Life, Art, and Therapy - To the Best of Our Knowledge

This week on NPR's To the Best of Our Knowledge, the topic is psychoanalysis - whatever happened to it? Sadly, the question they ask refers more to Freudian psychoanalysis, and not any of the relational, object-relations, or intersubjective systems models that have emerged from the charred remains of Freudian analysis over the last several decades (beginning especially with the object-relations school in England and Kohut's Self Psychology in the U.S.).

Still, there is some interesting stuff here.

Life, Art, and Therapy

07.27.2014

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Whatever happened to psychoanalysis? It used to be the most influential science of the mind, but today its founder, Sigmund Freud, just looks like a sex-obsessed old man. Analyst Adam Phillips says we got Freud all wrong; he remains a radical thinker if we know how to read him. This hour explores the connections between therapy and art.

Guest(s):

• Adam Phillips
• Erin Clune
• Alison Bechdel
• Alain de Botton
• Nic Pizzolatto
• James McBride

Producer(s): Steve Paulson
Related Link(s):

• Alain de Botton's website
• James McBride's website

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Chapters:

Rethinking Freud - Adam Phillips

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Extended Interview

Psychoanalyst Adam Phillips says we've gotten Freud all wrong. He wasn't a scientist; he was a great writer and countercultural figure. And his insights still have the power to dazzle us.

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Growing Up Freudian - Erin Clune

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What's it like to grow up with a mom who's a Freudian therapist? Commentator Erin Clune has a few personal observations.

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Cartooning & Psychotherapy - Alison Bechdel

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Extended Interview

Acclaimed cartoonist Alison Bechdel has written two brutally honest memoirs about her parents. She tells Steve Paulson about her complicated relationship with her mother and how it inspired her as an artist.

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Art as Therapy - Alain de Botton

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Maybe you're familiar with art therapy - making art to cope with pain. Philosopher Alain de Botton has a different idea. He thinks just looking at great art can be therapeutic.

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BookMark: Nic Pizzolatto

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"True Detective" creator and writer Nic Pizzolatto recommends "Absalom, Absalom" by William Faulkner.

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On Our Minds: James McBride

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James McBride won the National Book Award for "The Good Lord Bird," his novel about the abolitionist John Brown. He explains why he doesn't like most fictional portraits of slavery and how he tried to tell a different story.

* * *

Related Books:


Becoming Freud
(Adam Phillips)


Are You My Mother?
(Alison Bechdel)

Art as Therapy
(Alain de Botton, John Armstrong)


The Good Lord Bird
(James McBride) 

Nancy McWilliams PhD is a seminal figure in contemporary psychoanalytic circles. Two her books, Psychoanalytic Diagnosis, Second Edition: Understanding Personality Structure in the Clinical Process (1994; 2nd ed. 2011), and Psychoanalytic Psychotherapy: A Practitioner’s Guide (2004) were used in the 2 1/2 year training I did in psychoanalytic psychotherapy (focused on Self Psychology and intersubjective theory). I regularly consult the Psychodynamic Diagnostic Manual (2006) when I want to better understand the etiology of specific behavioral adaptations. She is also author of Psychoanalytic Case Formulation (1999).

I was glad to stumble upon this podcast!

Shrink Rap Radio #376 – A Psychodynamic Understanding of Personality Structure with Nancy McWilliams PhD

A psychology podcast by David Van Nuys, Ph.D.
copyright 2013: David Van Nuys, Ph.D.



Posted on November 7, 2013

Nancy McWilliams PhD, who teaches at the Graduate School of Applied & Professional Psychology at Rutgers, the State University of New Jersey, is author of Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (1994, rev. ed. 2011), Psychoanalytic Case Formulation (1999), and Psychoanalytic Psychotherapy: A Practitioner’s Guide (2004), all with Guilford Press, and is Associate Editor of the Psychodynamic Diagnostic Manual (2006). She is Past President of the Division of Psychoanalysis (39) of the American Psychological Association and is on the editorial board of Psychoanalytic Psychology.

Recipient of many awards, Dr. McWilliams specializes in psychoanalytic psychotherapy and supervision; the relationship between psychodiagnosis and treatment; alternatives to DSM diagnostic conventions; integration of feminist theory and psychoanalytic knowledge; the application of psychoanalytic understanding to the problems of diverse clinical populations; altruism; narcissism; and trauma and dissociative disorders.

Podcast: Play in new window | Download

Check out the following Psychology CE Courses based on listening to Shrink Rap Radio interviews:

• Jungian Psychotherapy Part 1 (6 CEUs)
• Jungian Psychotherapy Part 2 (7 CEUs)
• Jungian Psychotherapy Part 3 (7 CEUs)
• Jungian Psychotherapy Part 4 (6 CEUs)
• Jungian Psychotherapy Part 5 (7 CEUs)
• Jungian Psychotherapy Package of the Five Above (33 CEUs)
• Wisdom of The Dream (4 CEUs)
• Positive Psychology (6 CEUs)
• Pros and Cons of Positive Psychology (5 CEUs)
• CERTIFICATE PROGRAM IN POSITIVE PSYCHOLOGY (32 CEUs)
• Body-Mind: Goodbye to Dualism (6 CEUs)
• Brain: Insights from Neuroscience (8 CEUs)
• Meditation & Psychotherapy (8 CEUs)
• Insights from Neuroscience (8 CEUs)
• Neuroscience and Healing (8 CEUs)

• Get our iPhone/Android app!
• Get 10% discount on all lectures at The JungPlatform using our discount code: DRDAVE

Bessel van der Kolk is one of the major figures in the conception and treatment of trauma and post-traumatic stress. Among his many books are Traumatic Stress: The Effects of Overwhelming Experience on the Mind, Body and Society (2006), Psychological Trauma (1987), and Overcoming Trauma through Yoga: Reclaiming Your Body (2011).

