Psychotherapy is a rewarding and effective practice that encompasses the depth and reach of human nature. It effectively heals psychiatric symptoms, the struggles of human character, and allows for the recovery of authenticity and the capacity to love. As a psychiatrist for the last forty years I have treated patients in the psychotherapy of character. Each of us coalesces our character as our genetic temperament fields responsiveness, abuse and deprivation during our formative years. This is at one with the organization of consciousness in the brain as a play with a cast of characters, feeling relationships between them, scenarios and plots. Psychotherapy operates through emotional holding with the therapist within the boundaries of the psychotherapy. This allows the patient to mourn and recover from the pain that shaped his character. The patient then deactivates his old problematic play and writes a new one in the brain in exactly the way the character story was written in the first place.
Human suffering and struggle is a human problem. The human condition is no different now than at any time, in any culture, in human history. To grapple with its mysteries requires a dedication to understand the pains of existence, the vagaries of love, of child rearing, the consequences of abuse and deprivation; to the struggles of self and other and relationship, to struggles with authenticity and emptiness; to the temptations of sex, drugs, drink, and gambling; to loss, to fear, to wonder, to sadness, to jealousy, envy, egotism, masochism, sadism; to humility; to life’s fulfillments and wisdom itself. In short, we bear witness to the richness of the comedy and tragedy of the human story.
There have been priests and shaman and practitioners in every culture and society who attend to the pains of human struggle in their own way. Until recently, psychiatry has embodied that role in our society. But somewhere along the way, we have gotten very lost. Suddenly, within a generation, the problems of people have been reduced to a fantasy that human struggle is brain disorder. And the treatment is taken to be psychoactive drugs. This idea has been embraced by psychiatry and the public at large. It is now conventionally believed to be true. And we consider it a very enlightened idea. The very idea that a pill can cure what ails us is an insult to the human condition and common sense. In short, the emperor has no clothes. And the sad thing is that we have had the answer all along – psychotherapy.
I have addressed the destructive history of brain psychiatry in "Do No Harm: The Destructive History of Pharmaceutical Psychiatry and Its Bedfellows— Electro Shock, Insulin Shock, and Lobotomies" (the appendix to my book). The bible of today’s brain psychiatry is the DSM-5. It is 947 pages long and costs $100 or almost $.10 per precious page. Has anyone heard of Occam’s Razor? - the simplest explanation for some phenomenon is more likely to be accurate than more complicated and convoluted explanations.
I would suggest the following as an alternative to the DSM-5. (Please note that I do not use the demeaning term psychopathology.) We can break down the degree of formative trauma (abuse and deprivation) in early childhood on the development of character into roughly three groups: (1) In the context of moderate problematic damage, mixed with some good-enough care, we have four major types of character worlds, depending on which temperaments are in ascendancy— obsessional, phobic, compulsive, and dissociative characters. (2) In the context of severe damage, the different array of temperaments generate schizoid and paranoid characters, sadistic and masochistic characters, narcissistic and echoistic characters, borderlinism, affective characters, anorexia, germ phobias, psychopathy, and psychotic depression. (3) Finally, we have the psychotic character worlds in which there is a fragmentation of the intactness of the self persona and a rupture of the cohesion of the play itself. This derives from a damaged Authentic-Being, due to some combination of extremely early maternal damage, with some genetic predisposition, and possibly epigenetic effects, all still forged through the different temperamental orientations. The psychotic character worlds are hebephrenia, catatonic schizophrenia, paranoid schizophrenia, schizoaffective schizophrenia, manic depression, and paranoid state. We don’t even see hebephrenia and catatonia mentioned much anymore because they don’t fit contemporary models. But they did not disappear and are still there. So here it is, less than a page, one paragraph. And this is actually meaningful in relation to actual treatment.
Yes, I understand the historical problems with psychotherapy. There have been charlatans. There have been incompetent practitioners. There have been byzantine and frankly incomprehensible theories which are off base. I understand that it takes a long time and is very expensive. I understand that there are very few therapists these days who have dedicated themselves to the mastery of the art of psychotherapy. Nonetheless, this does not change the basic truth of its value.
I get three major critiques – “Not another mother blamer”; “one size fits all” has the same fallacy as your own critique; and psychotherapy is not “evidence based”.
Regarding “Not another mother blamer”: Therapy is not about blaming. It is about mourning the pain that formed one’s characterological play. The fact is that we are mammals and the actualities of our child rearing affects the limbic-cortical mapping of our experience. Motherhood embodies the most important function of our existence. The responsibility is there for love, abuse, or deprivation, whether anyone likes it or not. A patient has to face and mourn whatever the issues are. We don’t get to chose them or declare them irrelevant because someone doesn’t like it.
“One size fits all”: If one concludes, as I have, that drugs are not only not helpful but destructive, then why would I profess that it is OK to damage some people to be fair to big Pharma. Be clear that there is some use for drugs in schizophrenia and manic depression because part of the damage is either very early mothering, genetic, or epigenetic. It is constructive to ameliorate the terror of schizophrenic dissolution and the rampaging moods of mania. However, that is but an aid to the treatment of a problematic psychotic character play, no different from the rest of psychiatry. People with schizophrenia are people too. Drugs are not the treatment per se.
And finally, we have so-called evidenced based science. My experience is that psychotherapy is almost always effective in ameliorating the suffering of our patients. I cannot prove this according to the parameters of pseudo evidence-based criteria. Keep in mind that this criteria is fraudulent and faulty in the first place. I have addressed this in “No it’s not the Neurotransmitters, Depression is not a biological disease caused by an imbalance of serotonin”. At best, the ‘evidence’ for antidepressants is that it is effective 10% of the time. And there is no real mechanism that is proven that explains the actual source of psychiatric symptoms, as I do with the damaged ‘Play of Consciousness’ in the brain. There are just unsubstantiated biochemical theories. And to then apply this faulty science to some social science model of measuring some ‘cure’ of psychiatric symptoms like it is a rat in a maze, is an absurdity. We are far too complex and this does not have any meaning. Dispensing drugs is not psychiatry, and it certainly will not attract young people with any familiarity with or interest in the eternal struggles of the human condition. What we need instead is a major commitment of time and money to teach psychotherapy to young people. If we let it die, then we will have to invent it all over again.
Robert A. Berezin, MD is the author of “Psychotherapy of Character, the Play of Consciousness in the Theater of the Brain”