| Talk is Not Enough |
By Willard Gaylin, M.D.
Genre: Inspirational & Self-Help
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Who Needs Help?
Until the end of the nineteenth century, few people with emotional disorders went for "help," i.e., professional treatment. They were taken, or more accurately dumped, someplace, that place usually being the insane asylum. These people were not defined as "mentally ill"; something was wrong with their brains or their nerves. The concept of mental illness diseases of the mind as distinguished from the brain had yet to evolve.
All illnesses, mental or otherwise, were perceived as dysfunctions whose causes were unknown but variously ascribed to humors, chills, trauma, spontaneous generation, or deterioration of organs from genetic or unknown causes. In other words, some physical disturbance of the anatomy (which by then was well understood) or the functions (which were only beginning to be understood) of the body parts.
The physician looked for a deterioration of structure comparable to what might be observed in any physical entity a church spire, a bridge, a roof due to aging or physical trauma. The prototype was heart disease. The heart is an extraordinary pump, with four valves and made of muscle fibers unlike any others in the body. Unlike all other muscle, it never fatigues or cramps from overuse. Thirty-eight million times a year it pumps! When it fails, one can safely assume some physical damage to the pump or its valves has occurred.
Consistent with this model, the insane were expected to have some damage to the brain. But this presented a problem. Abnormalities of the brain were difficult to identify, although the phrenologists tried. We did not (and still don't) understand even the basic anatomy of the brain and its interconnected parts, let alone the modes of operation of such higher activities as memory, cognition, and emotion.
In addition the insane were for years assumed to be different; not really sick but "possessed" by evil spirits dybbuks, devils, or demons. The metaphoric term "bats in the belfry" had an almost literal meaning. Since the leading cause of psychosis in those days was advanced syphilis, the brain was indeed occupied by little "demons," in this case the spirochete Treponema pallidum. But there would be no awareness of this until the birth of modern medicine and the discovery of the germ theory. We had little understanding, for that matter, of the true cause of any disease, mental or physical.
In the latter half of the nineteenth century, all this would change. With a stunning burst of research in the laboratories of France and Germany, the discoveries of such great medical pioneers as Louis Pasteur, Robert Koch, Paul Ehrlich, Ignaz Semmelweis, Wilhelm Wundt, Hermann Helmholtz, and Rudolf Virchow initiated the age of modern medicine. The actual causes of common illnesses could now be scientifically demonstrated in the most rigorous manner, pointing the way to specific, cause-related treatments (although, tragically, seventy-five years would pass between Pasteur's proof of the germ theory in 1862 and the emergence of an effective treatment for bacterial infections with the discovery of the sulfonamides and penicillins). This was not to be the case with mental illness, a concept yet to be discovered.
Modern psychiatry actually emerged from the field of neurology, the study of the structure, function, and abnormalities of the nervous system. The leading center for neurological studies was in Paris, where the brilliant neurologist Jean-Martin Charcot (1825-1893) headed his famous clinic. This pioneer of modern neurology was particularly interested in the study of hysteria. As a disease hysteria does not in any way correlate to such lay usage as overreaction, hyperemotionalism, or a tendency to make scenes in public places. In actuality, the grand hysteria of the nineteenth century was characterized by something quite the opposite, a symptom called la belle indifference the patients displayed profound physical symptoms to which they seemed quite indifferent.
What, then, was hysteria? Hysteria was a physical symptom that did not seem to have traditional physical causes blindness, deafness, numbness of the hand or foot, and occasionally seizures. Charcot suggested that these were due to some nervous disorder, meaning literally an inflammation of nerves that affected the end organs the eyes or the ears or the limbs. His theory was still firmly rooted in a physical model.
Sigmund Freud, the founder of psychoanalysis, may rightly be seen as the father of the concept of mental illness, and mental health. He was born in 1856 and received a medical degree from the University of Vienna in 1881. Freud was interested in research medicine, particularly in the field of neurology. He studied with Charcot and took Charcot's theory one giant step further. Freud decided that these nervous disorders neuroses were actually caused by psychic distress.
