The Trouble With the Psychotherapies

Success Stems from Empathetic Practices, Not Rigid Rituals

All Psychotherapies, each based upon a particular theoretical framework, promise their benefits, often vociferously.  Therapies and theories – and there are many — claim that anguish and suffering will be significantly abated or even replaced with contentment, peace, tranquility and happiness if therapy protocols are followed and practiced correctly by the sufferer, while dysfunctional habits and behavior will also be discarded.  Such claims are particularly associated with psychoanalysis and conditioning therapy — now both on the wane.

Therapists and sufferers have different outlooks.  The therapist is usually more of a realist, expecting at least some modest improvements in his patients’ conditions.  Sufferers hope for quick relief from their anguish while paradoxically tending to safeguard their psycho-pathologies: Reluctant to confront fears of change and underlying vanities, they have qualms about prolonged reappraisals of their inner life and thoughts; but this sustains their suffering and dysfunction.

Alas, the results of therapists’ efforts are often quite modest.  Studies truly demonstrating good results are few, and they are fraught with methodological difficulties.  Limited benefits are usually achieved only for certain mild conditions, and the benefits ironically are due mainly to unappreciated elements shared by all psychotherapies.  These elements have been sadly overlooked, and they are worth careful study.

Psychotherapy can be defined in many ways:  as a method, — such as the free association of Psychoanalysis; or as a cognitive confrontation and challenge, as in Cognitive Therapy; or as a maneuver to be practiced, such as a verbal exercise or a body modulation as in Zen and Yoga.  It can be also a guided contemplative state as in the Stochasmos of the ancient Greeks, aka the Transcendental Meditation of eastern teachings — to mention a few.

The sufferers, more often than not, have recurrent bouts of misery. The disorderly tend to continue their misbehaviors — in spite of the fact that these behaviors are grossly contrary to their own self-interest and the welfare of those close to them.  Practitioners explain away meager results by using terms like, “he/she is defensive,”  “he/she resists therapy,” or “he/she has deep seated problems.”

In spite of marginal progress, the typical sufferer soon develops a renewed hope of relief and once again becomes eager to embrace yet another therapy. (The latter pop up continuously like virtual particles in quantum physics!)  When in trouble, humans want relief quickly rather than the result of lengthy efforts.  But the very structure of human nature — ironically coded for survival – imposes numerous impediments to the “hoped for” changes and reliefs.

Temperamental Impediments

A major impediment to change can be traced to the tenacity of temperamental genotypes.  Let’s deal with this at some length.

Temperament can be defined as the set of inborn behavioral propensities that act as a kind of scaffold or template for the eventual unfolding of one’s personality.  Personality embraces the totality of a person’s characteristics, i.e. temperament modified by additional imprinted established attitudes and habits plus the cultural overcoat derived from early life experiences.  Thus the established final personality/character depends on the nature of inborn temperament combined with the type and strength of early experiences, whose significance is interpreted by the very temperament that is shaped by particular events.  In this milieu, the so-called Nature versus Nurture controversy becomes devoid of meaning.

Temperament is made up of components that arguably – since the field is woefully understudied — are comprised mainly of two clusters.  According to E.O. Wilson, whose propositions are based on mathematics and clinical reality as well empirical observations, these two clusters — chimera-like and in various mixes — are the very essence of our human nature.  The first cluster originates from evolutionary pressures on the individual related to self-serving asocial survival.  Emergent properties include self-centeredness, inner directness and selfishness, thinking the world, aloofness, calculations and perhaps additional components.  The second cluster originates from evolutionary pressures on the social aspects of individuals interacting as a group.  Such characteristics include empathy, feeling the world, connectedness, loyalty, tribalism, obedience within the tribe’s rules, and altruism.  Many more can be added, such as intensity, compulsivity, tenacity, emotionality, affability and ability for renewal (starting anew).  The latter subgroup can be shared by both of the above temperamental cluster types.  The list is incomplete and evolving, and many researchers use different adjectives similar in meaning to define these components.