On last week's On Being (NPR), Krista Tippett talks with van der Kolk about some of the newer body-centered approaches to treating trauma and traumatic stress.

Restoring the Body: Bessel van der Kolk on Treating Trauma with Yoga, EMDR, and Healing Therapies

July 11, 2013

Human memory is a sensory experience says psychiatrist Bessel van der Kolk. Through his longtime research and innovation in trauma treatment, he shares what he's learning how bodywork like yoga or eye movement therapy can restore a sense of goodness and safety. And what he’s learning speaks to a resilience we can all cultivate in the face of the overwhelming events that after all make up the drama of culture, of news, of life.

• Listen: Radio Show/Podcast (mp3, 51:23)

• Unedited Interview: Bessel van der Kolk (mp3, 79:05)

Voices on the Radio

Bessel van der Kolk is Medical Director of the Trauma Center at the Justice Resource Institute in Brookline, Massachusetts. He’s also Professor of Psychiatry at Boston University Medical School. His books include Traumatic Stress: The Effects of Overwhelming Experience on the Mind, Body and Society and Overcoming Trauma through Yoga: Reclaiming Your Body.

Production Credits

• Host/Executive Producer: Krista Tippett
• Senior Editor: Trent Gilliss
• Senior Producer: David McGuire
• Technical Director: Chris Heagle
• Coordinating Producer: Stefni Bell

Pertinent Posts from the On Being Blog

Beyond PTSD to "Moral Injury"

For service members returning home from combat, PTSD diagnoses are commonplace and extensive. But one VA psychologist argues that the complications of PTSD compound to create a moral injury — one that requires a community, not a clinic, in order to heal.

Refugee Yoga in Beirut

Can a yoga class really make a difference in the midst of a war zone? Emily O'Dell on finding our way home.

Nature in Our Backyards: Healing Places, Sacred Spaces

Folks continue to gift us with picturesque images of their physical sanctuaries and healing spaces. The common themes? Home and nature.

Drama Therapy on All in the Mind

From Australia's All in the Mind podcast, Lynne Malcolm author and psychologist Robert Landry, actress Rebecca Nelson, and actress Helen Morse about drama therapy and the transformative power of dramatic performance to heal.

Drama Therapy

• Listen now
• Download audio
• show transcript

Sunday 9 June 2013

IMAGE: THE LATE CARIS CORFMAN BEFORE HER BRAIN TUMOUR

Ever thought about what happens in the brains of actors and the audience during a theatrical performance? We hear about the therapeutic power of drama—and the story of how one actress, who lost her short term memory as the result of a brain tumour, found new meaning by writing and performing her own one-woman show.

IMAGE: CARIS CORFMAN BACKSTAGE (MICHAEL FALCO)

IMAGE: CARIS' ONE WOMAN SHOW (MICHAEL FALCO)

IMAGE: HELEN MORSE (JEFF BUSBY)

IMAGE: HELEN MORSE IN SUNDOWNER (JEFF BUSBY)

Guests

Robert Landy, Professor of Educational Theatre and Applied Psychology, New York University

Rebecca Nelson, New York actress, Co-director of film "Caris' Peace" with Gaylen Ross, Friend of Caris Corfman

Helen Morse, Award winning Australian actress, plays Peggy in the play "Sundowner"

Publications

Drama Therapy: Concepts, Theories, and Practices

Robert J.Landy

Films

Caris' Peace directed by Gaylen Ross & Rebecca Nelson

Homepage: http://www.imdb.com/title/tt1047450/

Further Information

Robert J. Landy NYU

Sundowner production details

Presenter: Lynne Malcolm

Most studies one reads on depression are examining the benefits or effects of antidepressant medications on depression, and sometimes they even analyze the added benefits of medication with psychotherapy (usually CBT).

In this new study from PLos MED, researchers looked at how seven different types of "talk therapy" (interpersonal psychotherapy, behavioural activation, cognitive behavioural therapy, problem solving therapy, psychodynamic therapy, social skills training and supportive counselling) and how they impact subjective experience of depression. According to the study, they all performed equally well:  "Overall, we found that different psychotherapeutic interventions for depression have comparable, moderate-to-large effects."

That's good news for those who would rather not deal with the troubling and sometimes disabling side effects of antidepressant medications.

On a related side note there are several studies suggesting that psychodynamic/psychoanalytic therapy continues to decrease symptoms and increase well-being even after leaving therapy (Jonathan Shedler, [2009], The Efficacy of Psychodynamic Psychotherapy). This would seem to give an advantage to that form of therapy over the other six used in the study.

Full Citation:
Barth J, Munder T, Gerger H, Nüesch E, Trelle S, et al. (2013). Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis. PLoS Med 10(5): e1001454. doi:10.1371/journal.pmed.1001454

Different Types of Psychotherapy Have Similar Benefits for Depression

May 28, 2013 — Treatments for depression that don't involve antidepressant drugs but rather focus on different forms of talking therapy (referred to as psychotherapeutic interventions) are all beneficial, with no one form of therapy being better than the others, according to a study by international researchers published in this week's PLOS Medicine.

These findings are important as they suggest that patients with depression should discuss different forms of non-drug therapy with their doctors and explore which type of psychotherapy best suits them.

The researchers, led by Jürgen Barth from the University of Bern in Switzerland, reached these conclusions by reviewing 198 published studies involving over 15,000 patients receiving one of seven types of psychotherapeutic intervention: Interpersonal psychotherapy, behavioural activation, cognitive behavioural therapy, problem solving therapy, psychodynamic therapy, social skills training and supportive counselling (definitions of each type of therapy are below). The authors compared each of the therapies with each other and with a control -- patients on a waiting list or continuing usual case -- and combined the results.