Freud's leap proved monumental. It abandoned the model common to all diseases physical damage and further put forward the incredible notion that feelings and ideas could produce illness as readily as toxins and bacteria. Freud postulated a new category of disease. These were clearly defined as mental disorders, impairments of function due to psychological processes, not inflammations of organs or neurological decays. Freud created the concept of mental illness as distinguished from brain damage. It was inevitable that we would now look at behavior in a new light and begin to redefine the mentally ill.
The Medicalization of Woe
Prior to Freud psychiatry only recognized what we now call the major psychoses. These patients were irrational and bizarre, different from the rest of us. "Crazy," "lunatic," "insane," were words interchangeably used by layman and physician. Freud began to elaborate an entire new group of illnesses, still not clearly defined as mental illnesses, which he labeled the psychoneuroses, that is, psychological disturbances caused by irritation or inflammation of the nerves. These were mental illnesses characterized by clear-cut symptoms phobias, obsessions, paranoias, and the like occurring in a normal (not insane) person.
In so doing, Freud destroyed the absolute dichotomy between sane and insane. The symptom neuroses suggested that one need not be totally crazy to demonstrate crazy patterns of behavior. Normal people like his friends and himself could have isolated pieces of behavior that were "crazy."
This began a process that led to an increasing array of mental disorders that, without preconception or intention, paved the way for a continuum from healthy to sick. The on-off light switch had been replaced by a dimmer, or rheostat. Once the process was started, the elaboration of mental illnesses was rapid, and the distinction between the healthy and the ill was blurred and eventually obliterated.
While Freud was continuing to catalog the whole new species of symptom neuroses, a colleague was formulating a definition of mental illness that involved no symptoms at all! Wilhelm Reich was interested in the structure of character or personality. It occurred to him that one did not have to have bizarre and irrational symptoms to be defined as mentally ill; the very character of the individual could be so damaged as to reduce his capacity for work or pleasure. He affirmed, in psychological terms, Heraclitus's observation that "a man's character is his fate."
Reich's theory was a pioneering piece of work that anticipated the direction of modern psychiatry. Today, particularly in ambulatory or office psychotherapy, the vast majority of patients do not have traditional psychological symptoms; rather, they suffer from what we call "character disorders": they can't succeed at work, they can't fall in love, they can't make permanent attachments, they're afraid of competition, they are overly aggressive or too timid, excessively seductive or painfully shy.
Freud, meantime, had begun to elaborate a general theory of neurosis that could encompass such disparate behaviors as paranoia and compulsiveness, delusion and hysteria. Beyond just explaining diverse mental symptoms, this ambitious theory would lay the foundation for understanding normal character traits, attitudes, cultural beliefs, and the very institutions of society. Freud's general theory would come to be called the libido theory. Here, all mental illness was seen as a function of something gone awry with the developing sexual instinct. In order to define what went wrong, he had to elaborate a "normal" development for human beings. Just as one assumed a normal physical progression of the infant from sitting up to crawling to standing, from infancy to puberty to maturity, so one could assume a traditional normal psychosexual evolution.
By setting a standard scheme of development, Freud allowed for mental illness to be explained in terms of the absence of expected normal functioning, as well as in terms of malfunctioning. The patient did not have to demonstrate any aberrancy; he could simply be missing that which we assumed normal people must possess to qualify for a definition of health. Significant omissions became part of the definition of mental illness. The failure to be able to achieve orgasm would be defined as a mental illness, as would the failure to be able to maintain an erection in an adult relationship.
These changing standards expanded the population of the mentally ill far beyond the original group of psychotic patients. By definition the mentally ill now included those with psychoses, symptom neuroses, significant omissions from normal behavior, and character disorders.
The next large group of patients to be added to the population of the mentally ill emerged from the research of physicians concerned with basic physiology and internal medicine rather than psychiatry. Modern medicine began to see links between emotional states and the emergence of physical conditions: hives, neurodermatitis, diarrhea. In addition, emotions were implicated in the onset of what had been formerly seen as purely physical diseases: asthma, ulcerative colitis, migraine headache, peptic ulcer, hypertension. These would come to be called psychosomatic diseases or conditions. Here we had a group of patients who were "mentally" ill, with no mental symptoms; nothing now had to be wrong with your mental functioning for you to be included in the population of the mentally ill.