Current scientific research has shown that human babies display remarkable “hard-wired” temperamental/behavioral biases within three months of birth.  Expression of temperament thus results from the particular underlying final structural reality of the brain for each individual.   Initially established and implanted temperament has amazing tenacity.  “Tzan chikar hui tzikmaz” a Turkish proverb aptly proclaims: “It is the soul that departs first and only then the temperament follows!”  Indeed there exists an enduring nature of the particular mixes of inborn components throughout life, and they resist any attempt to change or modify them.  This is especially true if they are extreme variants to normal ones, albeit over time the intensity and severity may be reduced.  Herein lies a major difficulty for psychotherapy.

Temperamental variability has survival value, not only directly for each individual, but also in contributing to tribal survival as a whole.  But there is strong clinical evidence that extreme temperamental variants, mainly originating from the self-centered side, create a pool of vulnerable individuals.  Some of these individuals probabilistically will end up developing major mental disorders (MMDs), specifically schizophrenia, bipolar and obsessive-compulsive disorders.  Their prevalence worldwide is 3% for each, irrespective of culture. Their enduring underlying extremes expressed with characteristic relapses and remissions are now termed Pre-Morbid Traits.  In addition and importantly, such lopsided temperament facilitates creativity in such individuals if they are also gifted and talented and endowed with tenacity and curiosity.

Early Imprinting

Difficulties of favorable outcomes in psychotherapeutic efforts can also be traced to a related second set of traits, namely the enduring nature and tenacity of early imprinting — faulty or not.  A Greek proverb aptly proclaims, “Beans you ate, beans you will manifest!”  Early environmental influences are recruited by inborn temperamental propensities of the individual, thus identical experiences will yield different impressions on different individuals.  A plethora of childhood influential factors are identified in the literature, but they tend to reflect not scientific certainty but the social zeitgeist of the authors.  Nevertheless, there exist five generically identified crucial factors for favorably shaping personality traits in early life for all humans.  These are: (1) Consonance of the child’s temperamental make up with the same gender parent.  Such consonance establishes the inner certainty in the child’s “personhood”;  (2) Consistency or sameness in their environment; (3) Expectancy to perform; (4) Fairness exhibited equally by family members; and above all (5) Structure and firmness (Pedagogy of the Greeks).  All of these in synchrony – with the addition of affection –form a fertile ground molding the temperament that settles into one’s personality.  They confer flexibility and competence to engage life’s challenges and specifically a sense of inner certainty, gregariousness, optimism and emotional stability.  Many sufferers lack elements of these components that, along with faulty temperament, will lead to development of anxiety and other pathologies resistant to psychotherapeutic efforts

A notable  fact is that all humans actually have to be born three years too early — barely in time for our large brains to accommodate the size of the birth canal!   This untimely event enables the brain of the otherwise helpless newborn to grow spectacularly in the subsequent months.  Thus we are born with numerous temperamental algorithms yet-to-be completed in earliest childhood in a complicated and subtle interplay among environmental experiences as discussed above.  Often their unfolding is less than ideal.  Viewed this way, the question of Nature versus Nurture again becomes devoid of meaning.

It is also worth mentioning that our culture rapidly and enthusiastically adopts new ideas and fads only to discard them precipitously later, perhaps retaining only a few morsels for practical use.  A belief was common in academia back in the 1950s that an individual is born “Tabula rasa,” i.e. an empty slate on which early childhood experiences are imprinted.  This was proclaimed as fundamental to a Standard Social Model that regarded these imprinted factors as the sole basis governing the algorithm of our humanity, as well as our attitudes, ethos, leading ultimately to our integrated personality.  This is a rather outlandish belief — that the algorithm of our humanity is written anew on an empty slate for each newly born individual!

And again back in the 50s and 60s, Major Mental Disorders were termed reactions to the environment, even coining such bizarre terms as “schizophrenogenic mother.”  (She was considered the cause of the disease in her offspring due to her noxious psychological influence!)  This saddled the mother with blame for her child’s condition:in fact  her exhibited  temperamental peculiarities were by  our current understanding ,   evidence of a genetic variant, which was a prologue to her child’s eventual development of full-blown schizophrenia.   Remnants of such beliefs still endure, exemplifying sources of unwarranted optimism for favorable outcomes in psychotherapy.

