Essays on the Edge

By David Begelman Ph.D.

"Essays On the Edge" is an anthology of articles on several different topics, including Psychotherapy, The Mental Illness Myth, Freud, The Unconscious, Method Technique, Ingmar Bergman, Stanislavsky, Psychiatric Misadventures, Abortion, Animal Rights, False Confessions, Immortalist Dreams and Art Unbound.

• Language: English
• Publisher: Xlibris US
• Release date: Aug 31, 2022
• ISBN: 9781669844921

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Copyright © 2022 by David Begelman Ph.D.

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

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Rev. date: 08/31/2022

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To the fragile

and disempowered everywhere.

Contents

The Four Faces of Psychotherapy

The Mental Illness Myth

Freud, Psychoanalysis and The Unconscious

A Dangerous Method: Blowing The Cover on The Shrinks: A Review

McHugh’s Psychiatric Misadventures¹

Some Remarks on Sacred Cows: Revisiting Method Technique

The Idea of Audience: The Elephant in The Room

An Ingmar Bergman Trope

Stanislavsky Revisited

A Dialogue (with apologies to Diderot)

Moshkeleh Ganev

Abortion, Church Law, and The Endless Controversy

Animal Rights

Now and Then: False Confessions, Beliefs, and Memories in The Modern and Early Modern Eras

Immortalist Dreams: Before and After

Art Unbound: Once More Unto The Breach

The Four Faces of Psychotherapy

Many things might be said about psychotherapy, including where and how it originated as a professional tradition. It might be tempting to locate its beginnings in the 19th century with Sigmund Freud and his disciples, although this hunch runs the risk of ignoring seeming harbingers of the practice figuring in other institutional vehicles. For example, the Catholic confessional might be one instance, and although it admittedly served a religious purpose of forgiving sins and encouraging patterns acceptable in the light of church doctrine, it incorporated components of a therapeutic-like process in what it provided parishioners. After all, the confessional embraced a context in which one authority listens to the unburdening of another and supplies a means by which personal guilt may be alleviated. The ritual likewise illustrates interactions between someone who comes for help and an authority who supplies it. The structure parallels other transcultural forms with a shamanistic flavor that might be seen as precursors to psychotherapy. Obviously, were we to expand our understanding of what is essential to psychotherapy, similarities could be found in a wide range of traditional practices, not to mention the form it illustrates currently.

When it comes to identifying separate dimensions or layers of psychotherapy as practiced nowadays, we can designate at least four distinguishable facets, and there might be others. The four we have in mind are its behavior-changing, status-affecting, meaning-imparting, and value-laden aspects. Let us flesh out what these amount to.

The behavior-changing aspect of the profession pertains to its most widely publicized feature: the reduction, amelioration or cure of specific psychological problems. The function consists in the removal of symptoms, or the facilitation of psychological goals through the application of certain techniques or, alternatively, reliance on personal interactions between therapist and patient, however undefined or non-specific they may be.

For example, a patient or client (as this term is the preferred one for specialists wishing to distance themselves from what is called the medical model) is referred to a psychotherapist for a drinking, marital, sexual, affective, cognitive or impulse control problem. It goes without saying that such referrals to non-medical practitioners are made when the possibility of an undisclosed medical problem is not deemed to be the origin of the condition in question. But we have to be careful here, because it’s a mistake to assume that because a problem has a biological component or basis, psychotherapy should be ruled out as either an essential or supplementary treatment option.

There are many conditions for which a biological factor is causally involved and for which psychotherapy still remains an appropriate modality of treatment. Examples would be serious diagnoses like schizophrenia and bipolar disorder. And there are other disorders with an indisputable organic or neurological basis for which a psychological or psychoeducational approach is the only treatment option. Among these are conditions in which cognitive limitations are especially noteworthy, as in Down’s Syndrome and neurodevelopmental disorders like autism.

Most of the time medical evaluations prior to referrals to practitioners in non-medical professions are routinely conducted in order to determine whether a possible biogenic factor would intrude on the treatment process, making medical care—usually involving a psychopharmacological approach—advisable or necessary, either as an exclusive treatment emphasis or as a collateral intervention.

Yet on the psychiatric level, a patient who has uncontrollable mood swings and who would benefit from a mood stabilizer, anti-psychotic and/or antidepressant medication may also benefit from scheduled psychotherapy sessions in order to regularize approaches to life problems left in the wake of unpredictable cycles of behavior. So when medication is appropriate in sundry cases, so too is the assistance of a counselor who, for example, can help the patient manage credit card use in a more moderated way, since debts of a runaway character may often be a symptom of the patient’s disorder when he or she is subject to manias.