The authors found that all seven therapies were better at reducing symptoms of depression than waiting list and usual care and that there were no significant differences between the different types of therapy. They also found that the therapies worked equally well for different patient groups with depression, such as for younger and older patients and for mothers who had depression after having given birth. Furthermore, the authors found no substantial differences when comparing individual with group therapy or with face-to-face therapy compared with internet-based interactions between therapist and patient.

The authors say: "We found evidence that most of the seven psychotherapeutic interventions under investigation have comparable effects on depressive symptoms and achieve moderate to large effects vis-à-vis waitlist."

They continue: "All seven psychotherapeutic interventions achieved a small to moderate effect compared to usual care."

The authors add: "Overall, we found that different psychotherapeutic interventions for depression have comparable, moderate-to-large effects."

Notes:

"Interpersonal psychotherapy" is short and highly structured, using a manual to focus on interpersonal issues in depression.

"Behavioral activation" raises the awareness of pleasant activities and seeks to increase positive interactions between the patient and his or her environment.

"Cognitive behavioural therapy" focuses on a patient's current negative beliefs, evaluates how they affect current and future behaviour, and attempts to restructure the beliefs and change the outlook. "Problem solving therapy" aims to define a patient's problems, propose multiple solutions for each problem, and then select, implement, and evaluate the best solution.

"Psychodynamic therapy" focuses on past unresolved conflicts and relationships and the impact they have on a patient's current situation.

In "social skills therapy," patients are taught skills that help to build and maintain healthy relationships based on honesty and respect.

"Supportive counselling" is a more general therapy that aims to get patients to talk about their experiences and emotions and to offer empathy without suggesting solutions or teaching new skills.

Funding: This research was supported by a Swiss National Science Foundation Grant (no. 105314-118312/1) awarded to JB, HJZ, and PJ.

Here is the beginning of the source research article:

Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis

Jürgen Barth, Thomas Munder, Heike Gerger, Eveline Nüesch, Sven Trelle, Hansjörg Znoj, Peter Jüni, Pim Cuijpers

Abstract

Background

Previous meta-analyses comparing the efficacy of psychotherapeutic interventions for depression were clouded by a limited number of within-study treatment comparisons. This study used network meta-analysis, a novel methodological approach that integrates direct and indirect evidence from randomised controlled studies, to re-examine the comparative efficacy of seven psychotherapeutic interventions for adult depression.

Methods and Findings

We conducted systematic literature searches in PubMed, PsycINFO, and Embase up to November 2012, and identified additional studies through earlier meta-analyses and the references of included studies. We identified 198 studies, including 15,118 adult patients with depression, and coded moderator variables. Each of the seven psychotherapeutic interventions was superior to a waitlist control condition with moderate to large effects (range d = −0.62 to d= −0.92). Relative effects of different psychotherapeutic interventions on depressive symptoms were absent to small (range d = 0.01 to d = −0.30). Interpersonal therapy was significantly more effective than supportive therapy (d = −0.30, 95% credibility interval [CrI] [−0.54 to −0.05]). Moderator analysis showed that patient characteristics had no influence on treatment effects, but identified aspects of study quality and sample size as effect modifiers. Smaller effects were found in studies of at least moderate (Δd = 0.29 [−0.01 to 0.58]; p = 0.063) and large size (Δd = 0.33 [0.08 to 0.61]; p = 0.012) and those that had adequate outcome assessment (Δd = 0.38 [−0.06 to 0.87]; p = 0.100). Stepwise restriction of analyses by sample size showed robust effects for cognitive-behavioural therapy, interpersonal therapy, and problem-solving therapy (all d>0.46) compared to waitlist. Empirical evidence from large studies was unavailable or limited for other psychotherapeutic interventions. 

Conclusions

Overall our results are consistent with the notion that different psychotherapeutic interventions for depression have comparable benefits. However, the robustness of the evidence varies considerably between different psychotherapeutic treatments.

Editors' Summary

Background

Depression is a very common condition. One in six people will experience depression at some time during their life. People who are depressed have recurrent feelings of sadness and hopelessness and might feel that life is no longer worth living. The condition can last for months and often includes physical symptoms such as headaches, sleeping problems, and weight gain or loss. Treatment of depression can include non-drug treatments (psychotherapy), antidepressant drugs, or a combination of the two. Especially for people with mild or intermediate depression, psychotherapy is often considered the preferred first option. Psychotherapy describes a range of different psychotherapies, and a number of established types of psychotherapies have all shown to work for at least some patients.

Why Was This Study Done?

While it is broadly accepted that psychotherapy can help people with depression, the question of which type of psychotherapy works best for most patients remains controversial. While many scientific studies have compared one psychotherapy with control conditions, there have been few studies that directly compared multiple treatments. Without such direct comparisons, it has been difficult to establish the respective merits of the different types of psychotherapy. Taking advantage of a recently developed method called “network meta-analysis,” the authors re-examine the evidence on seven different types of psychotherapy to see how well they have been shown to work and whether some work better than others.

What Did the Researchers Do and Find?

The researchers looked at seven different types of psychotherapy, which they defined as follows. “Interpersonal psychotherapy” is short and highly structured, using a manual to focus on interpersonal issues in depression. “Behavioral activation” raises the awareness of pleasant activities and seeks to increase positive interactions between the patient and his or her environment. “Cognitive behavioral therapy” focuses on a patient's current negative beliefs, evaluates how they affect current and future behavior, and attempts to restructure the beliefs and change the outlook. “Problem solving therapy” aims to define a patient's problems, propose multiple solutions for each problem, and then select, implement, and evaluate the best solution. “Psychodynamic therapy” focuses on past unresolved conflicts and relationships and the impact they have on a patient's current situation. In “social skills therapy,” patients are taught skills that help to build and maintain healthy relationships based on honesty and respect. “Supportive counseling” is a more general therapy that aims to get patients to talk about their experiences and emotions and to offer empathy without suggesting solutions or teaching new skills.