Narrow Phenotypic Flexibility

Another factor impeding favorable outcomes can be traced to the narrow nature of our phenotypic flexibility.  Humans can change and adopt new behavior patterns appropriate for evolving circumstances, but only within narrow limits, temporarily, and usually in unison with other humans (e.g. group phenomena).  This flexibility is even narrower, or even non-existent, for sufferers.  The more incapacitated and dysfunctional individuals are, the more they resist change.  Sadly, the very absence of phenotypic flexibility is an integral part of the disease itself: the system becomes narrowly entrained.  Conversely and ironically, people that need psychotherapy the least ,are the ones who benefit the most by it.  Having flexibility to learn and contemplate alternatives facilitates abilities to modify personal behavior.

Shared Elements in Successful Psychotherapy 

Although positive results from different types of psychotherapies may be modest, they nevertheless do occur consistently across the spectrum of methods.  This is due to the presence of generic factors that have no connection with any particular method or technique.   Let us consider them:

There exists a readiness of humans — social animals that we are — to respond to succor given by helpers who by temperament and background are equally motivated to offer help.  Such efforts are appreciated as solace by the distressed, who then become receptive to simple advice and management.   Dignifying suffering by sympathy marshals the recuperative forces of sufferers as well their receptivity.  Solace is augmented and amplified by a respectful, non-judgmental empathic stance of the helper to listen and respond.

In addition, and as tribute to our tribalism, we readily and positively accept relief, guidance and suggestions from assigned authorities – in our case white coats and all — who function as a kind of “peddlers of certainty” in a world of uncertainty and ambiguity.  This phenomenon is the source of the influence and power of all kinds of charismatic authorities, leaders, helpers, savants, sages, or healers.  Charismatic leaders are sure of themselves, articulate in their narrative, and firm in their demeanor.  Thus medical practitioners who are perceived as wise and powerful can be of real benefit to their patients, especially if they spend time forming empathic support and then counsel sufferers regarding the steps to be taken to correct their possible faulty practices.

New medications, while often dramatic in their effectiveness for seriously mentally ill people who are resistant to psychotherapy, are unfortunately fraught with problematic side effects.  Drugs do hasten remission and then protect the sufferer from recurrence of incapacitating periodic symptoms termed psychoses (usually the presence of confusion, delusions, hallucinations, difficulties in thinking, mood swings and ineffectual discharge of daily tasks).  Unfortunately the underlying extreme temperamental components mostly remain unaffected, and they are now currently termed residual traits.  A major problem is that psychoactive medicines are not customized for each patient’s unique final functional layout.  In addition they tend to adversely affect multiple systems in the body, creating metabolic disturbances among other side effects.

Currently,for seriously ill patients , the Counseling form of psychotherapy is offered as ancillary to pharmacotherapy.  It can, when wisely practiced, provide important support by addressing faulty life styles and dietary habits that often are precipitating or accompanying causes of the patient’s misery.   Nevertheless and sadly, family physicians often do not use much-needed counseling to the extent that it deserves.Currently Drugs are massively prescribed for presenting symptoms, such as tranquilizers for anxiety, statins for high levels of cholesterol, antihypertensives for high blood pressure, and multiple medications for diabetes.  The actual precipitating causes of these conditions, now reaching epidemic proportions, are mainly the results of faulty lifestyles and habits such as overeating and lack of exercise; but these facts go unaddressed.  Instead, the allotted time of physicians with physically ailing patients is wasted addressing current regulatory requirements regarding prescribed medicines and mentioning useless “one-liner” advice as afterthoughts.  Physicians offer hurried admonitions like, “You must loose weight!” instead of providing much needed counseling that requires inspiring empathic rapport and then addressing life styles and habits with statements as simple as: “Eat three times a day only what is put in front of you; Eat slowly; Do not drink sugary sodas; and Always take a walk after meals.”  Originating from attending physicians and helpers, this simple and yet powerful approach can eventually curtail the excessive harmful overprescribing of medicines-a kind of national “Pharmacomania ” that ironically perpetuate problems instead of reversing currently nightmarish cultural trends.  This could be highly effective if done in concert nationwide, concomitantly, clearly, directly and explicitly in medical practice, the media and schools.  Similar concerted efforts succeeded dramatically to diminish cigarette smoking.  Most present practices merely perpetuate the cultural trends of faulty life styles and habits.

