Their only protection from the encircling demons is a frightened trembling commitment to monogamy”.

I viewed this movie as primarily the sexual fantasy of a talented but disturbed individual who has serious difficulties in relating to the human and nonhuman environment around him; that is what it tells us about Stanley Kubrick. At a more general level, it also tells us about the capacity of certain men to tolerate what is for them the narcissistic injury involved in their discovery that women are capable of the same intense lust and aggression in their fantasy lives as well as in their behavior as men are. Perhaps Kubrick’s dismal view of humanity is based on his own disillusion and realization that women cannot represent the warm loving maternal breast without being accompanied by psychological baggage of their own, as many of our male patients search endlessly for and bitterly complain about because they cannot find it.

The moralistic ending of the movie, where the wife’s solution is to go home and “fuck,” falls very flat. Actually we never know to the very end whether death and destruction has threatened this couple or whether it is all a charade put on by a wealthy man. It is not hard to extrapolate from this the question of whether God exists and gives meaning to our miseries and sufferings or whether, as Sartre said, we are all simply the victims of contingency.

Dr. Chessick is Professor of Psychiatry and Behavioral Sciences, Northwestern University, and Senior Attending Psychiatrist, Evanston Hospital., and Training and Supervising Analyst, Chicago Center for Psychoanalytic Study

Correspondence to: Richard Chessick, MD, PhD, 9400 Drake Ave., Evanston, IL. 60203-1106

In Gratitude to the Czars

By: Richard A. Gardner, M.D.

In the middle of his 96th year, my father died suddenly. Sitting in a chair he called my mother, and when she got there, less than one minute later, he was dead. After his death, my mother told me that recently he had started to become incontinent. I myself had noted that his memory losses were becoming painfully more apparent. If death must come, what better way than quickly at the age of 95, just at the point when one is beginning to become a burden to oneself and others.
Among my ruminations following his death, I recalled a telephone call I received about 25 years ago from the principal of a nearby New Jersey suburban elementary school. It was during one of my occasional ad hoc consultations that she asked me this question: “Dr. Gardner, as a child psychiatrist, I’d like your opinion on whether our fifth graders can reasonably be relied upon to take a bike trip for a picnic two miles away?”

Chuckling, I responded: “Your question reminds me of an experience my father had, as a boy, that I believe will answer your question. As you know, the typical pattern for immigrant families was for the father to come to America first and periodically send money to his wife who would then send on the children seriatim. Finally, she would come with the youngest. In 1906 my father, then 7-1/2, left for America from Kulicow, a town in Austria-Hungry to which his father had fled from Russia. He was accompanied only by his 10-year-old brother. En route to Hamburg, where they were to board their boat, they were accidentally separated from one another. My father understood that both of them were to get off the train at a certain station for a stopover visit to the home of relatives. Mistakenly, my father got off and watched helplessly as the train pulled away with his brother. Of the various options my father considered, he decided it was most likely that his brother would get off at the next stop and wait for him until the next train arrived - whenever that would be. My father went into a nearby restaurant and explained his situation to the owner. She fed him and let him stay overnight. The next morning he boarded the train and upon arriving at the next station, he saw his brother - who had waited for him all night on the station platform. They both made it to Hamburg and then to New York.” The principal’s response: “Thank you, Dr. Gardner, I get your point. Well said!”

Jean Piaget, the renowned French psychologist, considered a central element in intelligence to be the ability to adapt in a novel situation. Although my father’s primary education did not go beyond the fifth grade, his basic intellectual capacities certainly revealed themselves with this experience. Most children that age would have just stood there and cried!

At the time of my father’s death, I thought about what his life might have been like had he stayed in Kulicow. In 1914 Austria-Hungary became embroiled in the first World War as an ally of Germany . He most likely would have been recruited into the Austrian army. It is reasonable to assume that, as a Jew, he would not have been selected for officers’ training and would most likely have ended up a foot soldier, traditionally referred to as Kanonenfutter (cannon fodder). Had he survived that bloodbath, he soon would have found himself no longer a denizen of Austria-Hungary, but of the newly reconstituted Poland.

