Jung At Heart

There are a number of writers in psychoanalysis that I enjoy reading. Thomas Ogden is one of them. Last week I read this description by him of the analytic process, a description which I find to be quite lovely:

"A person consults a psychoanalyst because he is in emotional pain, which unbeknownst to him, he is either unable to dream (i.e. unable to do unconscious psychological work) or is so disturbed by what he is dreaming that his dreaming is disrupted. To the extent that he is unable to dream his emotional experience, the individual is unable to change, or to grow, or to be become anything other than who he has been.The patient and analyst engage in an experiment within the terms of the psychoanalytic situation that is designed to generate conditions in which the analysand (with the analyst's participation) may become better able to dream his undreamt and interrupted dreams. The dreams dreamt by the patient and analyst are at the same time their own dreams (and reveries) and those of a third subject who is both and neither patient and analyst.

In the course of participating in dreaming the patient's undreamt and interrupted dreams, the analyst gets to know the patient in a way and at a depth that may allow him to say something to the patient that is true to the conscious and unconscious emotional experience that is occurring in the analytical relationship at a given moment. What the analyst says must be utilizable by the patient for purposes of conscious and unconscious psychological work, i.e., for dreaming his own experience, thereby dreaming himself more fully into existence. "

From This Art of Psychoanalysis:Dreaming Undreamt Dreams and Interrupted Cries

After reading the Newsweek article on bipolar disorder in children that both Furious Seasons and CP&P write about this week -- and please read them as they critique the article far better than can I -- I recall a child I was called to consult on years ago. This little guy was 4 and the nurse in his school was certain he had childhood schizophrenia. He had echolalic speech (Echolalia is the repetition of vocalizations made by another person) and made bizarre hand motions when he spoke, both of which are among the indicators for autism and childhood schizophrenia. I made a home visit and I saw a child who did indeed exhibit these odd behaviors But something about him didn't seem to fit those rather dire diagnoses. There was something in the way he looked at me and made eye contact with me that didn't fit. So on as a wild shot, I ordered a hearing exam by an audiologist. And lo and behold, it turned up a 75% loss in both ears. His speech and hand motions were also common in deaf children.

So I was thinking of him as I read about Max in the Newsweek article, Max who now at age 10 has been on 38 different psychiatric medications which have had who knows what effect on his brain development. And I wonder what would have happened to that little boy I saw years ago if he turned up today presenting the same symptoms. Would anyone think to look for horses instead of zebras? Or would he, like Max, be submitted to the none-too-tender mercies of medications not even certified for use in children? 

Those years ago, there were very few psych meds in use and even fewer with children. Without the hammer of medication, every symptom was not a nail. 

I wonder what was wrong with Max in the first place, back before he was "treated"?

My mother died 15 years ago today. She was a difficult woman, and as is the case for many, dealing with her influence in my life occupied a great deal of my analysis.

The mother complex is a potentially active component of everyone's psyche, informed first of all by experience of the personal mother, then by significant contact with other women and by collective assumptions. The constellation of a mother complex has differing effects according to whether it appears in a son or a daughter.(The Jung Lexicon)

It isn't possible to escape the influence of mother in the development of any and all of us.

Jung tells us of several forms the mother complex can take in a woman --

 The exaggeration of the feminine side means an intensification of all female instincts, above all the maternal instinct. The negative aspect is seen in the woman whose only goal is childbirth. To her the husband is . . . first and foremost the instrument of procreation, and she regards him merely as an object to be looked after, along with children, poor relations, cats, dogs, and household furniture.(Jung, CW 9i., par. 167.)

and

In another version, what Jung calls the feminine instinct is inhibited or wiped out --

As a substitute, an overdeveloped Eros results, and this almost invariably leads to an unconscious incestuous relationship with the father. The intensified Eros places an abnormal emphasis on the personality of others. Jealousy of the mother and the desire to outdo her become the leitmotifs of subsequent undertakings.(Jung,CW9i par. 168.)

This inhibition can also be expressed in another way, in which the woman identifies with the mother.

As a sort of superwoman (admired involuntarily by the daughter), the mother lives out for her beforehand all that the girl might have lived for herself. She is content to cling to her mother in selfless devotion, while at the same time unconsciously striving, almost against her will, to tyrannize over her, naturally under the mask of complete loyalty and devotion. The daughter leads a shadow-existence, often visibly sucked dry by her mother, and she prolongs her mother's life by a sort of continuous blood transfusion.(Jung, CW9i, par. 169.]

And then there is the negative mother complex, the stuff of novels and films, where there is tremendous resistance to mother and all that she stands for.

It is the supreme example of the negative mother-complex. The motto of this type is: Anything, so long as it is not like Mother! . . . All instinctive processes meet with unexpected difficulties; either sexuality does not function properly, or the children are unwanted, or maternal duties seem unbearable, or the demands of marital life are responded to with impatience and irritation.(Jung,CW9i., par. 170.]

This kind of daughter knows what she does not want but is usually completely at seaas to what she would choose as her own fate. All her instincts are concentrated on the mother in the negative form of resistance and are therefore of no use to her in building her own life.

"As we know, a complex can be really overcome only if it is lived out to the full. In other words, if we are to develop further we have to draw to us and drink down to the very dregs what, because of our complexes, we have held at a distance.