The researchers started with a systematic search of the medical literature for relevant studies. The search identified 198 articles that reported on such clinical trials. The trials included a total of 15,118 patients and compared one of the seven psychotherapies either with another one or with a common “control intervention”. In most cases, the control (no psychotherapy) was deferral of treatment by “wait-listing” patients or continuing “usual care.” With network meta-analysis they were able to summarize the results of all these trials in a meaningful way. They did this by integrating direct comparisons of several psychotherapies within the same trial (where those were available) with indirect comparisons across all trials (using no psychotherapy as a control intervention).

Based on the combined trial results, all seven psychotherapies tested were better than wait-listing or usual care, and the differences were moderate to large, meaning that the average person in the group that received therapy was better off than about half of the patients in the control group. When comparing the therapies with each other, the researchers saw small or no differences, meaning that none of them really stood out as much better or much worse than the others. They also found that the treatments worked equally well for different patient groups with depression (younger or older patients, or mothers who had depression after having given birth). Similarly, they saw no big differences when comparing individual with group therapy, or person-to-person with internet-based interactions between therapist and patient.

However, they did find that smaller and less rigorous studies generally found larger benefits of psychotherapies, and most of the studies included in the analysis were small. Only 36 of the studies had at least 50 patients who received the same treatment. When they restricted their analysis to those studies, the researchers still saw clear benefits of cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy, but not for the other four therapies.

What Do these Findings Mean?

Similar to earlier attempts to summarize and make sense of the many study results, this one finds benefits for all of the seven psychotherapies examined, and none of them stood as being much better than some or all others. The scientific support for being beneficial was stronger for some therapies, mostly because they had been tested more often and in larger studies.

Treatments with proven benefits still do not necessarily work for all patients, and which type of psychotherapy might work best for a particular patient likely depends on that individual. So overall this analysis suggests that patients with depression and their doctors should consider psychotherapies and explore which of the different types might be best suited for a particular patient.

The study also points to the need for further research. Whereas depression affects large numbers of people around the world, all of the trials identified were conducted in rich countries and Western societies. Trials in different settings are essential to inform treatment of patients worldwide. In addition, large high-quality studies should further explore the potential benefits of some of therapies for which less support currently exists. Where possible, future studies should compare psychotherapies with one another, because all of them have benefits, and it would not be ethical to withhold such beneficial treatment from patients. 

Additional Information

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1​001454.

• The US National Institute of Mental Health provides information on all aspects of depression (in English and Spanish); information on psychotherapy includes information on its most common forms
• The UK National Health Service Choices website also provides detailed information about depression and includes personal stories about depression
• The UK nonprofit Mind provides information on depression, including an explanation of the most common psychotherapies in the UK
• MedlinePlus provides links to other resources about depression (in English and Spanish)
• The UK nonprofit healthtalkonline.org has a unique database of personal and patient experiences on depression

Citation: Barth J, Munder T, Gerger H, Nüesch E, Trelle S, et al. (2013) Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis. PLoS Med 10(5): e1001454. doi:10.1371/journal.pmed.1001454

Competing interests: PJ is an unpaid member of steering group or executive committee of trials funded by Abbott Vascular, Biosensors, Medtronic and St. Jude Medical. CTU Bern, which is part of the University of Bern, has a staff policy of not accepting individual honoraria or consultancy fees. However, CTU Bern is involved in design, conduct, or analysis of clinical studies funded by Abbott Vascular, Ablynx, Amgen, AstraZeneca, Biosensors, Biotronic, Boehrhinger Ingelheim, Eisai, Eli Lilly, Exelixis, Geron, Gilead Sciences, Nestlé, Novartis, Novo Nordisc, Padma, Roche, Schering-Plough, St. Jude Medical, and Swiss Cardio Technologies. The other authors declare that no competing interests exist.

Abbreviations: ACT, behavioural activation; CBASP, cognitive behavioural-analysis system of psychotherapy; CBT, cognitive-behavioural therapy; CI, confidence interval; CrI, credibility interval; d, effect size; D, Somer's D; DYN, psychodynamic therapy; ES, d effect size; IPT, interpersonal therapy; k, number of comparisons; M, mean; p, p-value; PLA, placebo; PST, problem solving therapy; SD, standard deviation; SST, social skills training; SUP, supportive counselling; UC, usual care; WL, wait-list; T2, tau square

MDMA has been shown to improve the symptoms of post-traumatic stress disorder, so why not social anxiety as well?

Ecstasy-Assisted Therapy for Social Anxiety?

By TRACI PEDERSEN Associate News Editor
Reviewed by John M. Grohol, Psy.D. on May 26, 2013

The FDA recently approved a novel study that will examine whether the drug ecstasy could be of benefit to autistic adults suffering from social anxiety.

Ecstasy, known scientifically as N-methyl-3,4-methylenedioxyamphetamine (MDMA) has a reputation as a raver’s drug of choice and, in 1985, was classified as a Schedule I controlled substance — a category reserved for dangerous drugs with no medical value.

The drug, however, has been of interest to researchers who believe it could aid in psychotherapy.

Known for its “empathogenic effects,” MDMA has been shown to reduce the fear of emotional harm while promoting feelings of social connection. MDMA also produces a sense of euphoria and mild hallucinations.

Although “street ecstasy” often contains dangerous contaminants, the researchers believe using pure MDMA in a controlled setting could help certain patients.

“The study could start enrolling subjects in several months,” said Brad Burge, the communications director at Multidisciplinary Association for Psychedelic Studies.