Had my father still remained in the same area, it is likely that new griefs would have befallen him in 1939, not only as a Pole, whose country was now being eaten alive by both Germans and Russians but, more importantly, as a Jew. Whereas Jews in many Europeans countries could rely upon the assistance of some (admittedly few) brave gentiles to protect them from the Nazis, Jews in Poland were far less fortunate - so deep-rooted was the antisemitism. His most likely fate would have been the death camps, about which I need say no more.

If, however, he had somehow survived the Holocaust, in 1945 he would have found himself the citizen of yet another country: the U.S.S.R. Polish antisemitism would now be replaced by Russian antisemitism. Because Jewish “comrades” were “less equal” than other comrades, his life would have predictably been difficult. In 1991, in association with the breakup of the U.S.S.R. , he would have found himself a citizen of yet another nation - Ukraine.

I do not know how many people (Jew or gentile) who were born in Kulicow in 1898 lived until 1994 - but there could not have been many, and there may have been none.

But the story does not end there. There is a strange irony here with regard to one of his sons. In association with my professional work in the field of child psychiatry, I have been invited to lecture throughout the United States and occasionally abroad. Interestingly, a country in which my work is most enthusiastically embraced is Russia, the land not only of my father’s forebears but my mother’s as well. My therapeutic games and books are being enthusiastically translated, and I recently returned from my fifth (and last) trip there. For my more recent lecture series, people came from such remote parts of the former Soviet Union as central Asia and eastern Siberia. The son of an expelled immigrant, a person whose family fled the persecutions and pogroms of the czars, is welcomed back with honor and gratitude. During each visit I am swept up by the irony of the situation.

I often asked myself why I went back. Certainly not for the rubles. Even my professorial appointment at The University of St. Petersburg did not include a stipend, nor even reimbursement for travel and lodgings expenses. I admit to the ego enhancement attendant to my reception. It was an “ego trip” in every sense of the term. But there were more important reasons. I had the chance to reach out across time and distance to bridge a gap that divided people and separated me from my roots. Perhaps with each visit I helped counter anti-Semitism, admittedly in a very small way. I never said a word about it. My giving Russians the living experience that a Jew was helping them make up - admittedly in a very small way - for their 75 years of academic deprivation contributed to the reduction of their prejudicial stereotypes.

During my visits, I was continually confronted with the privation and frustration with which most Russians continually live. I could not help but think how lucky I was that my forebears left Russia when they did. I often think that the descendants of the Jews who were forced out of eastern Europe, who often prospered wherever they went, should build monuments to the czars in gratitude for their having driven us out.

Dr. Gardner is Clinical Professor of Child Psychiatry, Columbia University College of Physicians and Surgeons.

Correspondence to: Richard Gardner, MD 155 County Road, PO Box 522 Cresskill, NJ 07626-0522

On Not Being Able to Write about HAMLET

By: Harvey Roy Greenberg, M.D.

In my twin careers as adolescent therapist and film scholar, I have long since relinquished hopes of discovering the cure for pubescent angst or of formulating some sweeping psychoanalytic theory of cinema. My post-adolescent dreams of glory hover over a different rainbow: winning an event in the annual Las Vegas World Series of Poker and making a contribution to Hamlet studies.

The golden bracelet of a World Series poker championship far exceeds my reach. But, several months ago, I stumbled upon a nook of Hamlet that seems to have been scanted by previous scholarship. Now that I am finally in the trenches, I’ve found my Shakespearean venture is provoking surprising trepidation, hallmarked by the well-rationalized procrastination which inveterately signals the onset of a writing block for me. (Of the attendant fears that I may have already been scooped, more presently.) Whatever other purposes this prequel may serve, it comprises the first step to a true cure—writing the study entire.