Structural changes in dysfunctional (including non-responsive) personality disorders can occur, often dramatically, when individuals face catastrophic events — a kind of “narcissistic Waterloo.”  It takes place when caused by events such as sudden loss of an important job, abrupt social disgrace, bankruptcy, loss of a mate, sudden imprisonment, or a horrid experience in battle.  Following such experiences, empathic therapy can effect changes in a rather dramatic way.  An ancient Greek proverb defines the phenomenon: “In a great crisis, even gods will be persuaded.”

Evolving Conditions

The zeitgeist of a society in different eras not only puts particular types of stress on individuals but also promotes expression of their distress in the form of distinct syndromes.  For example at the tail end of the Victorian era, ethnic or female individuals were oppressed with injustices, repression, or outright hypocrisy — all fertile grounds for the development of various “neuroses.”  Psychotherapy of that particular era responded with free association for relief of unnecessary guilt, resultant anxiety, depression and other symptoms, a process that was time consuming with modest positive results .

A poignant example at the end of 19th century was the appearance of many cases of “Grand Hysteria” studied in a Paris Hospital with theatrical flare by the great neurologist Charcot and observed with rapt attention by his student Sigmund Freud.  The subjects of their studies were usually victimized “street girls” who became “penitents,” displaying conversion hysteria with its dramatic effects.  Their appealing display of “helplessness” effectively solicited the interest of “helpers.”  The offered therapy was hypnosis, based upon the theory that during this induced state the subject would reveal her conflicts and be relived of the symptoms.  Such phenomena are now rare because the current zeitgeist does not promote such overt expressions, nor allows women to be victimized so egregiously.

The current social climate is one of great economic distress coupled with enormous economic disparity.  Conversely, every individual has been promoted as a kind of “ideal consumer,” entitled and eager to be a participant in the so-called American Dream — the now illusory but enduring belief that, “One of these days, you too will be wealthy and successful.”  This perhaps promotes enterprise and marketing flexibility, but the existing reality has evoked plenty of anxiety, anger, confusion, and depression.in addition ,  often confusing freedom with license, individuals are frustrated, unstructured, angry, distressed and disorderly; and they often resort to the use of violence, drugs or alcohol.  Even worse, imprisonment is all too commonplace.  The therapies offered include ego-fostering reality-oriented Cognitive Therapy, such as the 12 steps of Alcoholics Anonymous and detoxification

Current Conundrums and Debacles

The human brain in its higher functions and faculties is a host to many competing algorithms or drives that often result in internal conflict with each other.  This fact explains the emergence of frequent anguish and behavior that is against the best interest of individuals and those around them — the domain of Euripides and Shakespeare and other great storytellers of our human nature and predicament.  These endemic phenomena have been poignantly expressed in maxims, “We recruit adversities to ourselves, as if the natural allotment falling from heaven is not enough;” or, “What can a human do, being only human!”

The demand of recent cultural trends for quick relief is unfortunately also augmented by the profusion of direct advertising to consumers by pharmaceutical industries promoting use of their medications.  Usually the legally required mentions of side effects of drug use are pandered in the form of ludicrous rapid chanting incantations that completely disguise their serious significance to the listener.   Further, frequently occurring transient symptoms of dysphoria (e.g. distress, anxiety, boredom, insomnia, insecurity, and anger) are now medicalized and given billable names.   Instead of empathic counseling and advice, sufferers are tantalized with quick-cure medications of dubious effectiveness or worse, often with addictive properties that may further compromise the natural coping powers of the distressed.  Fortunately there exists at present a surging nationwide cultural trend addressing healthy habits and diet, and diverse enjoyable activities and interests.  These are the things that lead to better health and lessen the occurrence of unnecessary suffering, resulting in a life worth living.  Meanwhile for severely mentally ill patients, promising new interventions such as deep magnetic stimulation, as well “rebooting” the brain -as the very effective Electroshock Therapy  does – perhaps by  inputing appropriate electronic signal  to the malfunctioning brain. Thus, bypassing the problematic side effects and gruesome esthetics of the electroconvulsive therapy- all  offer hope for relief from severe psychic suffering and incapacity

Nichols Pediaditakis MD DLFAPA

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