“However, it could be six months or more depending on how long the [Institutional Review Board] review process takes, how long it takes to set up the study site at the Harbor-UCLA Medical Center/Los Angeles Biomedical Research Institute, how long it takes to recruit subjects, and other factors. I estimate it will be four to eight months.”

The study would investigate the safety and therapeutic potential of MDMA-assisted therapy for treating social anxiety in 12 autistic adults.

“This study will be the first time MDMA-assisted therapy has been explored in a clinical trial for social anxiety, and the first time it’s been explored to help adults on the autism spectrum,” Burge said.

“The many case reports collected by study co-investigator Alicia Danforth in her recently submitted doctoral dissertation indicate that it is likely to provide at least some benefit.”

“Existing research also shows that MDMA is safe enough for use in clinical research,” he added. “It’s a promising area of research, and indicates a real shift in how the public sees MDMA and other psychedelics.”

The FDA concluded that the study was “reasonably safe to proceed as currently written,” but also offered some safety recommendations.

A similar study found that MDMA could help those suffering from post-traumatic stress disorder.

One rape survivor reported that the drug helped her cope with trauma by allowing her to “control where I was thinking and going, and look at things differently.”

Source: Multidisciplinary Association for Psychedelic Studies

Kathryn Schulz - The Self in Self-Help

From New York Magazine's's special issue on self-help, this is a very interesting article on the challenges of trying to help a self that most neuroscientists (and Buddhists) do not even believe to be real.

Schulz looks at the literature of self-help as well as the philosophical tradition up through the present in her attempt to identify what this self is that so many of us are trying to help.

The Self in Self-Help

We have no idea what a self is. So how can we fix it?

By Kathryn Schulz
Published Jan 6, 2013

Alex Prager (Photo: Asger Carlsen/CASEY)

In The Age of Anxiety, W.H. Auden observed that we human beings never become something without pretending to be it first. The corollary is more prosaic but, regrettably, at least as true: We humans never become most of the things we pretend we will someday be. Nevertheless, last Monday, you and I and several billion other incorrigible optimists raised our glasses and toasted all the ways we will be different in 2013.

It’s easy to understand why we want to be different. We are twenty pounds overweight; we are $20,000 in debt; we can’t believe we slept with that guy; we can’t believe we didn’t. What’s harder to understand is why transforming ourselves is so difficult. Changing other people is notoriously hard; the prevailing wisdom on that one is Don’t hold your breath. But it’s not obvious why changing oneself should present any difficulty at all. And yet, demonstrably, it does.

The noted self-help guru Saint Augustine identified this problem back in the fourth century A.D. In his Confessions, he records an observation: “The mind gives an order to the body and is at once obeyed, but when it gives an order to itself, it is resisted.” I cannot improve upon Augustine’s insight, but I can update his examples. Say you want to be skinny. You’ve signed on with Weight Watchers, taken up Zumba, read everything from Michael Pollan to French Women Don’t Get Fat, and scrupulously recorded your every workout, footstep, and calorie on your iPhone. So whence the impulsive Oreo binge? Or say you are a self-identified co-dependent. You know your Melody ­Beattie, listen to your therapist, and tell yourself every morning, quite firmly, just what you will and will not do that night. So what are you doing back in bed with that man? Or say you are a professional writer who values being conscientious, respects her editors, and passionately believes that good writing requires time. So—well, let’s drop the pretense. Why am I sitting here typing this at 4 a.m., two days past deadline?

I don’t know, but misery loves company, and such acts of auto-insubordination happen all the time. They go some way toward explaining the popularity of the self-help movement, since clearly we need help, but they also reveal a fundamental paradox at its heart. How can I want to achieve a goal so badly that I will expend considerable time, energy, and money trying to reach it while simultaneously needing to be coaxed, bribed, tricked, and punished into a compliance that is inconsistent at best?

This is where the cheerfully practical and accessible domain of self-help bumps up against one of the thorniest problems in all of science and philosophy. In the 1,600 years since Augustine left behind selfhood for sainthood, we’ve made very little empirical progress toward understanding our own inner workings. We have, however, developed an $11 billion industry dedicated to telling us how to improve our lives. Put those two facts together and you get a vexing question: Can self-help work if we have no idea how a self works?

~ ~ ~ ~ ~

I know people who wouldn’t so much as walk through the self-help section of a bookstore without The Paris Review under one arm and a puzzled oh-I-thought-the-bathroom-was-over-here look on their face. I understand where they’re coming from, since some of the genre’s most persistent pitfalls—charlatanism, cheerleading, bad science, silver bullets, New Age hoo-ha—are my own personal peanut allergies: deadly even in tiny ­doses. And yet I don’t share the contempt for self-help, not least because I have sought succor there myself. The first time was for writer’s block—which is, I realize, a rarefied little issue, sort of the artisanal pickle of personal problems. (I got over it: QED.) The second time was for its very nasty older brother, depression—of which more anon. In both cases, I ventured into the self-help section for the usual reason: the help. Last month, though, I went back to investigate the other half of the equation: the self.

If, like me, you have read your way through sober Stephen R. Covey (The 7 Habits of Highly Effective People) and godly Norman Vincent Peale (The Power of Positive Thinking), through exuberant Tony Robbins (Unleash the Power Within) and ridiculous Rhonda Byrne (The Secret), through John Gray who Is From Mars and Timothy Ferriss who has a four-hour everything and Deepak Chopra who at this point really is one with the universe (65 books and counting)—anyway, if you, too, have reckoned with the size and scope of the self-help movement, you probably share my initial intuition about what it has to say about the self: lots. It turns out, though, that all that surface noise is deceptive. Underneath what appears to be umptebajillion ideas about who we are and how we work, the self-help movement has a startling paucity of theories about the self. To be precise: It has one.