My “find”, if indeed such it be, involves Hamlet’s sojourn with the pirates who abduct him from the ship transporting him from Elsinore to England, after he slays Polonius. Two days into the voyage, Hamlet has winkled out Claudius’ letter to the English sovereign ordering his summary execution and turned it against its bearers—hapless, clueless Rosencrantz and Guildenstern. Shortly afterwards, a pirate vessel “of very war-like appearance” gives chase to Hamlet’s ship. “In the grapple” he boards it; instantly, the pirates swerve away—“so I alone became their prisoner”.

Hamlet describes his capture in a terse letter written to Horatio after the Prince has returned to Danish soil. It is not specified that the pair who convey it to Horatio are pirates themselves. They are called “sailors” and are given a few perfunctory lines. Hamlet writes that his captors are “thieves of mercy” who “knew what they did. Now, “I am to do a good turn for them.” Shakespeare discloses nothing more about these merciful thieves. They appear in absentia, occupying only a corner of the action. Yet the play’s conclusions certainly turns upon their prisoner’s release and safe dispatch back to Denmark, presumably so he can accomplish the undesignated “good turn.”

Shakespeare also does not indicate whether, or in what fashion Hamlet’s pirate stay may have worked upon the Prince’s psyche. His confinement comprises the blankest of screens upon which a host of questions, minor or most profound, may be projected. An initial survey indicates these have gone mysteriously unasked or are treated slimly in the vast body of Hamlet investigations. To cite just a few:

Who were Hamlet’s anonymous corsairs? Did they snatch him away accidentally or deliberately?

What were the pirate’s intentions? Ransom is not mentioned. Was the “good turn” a pardon for earlier misdeeds, to be granted by Claudius or one of his fellow rulers as a reward for preying upon enemies of Denmark or other Scandinavian states? (Such pardons have existed throughout piratical history).

How long did Hamlet dwell with his captors? Was he held onboard, or was he sent ashore to a pirate haven such as then existed in the Baltic or North Sea?

How was he received by the pirates? How did he perceive and behave towards them? What wracks of chance did he witness? What actions barbarous, chivalrous, or brave was he privy to?

Surely, the cardinal unaddressed issue raised by the pirate captivity is its possible relationship to the remarkable alteration in Hamlet’s character, evident when he reappears on Danish soil at the beginning of Act V. Critics have been struck by and wrestled with this mysterious “sea change” since the play’s first performance. Except for the violent struggle with Laertes at Ophelia’s funeral, a lambent tranquility appears to have descended upon the prince’s troubled soul. His rage against the impenetrable powers that shape our ends now has given way to a stoic acceptance of whatever destiny awaits him. His “thinking too precisely thinking on th’ event” has dissipated. He is finally prepared to revenge his father’s murder, to act even as he poignantly comprehends that action will very likely cause his end.

How could Hamlet mature so impressively in so short a time, let alone let alone stabilize his extravagant psychological disequilibrium subsequent to the Ghost’s revelations? It has been suggested that an audience of Shakespeare’s day, accustomed to temporal discontinuinities and compressions, would have no difficulty accepting that a mellowing of personality ordinarily requiring decades had transpired over the weeks or months Hamlet has been gone from Elsinore—wherever he has been sojourning.

Mere absence from the court’s byzantine intrigue has also been invoked as the chief cause of Hamlet’s striking transformation, but seems insufficient grounds to me. According to another line of scholarship, Hamlet’s newly won equanimity develops only after he returns from the aborted voyage to England. It has, for instance, been argued that his serenity attends the acceptance of mortality that develops during the graveyard scene, emerging from a trajectory which includes Hamlet’s mordant observations to Horatio about the gravedigger’s macabre employment, his banter with the ribald gravedigger, and the trenchant soliloquy over Yorick’s skull.