This type [the woman with a negative mother complex] started out in the world with an averted face, like Lot's wife looking back on Sodom and Gomorrah. And all the while the world and life pass by her like a dream -- an annoying source of illusions, disappointments, and irritations, all of which are due solely to the fact that she cannot bring herself to look straight ahead for once. Because of her unconscious reactive attitude toward reality, her life actually becomes dominated by that which she fought hardest against...But if she should turn her face, she will see the world for the first time, so to speak, in the light of maturity, and see it embellished with all the colors and enchanting wonders of youth, and sometimes even of childhood. It is  a vision that brings knowledge and discovery of truth, the indispensable prerequisite for consciousness. A part of life was lost, but the meaning of life has been salvaged for her."(Jung, CW9i)

I received an email the other day from a reader asking me what I thought the diagnosis for Sophie of In Treatment would be. The reader speculated either Oppositional Defiant Disorder or Bi-Polar Disorder, because of the suicide attempt. So I thought I would write about that today.

Back in the dark ages when I was first in grad school in clinical psychology, it was *very* unusual for a teenager to be given a major psychiatric diagnosis. Our understanding then was that teenagers are in the normal course of things pretty volatile and that distinguishing normal adolescent mood swings and behavior from pathology is very difficult. Having now had 35 years of clinical experience plus the opportunity to be up close and personal with my own children and their friends, I see no reason to change that notion. 

The excuse given for burdening children and teens with these major diagnoses is that it gets them treatment earlier. But when that treatment all too often consists only of psychotropic meds with very little if any literature about their long term effects on development, one has to wonder if treatment is of net benefit to them. To say nothing of what it means to an adolescent to have a psychiatric label become a significant part of her identity. And we know that identity formation is one of the major developmental tasks of adolescence.

Sophie appears to be doing fine in school and she is a talented gymnast. There do not seem to be any behavioral concerns about her from either of those quarters of her life. She does have a great deal of conflict with her mother, but that is not of a magnitude or seriousness to warrant a diagnosis of any kind. To me, it appears that her symptoms are primarily in response to issues in her environment -- her father's neglect and acting out, the poor boundaries of her coach. I can't see any of her symptoms as other than at the outside of what teenagers sometimes do.

Sophie also responds very well to therapy. She forms a solid therapeutic relationship with Paul and makes significant progress. This argues against major mental illness. 

So my inclination would be to avoid any major diagnosis -- if pressed I would likely use adolescent adjustment disorder. Given the research showing the over-diagnosis of bi-polar disorder and the questions many, including me, have about the appropriateness of making a BPD diagnosis in a minor, that diagnosis seems unwarranted altogether.

The basic message I would want to convey to Sophie and her parents is not that she is "sick" or "mentally ill", but that she is under considerable stress and that with help she can learn better means of handling stress so that her life works better for her. I would want to concentrate on empowering her in developing good decision making skills and other tools necessary for successful life as an adult. 

Thanks to Furious Seasons for pointing me to this study suggesting what many have known a long time, namely that bi-polar disorder is overdiagnosed, though I would submit that it is but one of several instances of overdiagnosis.

"Lead author Mark Zimmerman, M.D., director of outpatient psychiatry at Rhode Island Hospital and associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, notes, "Clinicians are inclined to diagnose disorders that they feel more comfortable treating. We hypothesize that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication responsive." He continues, "This bias is reinforced by the marketing message of pharmaceutical companies to physicians, which has emphasized the literature on the delayed and underrecognition of bipolar disorder, and may be sensitizing clinicians to avoid missing the diagnosis of bipolar disorder."

That a  patient might be diagnosed as bi-polar, in one setting and borderline in another while presenting the same symptoms suggests how primitive our ability to make distinctions really is. Local custom, training of the examiner, examiner biases, insurance coverage, perceived stigma carried by various diagnoses, and funding sources can all influence the diagnosis made as much as the behavior and history of the patient.

That such factors as funding sources and examiner bias influence diagnosis goes against the image of the medical model as scientific. However, subjective and external factors often matter more than the symptoms displayed. In private practice, the fact that medical and insurance records cannot be guaranteed to be private, the tendency is to choose the least stigmatizing diagnosis possible. Occasionally a psychiatrist or therapist might apply a more serious diagnosis to someone they find irritating, in an unconscious attempt at retaliation. Or a facility has beds for patients with one kind of diagnosis but not another, so the effort is made to fit the patient where the space is. Or health insurance severely limits coverage for treatment for minor disorders but is more generous for ones that are more serious, resulting in the push to gain coverage, not strive for accuracy in diagnosis. All of these disturbances, in what we might like to believe are an orderly and scientifically based process, reflect variations in the consensus reality and its deviance from the ideal.

Another factor is the mostly unconscious desire of the prescriber to be perceived by the patient as helpful. Peter Giovacchini wrote some years ago that he thought the reason there were so many antidepressants on the market was that the depressed often do not respond rapidly to therapy and thus can be less than gratifying to treat but when the psychiatrist could prescribe a medication, the patient was often very grateful. Of course he was writing in the day when most psychiatrists did therapy as well as prescribe medications. 

More than sixty years ago, Jung was expressing doubts about the value of establishing a diagnosis:

It is generally assumed in medical circles that the examination of a patient should lead to the diagnosis of his illness, so far as this is possible at all, and that with the establishment of the diagnosis an important decision has been arrived at as regards prognosis and therapy. Psychotherapy forms a startling exception to this rule: the diagnosis is a highly irrelevant affair since, apart from affixing a more or less lucky label to a neurotic condition, nothing is gained by it, least of all as regards prognosis and therapy. (Jung, Collected Works, vol. 16, p86)