Not all symptomatic patterns are as easy to pin down as those well-defined entries listed in manuals like the DSM-V. A person may seek help for a problem he or she nonetheless finds hard to formulate, as in the so-called existential neuroses: or experiences of anomie, alienation or aimlessness. I suspect that such bouts of self-doubt—when they are not symptoms of depression—were more widespread in eras in which a drive toward conformity encouraged everyone to accommodate to conventional or preordained social molds. I daresay such complaints led to more referrals in the forties and fifties in this country, possibly because many persons, especially college students, felt any old grumble about life made one a candidate for long-term psychoanalysis. This therapeutic approach was more of a thriving industry in yesteryear than it is these days, and I venture to say that undergoing orthodox psychoanalysis to the tune of several sessions a week for extravagant fees is nowadays much less likely, or at any rate last on a list for most problems.

I remember college peers of mine who felt they should be psychoanalyzed because they had nothing to complain about. For them, this amounted to a chronic condition resolved by spending years on the couch several times a week while reporting dreams to analysts who were for the most part silent partners. As was indicated, this version of care appears to have undergone a diminuendo of popularity over the years, confining its public appearances to such venues as Alfred Hitchcock films like Spellbound, or in a lighter vein, Mel Brooks’ film High Anxiety.

Eradicating the unwanted aspects of a problem through behavior-change techniques hopefully involves replacing it with a more desirable pattern. Accordingly, behavior-changing not only implies remediation; replacement by desirable patterns is likewise a collateral goal. It may in many cases be an inevitable one. After all, the reduction of symptomatic behavior often means leaving in its wake patterns that have more to recommend them than simply the absence of what they replace. For example, continued sobriety in career drinkers may mean more to them than just the cessation of bouts of inebriation; the termination of hallucinations in a young adult is more than merely an end to mental destabilization; and relief from post-partum depression in a young mother means more than just the end of her dysphoria. So getting rid of the unwanted symptom often ensures a positive consequence, although enhancing the latter may not be an additional technical step to be undertaken within behavior-change program techniques.

Behavior-change as I understand it is not restricted to overt patterns exclusively. Such things as thoughts, feelings, hopes, wishes, desires and intentions are also subclasses of behavior included in the realm of consideration. A constricted definition of behavior may be at the bottom of misinterpretations of the therapeutic compass of the Cognitive-Behavioral approach to deviancy by its practitioners. The latter use the term behavior in a much wider sense than that attributed to them by their psychodynamic colleagues. The latter sometimes fault behavioristic modalities for ignoring the inner life of patients, of not treating the whole person, as it were. One psychodynamically-oriented specialist describes Cognitive Behavioral Therapy as a cookie cutter or manualized approach to treatment, as though a truly humanistic or searching avenue in psychotherapy were being side-stepped or short-circuited. Yet as I understand its applications, behavioral practitioners of whatever stripe insist that their methods may be adapted for any human problem, not merely the distress of persons who don’t know what to do with fidgety hands or hair-pulling patterns, as in trichotillomania.

Behavior-changing strategies come in at least two different forms. One of these is an array of specific or standardized techniques. The other form is more varied and elusive, not easily something that can be taught or outlined in an instructional handbook. This is the being with functions a therapist inevitably adopts, although these may vary greatly, depending upon the practitioner.

As intangible as this function is, incorporating as it does complex levels of therapist-patient interaction still remains another dimension of behavior-changing service. It involves such elements as caring, acceptance, empathic understanding and the interactions, verbal and otherwise, of two persons who engage each other. The purely technical component and the being with component I lump together under behavior-changing modalities because they both can be causally related to positive therapeutic outcome. However, there is no guarantee that either of these components always ensures treatment efficacy, and the insistence that they do in the absence of proof has to be one of the most glaring wish-fulfillments of a professional elite discharging mandates it is confident always work as advertised.

The distinction between specialized techniques and the being-with aspects of psychotherapy seems apt when we consider that while the former may be teachable as part of a training curriculum, the other seems to be a knack of a therapist’s personality, deriving from his or her natural talents as a caring human being. If the being with function is teachable at all—we take no position on this possibility one way or another—the training in question would probably be much more complex and prolonged than that requisite for administering specialized and more formulated techniques.

On the other hand, just as skills in applying techniques won’t guarantee therapeutic success, neither does being a decent human being guarantee therapeutic results in the consulting room, nor does it guarantee that a therapist suffused with decency and fully capable of discharging both the technical or being with functions has to succeed in meeting formulated treatment goals. Success often seems to depend on many factors coalescing.

Psychotherapists also provide status-affecting services. These are diagnostic, classificatory acts or assessments designed to meet criteria for entries listed in standard nomenclature manuals like DSM-V or ICD-10. Is the patient really paranoid, or is his hostility more fleeting and situationally derived? Is this parent a child abuser, unable to bond properly with her child? Does the patient meet criteria of Borderline Personality Disorder? Formalizing this approach in order to answer such questions often involves administering batteries of standardized tests familiar to clinical psychologists or neuropsychologists.