My investigation proposes to seek out the origins of Hamlet’s sea change in that briny element itself, notably in the buccaneering milieu and its impact upon the abducted Prince’s perturbed spirit. I intend to touch upon Galenic/Elizabethan notions on the salutory effect of sea and sea-air and describe the piratical practice of Shakespeare’s day. I will then construct various scenarios of a typical Elizabethan pirate captivity, during which Hamlet’s gloom and paralysis of will might be remedied. Each “cure” will correspond, be responsive to a theory about Hamlet’s afflictions advanced by a prominent Hamlet scholar, past or present.

To cite one example: Samuel Coleridge famously speculates that Hamlet’s elemental pathology consists in a wretched excess of brain over brawn, in “enormous intellectual activity and a consequent proportionate aversion to real action….” Immediately before departing from Denmark, Hamlet encounters a troop of Fortinbras’ soldiers marching to battle. In the subsequent “rogue and peasant slave” soliloquy, he contrasts Fortinbras’ boldness with his own perceived fecklessness. Might the captive Hamlet, consummate role-player, introject the pirates’ robust pugnacity, under the added sway of that curious compulsion to identify with the aggressor frequently noted in the sufferers of Stockholm syndrome? Could Hamlet then reinvent himself as a buccaneering Fortinbras, perhaps even lead his erstwhile captors—now colleagues—in piratical “enterprises of great pitch and moment,” thus liberate himself from the “sickly cast of thought”?

Simply writing this precis has succeeded in jump-starting my project—as so often happens when one finally brings oneself to confront a mild phobia head on. A noted psychoanalytic literary/Shakespeare scholar and mentor to whom I’ve confided my notions also wrought more than he knew by deeming my interest Hamlet’s pirates worthwhile. Nevertheless, my disquiet lingers.

Not surprisingly, the anxiety—like its subject—is overdetermined. I’ve been an avid pirate enthusiast since reading Treasure Island and viewing swashbucklers like Captain Blood in childhood. Like many of my friends, I was immensely drawn to the exotic locales of pirate tales; to the dash and swagger, the pure aggressive energy of buccaneering exploits. But most enticing to an obsessive, dutiful thirteen-year-old being raised by doting, demanding parents in a cloistered suburban milieu, was the pirates’ boisterous bold defiance of society’s rules, the glory they took in living—and dying—by their own smash-and-grab code.

As an adult, I’ve continued to savor the idiosyncratic anarchic elan vital of pirates as purveyed in sagas of the Napoleonic era’s “iron men and wooden ships” by authors like C.S. Forester, Alexander Knox, and Dudley Pope. I’ve become an addict of the undeniable best of class, the late Patrick O’Brian in the extraordinary cycle of twenty Aubrey/Maturin novels, O’Brian frequently pens vivid descriptions—based on contemporary chronicles—of bloody encounters between Nelson’s navy and corsairs of every stripe, from South Seas marauders to the pirates who preyed in northern waters, upon ships like the one in which Hamlet voyaged.

As a film scholar, I have always endeavored to ground hypotheses about so called pro-filmic events on a solid textual foundation, analogous to the well-reasoned scholarly speculation about events in the Danish court prior to Hamlet. For instance, Shakespeare provides ample clues from which one may easily surmise that Gertrude’s affair with Claudius commenced while her husband was alive, that Hamlet has already grasped, however dimly, the incestuous, adulterate rottenness prevailing in the state of Denmark before the curtain rises.

No such clues, however, are tendered about Hamlet’s pirate captivity, so that conjectures on this score essentially must be fabricated out of purest air. Extra-textual sources such as contemporary accounts of Elizabethan piracy are useful in filling in the blanks, but ultimately are no substitute for firm textual evidence.