Let us call it the master theory of self-help. It goes like this: Somewhere below or above or beyond the part of you that is struggling with weight loss or procrastination or whatever your particular problem might be, there is another part of you that is immune to that problem and capable of solving it for the rest of you. In other words, this master theory is fundamentally dualist. It posits, at a minimum, two selves: one that needs a kick in the ass and one that is capable of kicking.

This model of selfhood is intuitively appealing, not least because it describes an all-too-familiar experience. As I began by saying, all of us struggle to keep faith with our plans and goals, and all of us can envision better selves more readily than we can be them. Indeed, the reason we go to the self-help section in the first place is that some part of us wants to do something that some other part resists.

Of course, intuitive appeal is a poor indicator of the merits of a model; the geocentric universe is intuitively appealing, too. But even though this master theory of self-help is coarse, misleading, none too useful, and probably just plain wrong, it does capture something crucial about the experience of being human. One of the strange and possibly unique facts about our species is that we really can intervene on ourselves. Get a lab rat addicted to alcohol and you will have yourself an addicted rat. Get a teenager addicted to alcohol and eventually you might find yourself celebrating his 30th year of sobriety. It isn’t consistent, it isn’t predictable, and God knows it isn’t easy—and yet somehow, sometimes, we do manage to change. The self really can help itself. The question is: How?

~ ~ ~ ~ ~

Master theories—of self-help or anything else—don’t really answer questions like that. Instead, they dictate the shape an answer must take. Consider, for example, the way language works. En­glish is a subject-verb-object language, meaning that the sentences we produce must all conform to that grammatical pattern. Within that constraint, however, the number of sentences we can generate is infinite: “We have not yet begun to fight.” “A screaming came across the sky.” “I’m intercontinental when I eat French toast.” The master rule controls the form, but it’s completely agnostic about the content.

So too with the master theory of self-help: It mandates a conflict between two parts of the self, but beyond that, it makes no particular demands and answers no particular questions. Who is divided against whom, who has the power and who is powerless, how to ensure that the “right” part of yourself winds up in charge: All this is up for grabs. Accordingly, self-help strategies distinguish themselves from one another—and pledge to solve your problems—by carving up the self at different joints: a mind and a brain, a consciousness and an unconscious, an evolved self and a primitive self—you get the picture. Such distinctions inevitably reflect different beliefs about what kind of creatures we are and often reflect different beliefs about our place in the universe. That makes them philosophically interesting—but, alas, it does not make them particularly useful.

To see why not, consider two examples. In self-help programs that draw on religious or spiritual practices, the locus of control is largely externalized; the real power belongs to God (or a supreme being, a universal consciousness—whatever you care to call it). But these programs also posit a part of the self that is receptive to or one with that external force: an internal fragment of the divine that can triumph over human weakness.

This is pretty much the oldest kind of dualism in the book: your sacred soul against your mortal flesh. You can see it at work in 12-step programs, where addicts begin by admitting they are powerless to control their addiction and then make “a decision to turn our will and our lives over to the care of God.” But think about that for a moment: How do recovering addicts simultaneously exercise and abdicate their right to make decisions? How do they choose to let a higher power do the choosing—not just once but every time temptation comes along? Twelve-step programs are reputed to be one of the more effective ways to treat addiction, yet how their followers pull off this sleight-of-self remains a mystery.

Now consider what seems, at first, like a completely different model of selfhood. “Everything you and I do, we do either out of our need to avoid pain or our desire to gain pleasure,” Tony Robbins writes in Awaken the Giant Within. Robbins’s vision of the self is Skinnerian rather than spiritual: We are conditioned, like dogs to a whistle or unluckier dogs to a kick, to certain habits of thought and action. How, then, are we supposed to change? “The most effective way,” he tells us, is to “get your brain to associate massive pain to the old belief.”

Well, wait a second: Who is the “you” who gets “your brain” to rewire, and how does it do so? Through “the power of decision,” Robbins says, which “gives you the capacity to get past any excuse to change any and every part of your life in an instant.” But if we are creatures of conditioning, how did this one part of ourselves remain independent? Where did it hide while we were being conditioned, and how will it emerge, and by what mechanism will it make decisions for the rest of us?

You see the problem. The self-help movement seeks to account for and overcome the difficulties we experience when we are trying to make a desired change—but doing so by invoking an immortal soul and a mortal sinner (or an ego and an id, a homunculus and its minion) is not much different from saying that we “are of two minds,” or “feel torn,” or for that matter that we have a devil on one shoulder and an angel on the other. These are not explanations for the self. They are metaphors for the self. And metaphors, while evocative and illuminating, do not provide concrete causal explanations. Accordingly, they are not terribly likely to generate concrete solutions. True, self-help literature is full of good advice, but good advice is not the issue; most of it has been around for centuries. The issue is how to implement it. In the words of the emphasis-happy Robbins, “Lots of people know what to do, but few people actually do what theyknow.”

When it comes to solving that problem—which is the problem—all self-help literature offers is a kind of metaphysical power of attorney for our putative better halves. But if you identify with the above-mentioned Oreo-eater or healthy-­relationship saboteur or procrastinator, you yourself are evidence that this is a nonsolution. If giving your better half executive control by fiat could change your life, sales of self-help material would plummet overnight. It is a somewhat beautiful fact that the underlying theory of the self-help industry is contradicted by the self-help industry’s existence.

~ ~ ~ ~ ~

But, in the spirit of being a better person, I should not be so hard on self-help. The fact is, selves are profoundly difficult to understand. “There is nothing that we know more intimately than conscious experience,” the contemporary philosopher David Chalmers observes, “but there is nothing that is harder to explain.”