Some of the early theoreticians of psychosomatic medicine became heady with the opportunity of explaining physical symptoms in terms of psychodynamic causes. They slipped into a disastrous habit of looking for a specific dynamic, or force, for each disease. The silly season arrived and almost sank the ship before the voyage began. I recall reading a psychiatric paper that explained a peptic ulcer as being the "bite of the introjected [swallowed up] mother," whatever that was supposed to mean. More sophisticated researchers began to be aware that mental processes played a part in, but did not have to be the exclusive cause of, psychosomatic diseases. Today we understand how complicated the interplay is between emotion and body functions.
The layman always understood this. The diarrhea that occurred the night before the examination was not seen by the student as some unlucky accident compounding his anxiety about the examination, but rather the product and proof of that anxiety. We knew that we sweated when we were nervous, flushed with embarrassment, often wet our pants with terror or even excitement. But now exact research studies would enable people to understand the mechanisms by which an emotion could provoke a physical reaction. Anger could trigger an increase in hydrochloric acid secretion in the stomach, thus being, if not the sole cause, a contributing factor in a peptic ulcer. We know that specific allergies are due to specific antigens. We can demonstrate this by creating the symptoms in our patients with minute doses of these allergens. We also know that emotions can precipitate the very same allergic responses.
The more sophisticated we become in our knowledge of human physiology, the more we erase the mind-body dichotomy from human medicine. We know that emotions can trigger hormonal releases, changing blood chemistries that act on such end organs as bronchi, lungs, the colon, or the skin to produce symptoms.
This brutally abbreviated "history" of the evolution and expansion of the definition of mental illnesses is presented not for scholarly purposes, but merely to demonstrate why the ranks of the mentally ill have seemed to increase so precipitously. People aren't more neurotic than they once were. Society is not causing the population of the mentally ill to increase. We are changing the definitions.
By narrowing the amount of impairment necessary to define a person as mentally ill, we have broadened the population of the mentally ill. So much so that by the mid-twentieth century, major researchers could do epidemiological studies of the Upper East Side of Manhattan and discover that over 70 percent of the population had evidence and traits of mental distress. Admittedly, the Upper East Side of Manhattan is a peculiar location, but I suspect that these same researchers could have gone into any community and found the same proportion of mental problems.
Psychiatry had now captured 75 percent of the population as a potential constituency. But the net was still not fine enough. What about the 25 percent that eluded our grasp? The mental hygiene movement took care of them.
The mental hygiene movement emerging in midcentury was part of the increased interest in preventive medicine. If we now understood normal psychological development as we understood normal physical development, why should we wait for the deterioration of function or the development of symptoms? Why not act prophylactically, thus guaranteeing healthy development by insuring a proper psychosocial environment?
We had arrived at a point where almost everyone was a little sick and even the healthy could benefit from some psychological guidance. Everything would eventually become a form of mental illness, every failure, even a lack of success a bad marriage, a disobedient child, antisocial behavior, ennui, mere unhappiness. This being the case, all sorts of problems that formerly might have been directed to ministers, counselors, friends, relatives, correctional officers, teachers, lovers, or parents could now be directed to psychiatrists. If all of these behaviors were a form of sickness, shouldn't they be treated by a doctor? In the beginning it worked just that way. The medicalization of misery led to an expanding population of psychotherapists who were psychiatrists, i.e., doctors.
So now "patients" were consulting with their "doctors," seeking "cures" for "illnesses" miseries that were never before perceived of as medical. We had engineered the medicalization of woe.
Consequences of the Medical Model
What had formerly been seen as unhappiness, or a crisis in confidence, or a moral failing was now defined as a clinical condition. Some might say: "What's the difference? Only the name of the game has been changed."
Nothing could be further from the truth. With a change of definition comes a change in rules and attitudes. When you go to a psychotherapist for your distress rather than to your minister, you are not simply speaking to a different person about the same problems. You are speaking to a different professional with different attitudes about your problems. As a result, your problems will be defined in different ways.
To be "sick" is different from being "bad" or even "unhappy." Compare therapy with the Catholic confessional with which there is some similarity. Confession in either case can lead to some comfort or relief of distress. But what follows differs dramatically, depending on whether the behavior confided is defined as a sin or a symptom. The penitent goes to his priest confessing something he knows to be "sinful." The priest listens and in a religion of forgiveness like Christianity offers penance that absolves the penitent from the consequences of his immoral behavior, or sin. It is clear to both penitent and priest that what the individual has done was wrong, evil, sinful, immoral, name it what you will. The purpose of the confessional is to both condemn the sin and forgive the sinner.