Confabulating Hamlet/Hamlet’s past seems nervier than constructing a past for Rambo or James Bond, because of my intense admiration/intimidation regarding Shakespeare which began at the same age I was growing enamored of pirates and piracy. Probing the fiction of Henry James inter alia hasn’t been problematic for me, but I’ve always hesitated over writing about Shakespeare, absent a passing analogy drawn in a study of The Maltese Falcon between Hamlet’s disavowed death wishes towards his father, and Sam Spade’s unconscious murderous intentions towards his partner Miles Archer, whose wife Spade has been bedding. I am hardly the first to assert that Shakespeare’s grasp of character and conflict in every sphere of human activity, his consummate facility to create worlds vivid as the reality I inhabit seem nothing short of godlike. Even conducted in a spirit of respectful inquiry, intrusion upon the ineffable wholeness of Hamlet’s domain by inventing action its author never depicted registers at least as presumptuous—and even a bit dangerous in some obscure Promethean fashion. One lacks the cheek of the downtown impresario whose playbill for a Yiddish production announced:

Schauspiel von Shakespeare
Verandert und Verbessert!!
(“Hamlet/Drama by Shakespeare/Changed and Improved! !”).

My youthful reverence for Shakespeare came to encompass the famous critics, past and present, whose diverse interpretations of Hamlet’s irresolute melancholy is to ground my imaginary piratical “solutions” to the sea change. Contemplating august figures like Coleridge, Samuel Johnson, A.C. Bradley, and Harold Bloom, one feels like a pygmy amongst giants (and let us not forget founding father Freud, either). As a result, I’ve become preoccupied with accurately reprising their judgements—and have waxed ever more dilatory lest I fail.

My rumination over scrupulous redaction of the celebrated critical sources has lead in turn to an obsessive pursuit of less well known (and well regarded) opinions. With an almost oneiric inevitability, I’ve been drawn into a Shakespearean scholarship dauntingly Talmudic in scope; from thence, into related subjects whose highways and byways seem to bifurcate endlessly: the wind and weather of the North or Baltic sea lanes Hamlet’s vessel may have navigated; Elizabethan beliefs about spirits and hauntings; the exploits of Sir Frances Drake, so forth. One must cry halt at some point, but as one agonizes over the potential assailability of one’s research that point threatens to recede into infinity. (The problem is further compounded by that hint of Attention Deficit Disorder I’ve always suspected in myself.) One experiences at first hand how the courses of even an unpretentious critical venture can turn awry, “and lose the name of action.”

I must now own up to a conflictual shadow side to these professions of modesty before Shakespeare’s genius, and the accomplishments of his critics—regarding which my redactive frenzy takes on the stamp of a reaction-formation. I will not cite chapter and verse of relevant intimate dreams and associations. Suffice to say that these have revealed that a genuine diffidence masks a conflicted competitiveness which I had thought to have worked through years ago—here, competition with scholarly predecessors both quick and dead. The consuming ambition my project has kicked up, with its implicit Oedipal overtones, has contributed to its stall—under the rubric that no son really wants to win the battle for supremacy with his father, only to go down fighting.

Harold Bloom has written persuasively about the oedipally inflected “anxiety of influence” which dictates a young poet’s disavowal of an older poet’s vigorous work and the consequent “swerve” of his own radical innovations. In time, these fruits of youthful rebellion often become canonic and then rather poignantly constitute the spur of the next generations’s anxiety of influence. “Don’t be so modest, you’re not so great,” Golda Meier once gibed at a colleague. Even as I avow that my pirate study crucially depends upon the prominent forebears who have plumbed Hamlet’s psychological depths, I must acknowledge my anxiety about their influence, articulated with an overweaning fantasy of surpassing their accomplishments—“pirating” these in a spirit of neurotic ruthlessness so that I may score my own critical triumph. I may not have unpacked yet another reason for Hamlet’s despairing procrastination. But, surely—or so my cutthroat alter ego would like to believe—I’ve staked the authoritative claim on the site where Hamlet’s healing commences—the pirate captivity, nowhere else. From the wider world’s perspective, Hamlet scholarship constitutes a small pond. Yet one absurdly persists in yearning to be one of its big frogs.