Part of why we can’t explain the self is that we can’t even find it. Here’s William James, an exceptionally acute internal observer, giving it a try. “My present Me is felt with warmth and intimacy,” he wrote in Psychology: Briefer Course.“The heavy warm mass of my body is there, and the nucleus of the ‘spiritual me,’ the sense of intimate activity is there. We cannot realize our present self without simultaneously feeling one or other of these two things.” That was as close as James ever got to figuring out how to find a self: on the basis of a warm fuzzy feeling, emphasis on fuzzy.

David Hume, meanwhile, couldn’t find himself at all. “When I enter most intimately into what I call myself,” he wrote, “I always stumble on some particular perception or other, of heat or cold, light or shade, love or hatred, pain or pleasure. I never can catch myself at any time without a perception, and never can observe any thing but the perception.” If there was an essential “I” beneath all that, Hume couldn’t find it. Ultimately, he proposed that it doesn’t exist—that we are not sum, only parts: “nothing but a bundle or collection of different perceptions.” That idea poses a major problem for the master theory of self-help, with its internal governor, its you ex machina.Apparently, self-help has assigned the lead part in our show to an actor who is nowhere to be found.

Nor has science made much progress in locating the self, let alone explaining it. These days, most people who study the mind believe that our sense of having an “I” somehow arises from cognitive processes like the ones Hume described. That rules out Descartes’s theory that our inner essence was rooted in the pineal gland, but it still leaves us intellectual light-years from anything like a fully developed scientific theory of the self. To put the problem in perspective, consider that, three centuries after Isaac Newton pioneered the study of optics, vision scientists are just starting to understand how our brain handles the problem of recognizing faces. Those discoveries are interesting and admirable on their own merits. But it is a very long way—probably many more centuries—from understanding how the mind sees faces to understanding how the mind sees itself. In the meantime, perhaps we should start looking beyond the constraints of the master theory of self—and, indeed, beyond the self entirely—for ways to improve our lives.

~ ~ ~ ~ ~

The expression “self-help” comes from a book of that name, published in 1859 by the great-grandfather of the modern movement, one Samuel Smiles. (I kid you not.) These days, the phrase is so commonplace that we no longer hear the ideology implicit in it. But there is one: We are here to help ourselves, not to get help from others nor lend it to them. Unlike his contemporary Charles Dickens, Smiles was unmoved by appalling social conditions; on the contrary, he regarded them as a convenient whetstone on which to hone one’s character. As a corollary, he did not believe that altering the structure of society would improve anyone’s lot. “No laws, however stringent, can make the idle industrious, the thriftless provident, or the drunken sober,” he wrote. “Such reforms can only be effected by means of individual action, economy, and self-­denial; by better habits, rather than by greater rights.”

Smiles was Scottish, but it makes sense that his ideas received their most enthusiastic and enduring reception in the United States: a nation founded on faith in self-governance, belief in the physics-defying power of bootstraps, and the cheery but historically anomalous conviction that we all have the right to try to be happy. But this now-ubiquitous model of self-help might do an injustice to both the source of our problems and their potential solutions. We are social creatures, and we function (and dysfunction) in context. All of us know that we are notably different from one environment (Grandma’s assisted-living facility) to the next (Pyramid Club, East Village, 3 a.m.). What none of us knows is who we would be—or could be—if our context were altered in crucial ways at critical times. It’s entirely possible that socioeconomic background and current community exert a more powerful influence over us than our ostensibly independent inner selves. In that case, the best self-improvement effort would be to better society.

The larger point is this: God knows we all need more help, but possibly we need less self. That has long been the political response to the self-help movement, and it is also, in a different sense, what Buddhists believe. Curiously, Buddhism is simultaneously a burgeoning influence on the Western self-help movement and entirely at odds with it: anti-self, and anti-help. It is anti-help insofar as it emphasizes radical self-acceptance and also insofar as it emphasizes remaining in the present. (Improvement, needless to say, requires you to focus on the future.) It is anti-self in that it treats thoughts as passing ephemera rather than as the valuable products of a distinct and consistent mind. The journalist Josh Rothman once wrote a lovely description of what a cloud really is: not an entity, as we perceive it, but just a region of space that’s cooler than the regions around it, so that water vapor entering it condenses from the cold, then evaporates again as it drifts back out. A cloud is no more a thing, Rothman concluded, than “the pool of light a flashlight makes as you shine it around a dark room.” And the self, the Buddhists would say, is no more a thing than a region of air with thoughts passing through.

I’m not just mentioning these two anti-self self-improvement measures because they appeal to me, although they do. I mention them because, when it comes to helping ourselves (and, okay, also in some other areas), I believe in heterogeneity and promiscuity. Most of the time, when we want to solve a problem, we try to eliminate hypotheses until a single one remains standing: a theory, in the scientific sense. But there’s a case to be made that we should try to increase rather than decrease the available hypotheses about helping ourselves. I’ll make that case by way of conclusion and by way of making my own small and questionable contribution to the large and questionable body of self-help advice. And since this is after all an essay about selves, I will also make it, if you’ll forgive me, by getting momentarily personal.

~ ~ ~ ~ ~

I have no idea how I got over my depression. I spent a year doing the things one does: I read Feeling Good, went to therapy, got exercise, tried to eat well in the utter absence of appetite, and routinely forced myself into sympathetic company when every particle of my being—or, I suppose, every particle but one—wanted to curl up alone in the dark. I did all these things not out of any real hope that they would work but because the failure to do them seemed like it would cede more ground to the awfulness. And then some moon in my inner universe set silently, and the awfulness went out like a tide.

The self helps itself. I know it firsthand, as well as second- and third-hand, and so do you. But none of us—no matter what anyone says to the contrary—can tell you precisely how it happens. Maybe it was the therapy, in my case. Maybe it was the running. Maybe it was David D. Burns, M.D. Maybe it was two or three or all of the above in combination. Maybe it was some slight incident I didn’t even register at the time. Maybe it was time.