Something much more complex happens in a medical model. The very same behavior is no longer defined as sinful, nor stigmatized. We do not condemn the symptom of a disease. No moral judgments are made about a festering sore or a leaky heart valve. A doctor does not look at your impetigo or your bloody sputum with disgust and condemnation. They are "not your fault." You are the suffering victim of your own symptoms. The doctor's role is to cure the symptoms that are disturbing your life. These symptoms are viewed as independent of your autonomy and therefore are not your responsibility.
To the psychotherapist, as well as to the sophisticated layman, the model of symptoms and disease in mental illness is perceived in the same manner as in physical illness. The drug addict and all of the behavior that is interpreted as being contingent upon his addiction is observed neutrally by the psychotherapist, without condemnation, without introduction of ideas of retribution or penance. Drug addicts are to be treated. Similarly, there will be no moral judgments made about the phobic, the obsessive, the hysteric, the kleptomaniac (formerly, "thief"), or the sexual voyeur (formerly, "Peeping Tom").
Being cast in the sick role places one in a different scenario from that of the sinner or criminal. The patient is not responsible for his symptom. It is visited upon him from a hostile environment or from his developmental past. The patient is neither sinner nor criminal, but a victim. He is not to be forgiven, he is to be pitied. He is not to receive penance, but treatment. He is not to receive condemnation and scorn, but succor and sympathy. Whatever we are prepared to define as a symptom of a disease, whether it be exhibitionism, alcoholism, or brutality, will be protected from moral judgment or criminal culpability under the medical model. Theoretically you are no more blameworthy for the bad temper that caused you to beat your wife than you would be for an epileptic seizure. This already suggests some of the problems that follow when attempting to apply the medical model (suitable to psychotherapy) to the broader world of social living.
The ramifications of the medical model are profound, influencing such diverse areas as the schools, the courts, and the workplace. Moral and legal culpability for many actions for which we would formerly have been held accountable are mitigated when such behavior is seen as the symptom of a disease rather than a willful choice. For our purposes here, it is only important to realize that the therapist, in his dealing with the same piece of behavior that the court or the priest had dealt with previously, will have a different frame of mind, create a different set of conditions, and institute different methods of change.
The Walking Wounded and the Worried Well
While the population of the mentally ill has grown dramatically since Freud's time (by definition, if by no other means), the percentage of that population who seek and receive treatment is still small. And a bizarre situation has evolved. The sickest, the traditional mentally ill, are receiving less attention than the less sick. Psychotherapy in particular has been occupied with treating the least disadvantaged. A number of events have conspired to create this anomaly.
A person's decision to go for psychiatric treatment is not determined by his psychological or emotional condition alone. Some of the most profoundly disturbed will never receive help, while others will devote years to treatment for the alleviation of what may be perceived by friends or acquaintances as a relatively minor dysfunction. An individual will seek psychotherapy not only because his mental health requires it, but also because certain social conditions are conducive to his going to a therapist.
A number of factors influence a person's decision to seek treatment: the extent to which a particular emotional illness burdens him socially or financially; the value he places on the function impaired by such illness; the readiness to define his pain (headaches) or disability (the inability to hold down a job) as a psychological problem; the degree of his understanding that emotional illnesses are treatable; the availability of psychotherapy; the availability of money for psychotherapy; the stigma he and his community attach to psychotherapy.
Let me offer some examples. If a sophisticated, urban, young, male advertising executive was suddenly to find himself incapable of maintaining an erection, he would be likely to end up in a psychotherapist's office, even fifty years ago. If a comparable woman was completely frigid, she would, until very recently, be unlikely to seek treatment.
This difference has been dictated by several facts. First, the biological peculiarity of the male genitalia is such that a man has to be aroused to perform. No interest means no action; the pleasure and procreative aspects of sex are linked. In a woman, however, sexual arousal and fecundity are biologically separated. A woman can, despite the total crippling of her sexual pleasure, support intercourse and be capable of procreating.