Further reflection yields a sobering insight: my vaulting ambition has also been spurred by a Grail-like “myth of origin” of the type David Carroll shrewdly discerns to be a significant underpinning of the psychoanalytic enterprise—in that case, the primal fount of neurotic suffering, whether it resides in oedipal or pre-oedipal conflict, in the sway of Jungian archetypes, so forth. Such essentialist constructs pale before the convolutions of the psyche and the external world’s complexity. At origin, Carroll asserts, there is no origin, only a seductive hope one can be found.

As in life, so in art. Act I, Scene I, of Hamlet begins upon the battlements of Elsinore where a sentry, Francesco, is braced by another soldier, Bernardo, as the latter emerges out of the darkness.

Bernardo: Who’s there?
Francesco: Nay, answer me; stand, and unfold yourself.

Ordinarily the sentry’s challenge would be given by Francesco to Bernardo, issuing from watchman to intruder. Their reversed exchange contains the first question and paradox of a drama replete with inquiry, fraught with ambiguity, whose hero is arguably the most enigmatic character ever to appear on the stage.

Shortly after the play-within-a-play exposes Claudius’ guilty conscience, Hamlet defies Rosencranz and Guildenstern’s clumsy attempts to probe his purposes:

“...You would pluck out the heart of my mystery; you would sound me from my lowest note to the top of my compass….

‘Sblood, do you think I am easier to be played on than a pipe? Call me what instrument you will, though you can fret me, you cannot play upon me…”

Hamlet’s provocation of his untrustworthy friends may be construed at another level—as a challenge this most open of Shakespearean texts thrown down before the critic about the inherent limits of its interpretation. I submit there will never be a definitive explanation for the sources of Hamlet’s melancholy; for the status of his affection for Ophelia; for the nature and causes of the sea-change; and—to the point of this discussion—for the events of the pirate captivity, and their significance to the drama’s tragic, strangely liberating denouement.

With a bow to Carroll, there can be no original “onlie begetting” of these major issues (and many minor ones, e.g. Hamlet’s age), only the seductive illusion that the sundry paradoxes and obscurities within the drama can ever be tidily resolved; that answers will ever be yielded up, within Hamlet’s time or our own, to the knotty questions Shakespeare and his princely stand-in propose about the human condition. Even the certainty of death itself seems to melt away before the undiscovered country from which the Ghost has traveled.

The uncertainty, indeed the impossibility of conclusive interpretation pervades Hamlet, from particularities of plot to the general issues of being in the world, uncannily informing its construction and intentions as in no other Shakespearean drama. This central insurmountability of explanation, conflated with a tantalizing promise of elucidation which Hamlet/Hamlet holds forth on so many material and philosophical problems, resides at the heart of Shakespeare’s high and mysterious art.

I return to my apprehension that some blissfully unblocked investigator may be busily putting an end to his or her labors even as I am beginning mine. Like Poe’s Purloined Letter, Hamlet’s pirates have been lying about in plain sight for four centuries of critics to contemplate. My paranoia about being scooped is admittedly a product of the neurotic baggage anatomized above—my “piratical” competitiveness with scholars past and present, disavowed and projected, a grandiose overvaluation of my “myth of origin”, all of which I hope to have relinquished. But beyond helping to resolve the block about “unfolding myself,” these notes have also succeeded in placing the essence of my arguments about Hamlet’s kidnappers in plain sight—and thus suitable for scholarly citation. Like the man said, even paranoids have enemies. I have forestalled those who would pirate my piratical idea.

Dr. Greenberg is Clinical Professor of Psychiatry at Albert Einstein College of Medicine and publishes frequently on film, media, and popular culture.

Correspondence to: Harvey Roy Greenberg, MD, 320 West 86th Street New York, NY 10024

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Silas Warner and The American Academy of Psychoanalysis

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