A therapist can be incandescent with patient-friendly virtues, yet bomb out as a treatment specialist in the consulting room. But I suspect that without the being with capability, a practitioner most of the time is at a serious disadvantage in dealing with certain patient populations. Yet it may be a misconception to assume that the being with function is the only one making psychotherapy effective, although I daresay there are some who believe this. Accordingly, a mythology is often perpetuated about treatment being effective only when the being with function is alive and well. Despite this, just as the technical application function sometimes avails little when the therapist is short on the being with capability, so too might this component sometimes come to naught in relation to other problems or other clinical populations.

In line with this, there remain techniques in the professional armamentarium research indicates are superior to being with abilities in bringing about successful outcomes. Among these might be listed those developed for the treatment of phobias, panic disorder, types of sexual dysfunction and obsessive-compulsive disorder. Treatment for these conditions administered in the future by a sophisticated robot might, from the standpoint of symptom reduction, be superior to a live therapist palpitating with holistic wisdom, albeit clueless about the advantage of such techniques as flooding, exposure or response prevention in the treatment of OCD. So it may be a mistake to insist that the essential variable in every case of treatment success is the personality of the therapist.

In line with this, a mythology seems to be flourishing in the media where all manner of assumptions about psychotherapy enliven discussions of the subject. In all likelihood there is no common denominator, personality or otherwise, that can be identified as a common thread in successful treatment. Moreover, psychotherapists run a gamut of personality styles that are markedly different. In the past there were soft-edge personality practitioners like Rollo May and Carl Rogers, therapists with a hard-edge style like Albert Ellis and Fritz Perls, therapists who emphasize highly structured approaches like Aaron Beck, Joseph Wolpe or Albert Bandura, and those who radiate nurturance, like Frieda Fromm-Reichman. There are combative psychotherapists like John Rosen, those dedicated to body work, like Wilhelm Reich and Alexander Lowen, those who prize freedom of choice and contractual obligations like Thomas Szasz, low-profile interactions like Charles Brenner, those who are in the tradition of left-wing chic like R. D. Laing, and those who depend on the collective unconscious or archetypal functions like Carl Jung.

Some of those cited emphasize cognitions as concepts central to treatment, some unconscious motives, some biological factors, some group or family dynamics, some contingencies of reinforcement, some nutrition, some synchronicity, mysticism or spirituality, some the past (including past lives), others the future, and some a combination of several of these. If practitioners who promote such diverse forms of treatment share anything in common, it is evidently the unyielding belief that their approach is not only beneficial, it is more so than all the others. Unfortunately, research does not seem to back up their claims to sovereignty over treatment results. Practitioners comprise a panoply of temperaments bewilderingly diverse for an enterprise some of whose representatives insist require indispensable characteristics of personality style. If personality style is a critical ingredient, evidently any will do, a lesson to be drawn from a brief glance at the passing parade.

Meaning-imparting aspects of psychotherapy are a third aspect or layer of service. Yet it is an elusive one, because meaning can be defined in many ways. What psychotherapy means to a patient may not be what it means to his or her therapist, and what Meaning (spelled with a capital M) means to an existential therapist of the kind celebrated by Jean-Paul Sartre is yet another story. In an approach like Viktor Frankl’s Logotherapy, the aim is to restore or originate Meaning (also spelled with a capital M) in a patient’s life. In these systems and in accordance with the thinking of the existentialists, meaning is construed as that sense of personal actualization—if not identity—created by engaging life in an action-oriented way, one which defines our Being (also spelled here with a capital B.)

When I speak of the meaning-imparting function of psychotherapy, however, I refer to a somewhat broader conception of meaning than do the Existentialists, whether treatment specialists or philosophers. I wish to focus on it as nothing less than a dimension of life—psychotherapy being a form of life—pertaining to such admittedly nebulous things as the significance of the therapeutic encounter independent of behavior-change. In this sense of meaning, I use the term to refer to a patient’s perceived or experiential world that can be separated, as it were, from his or her decision-making, how symptomatic patterns are changed or affected, or how status-affecting practices impact on the course of treatment. Meaning, as herein understood, is a largish dimension left over after behavior-changing and status-affecting components are subtracted out.

It’s difficult to dwell on the meaning-imparting function without sounding trendy. Maybe this is because we associate it with the practices of a generation of treatment practitioners some of us feel have defaulted on the promise to develop evidence-based behavior-change techniques, or because they confuse real change with the trappings of counter-culture sensibility like those flourishing in the sixties. Indeed, many clinicians in the hard-nosed tradition of service feel that Third Force Psychology—at least in many of its forms—is a hodge-podge of wacky techniques administered by dotty gurus to flakey disciples. So the constituency brandishing an empiricist, evidence-based banner feel that what is called Humanistic or New Age Psychology fairly bulges with self-styled prophets, diets, communes, holistic health, Oriental philosophies, weekends at mountain retreats, forms of body massage, marathon assemblies in which hundreds congregate to take the training before taking responsibility and Temple Dances choreographed by avatars of insular societies touting these rituals as necessary for achieving higher levels of consciousness.

Be that as it may, we should not construe