In addition, a man's impotence is publicly announced to his mate. A woman can dissemble. But more important, her rights to sexual pleasure had not been fully established until very recently. Many women simply did not know what they were missing, and when they did they did not feel the right to claim their pleasurable due. Orgasm was not fully established even in a woman's own mind, let alone in societal judgment, as her right and her norm. Whereas the absence of potency threatened the very identity of a man, the presence of female sexual passion was often viewed as somewhat inelegant and unladylike. Male and female sexual impotence are both crippling, yet one was much more likely to drive the individual to seek help than the other.
Even now, when the attitudes that contributed to such divergent behavior are changing, it remains true that an educated and sophisticated New York professional woman will be more likely to seek psychotherapy than a small-town or rural housewife. The sophisticated urban woman assumes that lack of orgasm is a medical problem; that it is treatable by psychotherapy; that there are therapists in the community who earn their living treating such conditions. Many unsophisticated women still view sex as a masculine pleasure and a feminine duty.
With neuroses in general, peer attitudes influence people's perspectives and determine their readiness to seek treatment. During the fifties, in certain professions such as acting, psychoanalysis was not only acceptable but de rigueur.
As previously suggested, geography can also be a factor. A white, upper-middle-class New Yorker is more likely to be analyzed than her Laramie or Biloxi counterpart. One reason is that there are more therapists in New York than elsewhere. Their mere availability permits people who are enduring certain problems to think in terms of therapeutic solutions.
The fact is that those who seek psychotherapy these days are not necessarily sicker than those who do not. They are often simply more ambitious, unwilling to settle for less than what they perceive as the fullest and richest life. Similarly, lack of education, social class, and religious bias all cause some people to go through life operating at less than their full potential rather than face what is seen as the indignity of seeking help.
That a person has undergone psychotherapy must not be perceived as an indication of emotional impairment. It may actually indicate reasonableness, courage, and emotional maturity. I have never found my patients to be a sicker population than my circle of friends.
Meanwhile, some perverse and paradoxical cultural effects are emerging in the attention we are paying to differing forms of mental illness. We have divided the population of the noninstitutionalized mentally ill into two divergent, and often politically antagonistic, camps, sometimes labeled the walking wounded and the worried well.
It early had become apparent to Freud and his immediate followers that psychoanalysis was ineffectual with the classically psychotic patients those suffering from delusions, hallucinations, and major disruptions of lifestyle. Some psychotics were totally incapable of functioning on their own, but others "compensated" psychotics were still able to operate in the everyday world. Nonetheless, even this latter group, the so-called walking wounded, were screened out of the psychoanalyst's practice. This was not just because they were unresponsive to psychoanalytic methods, but also because psychoanalysis can be disastrous for them, precipitating acute psychotic breakdowns in schizophrenics who are tentatively holding on to their sense of reality.
Early treatment for severe psychoses consisted of rest, confinement, care, time, and nurture. In recent times we have seen the blessed emergence of psychotropic drugs. Antipsychotic drugs have revolutionized the treatment of the severely mentally ill. Many of these patients could still benefit from the support and counsel of a therapist, but, alas, they will often avoid therapy once their primary symptoms have been alleviated through drugs. In addition, such supportive treatment of psychotic patients is less dynamic, and therefore less exciting and challenging for most therapists. Chronic illness is "less fun" for physicians than acute illness. Curing is more exciting than caring. Both these factors the patient's avoidance and the therapist's indifference contribute to therapeutic neglect of this population.
The discrepancy in who gets psychotherapy has become illuminated in the battle of the bucks. In these days when budgets for health care are lean, with mental illness the particular stepchild, there is real danger that the sickest people, the traditional mentally ill the walking wounded are getting shortchanged.
Whether it is fair or not, those suffering from neuroses or simple maladjustments the worried well form the majority of patients in psychotherapy. The term does them an injustice. They are not well, and they are more than worried. They are suffering. These are, at any rate, the people who constitute the population that seeks ongoing psychotherapy (the "talking cures"), and these are the people that I will deal with in this book.
Excerpted from Talk is Not Enough , by Willard Gaylin, M.D. . Copyright (c) 2000 by Willard Gaylin, M.D. . Reprinted by permission of Little, Brown and Company, New York, NY. All rights reserved.Back to top