Or maybe we humans change the way species do: through random variation. If that’s the case, then the strategy we’ve arrived at out of necessity might be the best one anyone could design. Try something. Better still, try everything—throw all the options at the occluding wall of the self and see what sticks. Meditation, marathon training, fasting, freewriting, hiking the Pacific Crest Trail, speed dating, volunteering, moving to Auckland, redecorating the living room: As long as you steer clear of self-harm and felony, you might as well do anything you can to your inner and outer ecosystems that might induce a beneficial mutation.

The good news is that, in my experience, this is what most of us do anyway. We sample profligately from the vast universe of hypotheses about how to improve our lives: We try organizing our desk according to David Allen, our abs according to Timothy Ferriss, our hearts according to the Buddha. We obey a command: Know thyself. And another: Forget thyself. It might not work. It might not even be how we work. But it does at least pay homage to the day-to-day, problem-to-problem, mood-to-mood complexity of being human.

The bad news is that even if you succeed with this approach, you will never truly know which specific tactic worked—even after the fact, let alone beforehand. In other words, as scientists would say, this method of self-help is an uncontrolled experiment. But so what? Life is an uncontrolled experiment: confounded, confounding, and, above all, completely impossible to replicate—tragically so, and wonderfully so. I try to remind myself of that as often as I can. Sometimes it helps.

Jonathan Shedler, PhD - Where is the Evidence for Evidence Based Therapies?

Jonathan Shedler, PhD, is somewhat of a hero of mine. He has offered the best meta-analysis and most convincing evidence available that not only is cognitive behavioral therapy (CBT) not very effective, in general (and that few CBT therapists actually practice manualized CBT), but that psychodynamic is considerably more effective in nearly every measure (see The Efficacy of Psychodynamic Psychotherapy, 2010).

He also authored That Was Then, This Is Now: Psychoanalytic Psychotherapy for the Rest of Us (2006/2010), a work-in-progress on the current state of psychoanalytic psychotherapy. For anyone who thinks psychoanalytic therapy is still about laying on a couch with the therapist acting as a "blank slate" and offering little in the way of interaction, aside from abstract interpretations, this article will get you up to speed.

If you would like a little more, see his Scientific American article, Getting to Know Me: Psychodynamic therapy has been caricatured as navel-gazing, but studies show powerful benefits (2010). This is a shorter, more accessible version of "The Efficacy of Psychodynamic Psychotherapy."

In the post below, Dr. Shedler has started what may be a multi-part series (we know there will be at least two parts) looking at the lack of evidence for the so-called evidence-based therapies, such as CBT, REBT, and so on.

Where is the Evidence for Evidence Based Therapies? 

A study from a prestigious psychology journal recently crossed my desk. It found that clinicians who provide Cognitive Behavior Therapy—including the most experienced clinicians—routinely depart from CBT techniques described in treatment manuals. “Only half of the clinicians claiming to use CBT use an approach that even approximates to CBT,” the authors wrote.

The finding is not surprising, since there is no evidence that manualized therapy leads to better outcomes, and therapists in the real world naturally adapt their approaches to the needs of individual patients. Their practice methods also evolve over time as they learn through hard-won experience what is helpful to patients and what isn’t.

In fact, studies show that when CBT is effective, it is at least in part because the more skilled practitioners incorporate methods that are fundamentally psychodynamic. These include open-ended, unstructured sessions (versus following an agenda from a manual), working with defenses, discussing the therapy relationship, and drawing connections between the therapy relationship and other relationships.

So the research finding was no surprise. Something would be seriously amiss if experienced clinicians practiced like beginners, following an instruction manual like a consumer trying to assemble a new appliance. What caught my eye was the authors’ conclusion that clinicians should be trained to adhere to CBT interventions “to give patients the best chance of recovery.”

The study did not evaluate treatment outcome, so the authors had no way of knowing which clinicians were effective or which patients got better. They just presumed, a priori, that departure from treatment manuals means poorer therapy. And this presumption—which flies in the face of actual scientific evidence—slipped right past the “evidence oriented” reviewers and editors of a top-tier research journal. They probably never gave it a second thought.

The Big Lie

Academic researchers have usurped and appropriated the term “evidence based” to refer to a group of therapies conducted according to step-by-step instruction manuals (manualized therapies). The other things these therapies have in common are that they are typically brief, highly structured, and almost exclusively identified with CBT. The term “evidence based therapy” is also, de facto, a code word for “not psychodynamic.” It seems not seem to matter that scientific evidence shows that psychodynamic therapy is at least as effective as CBT. Proponents of “evidence based therapies” tend to denigrate psychodynamic approaches (or more correctly, their stereotypes and caricatures of psychodynamic approaches). When they use the term “evidence based,” it is often with an implicit wink and a nod and the unspoken message: “Manualized treatments are Science. Psychodynamic treatment is superstition.”

Some explanation is in order, since this is not how things are usually portrayed in textbooks or psychology classes. In past decades, most therapists practiced psychodynamic therapy or were strongly influenced by psychodynamic thought. Psychodynamic therapy aims at enhancing self-knowledge in the context of a deeply personal relationship between therapist and patient.

Psychodynamic or psychoanalytic clinicians in the old days were not especially supportive of empirical outcome research. Many believed that therapy required a level of privacy that precluded independent observation. Many also believed that research instruments could not measure important treatment benefits like self-awareness, freedom from inner constraints, or more intimate relationships. In contrast, academic researchers routinely conducted controlled trials comparing manualized CBT to control groups. These manualized forms of CBT were therefore described as “empirically validated” (the preferred term later morphed into “empirically supported” and later, “evidence based”).

Research findings never suggested that manualized CBT was more effective than psychodynamic therapy. It was just more often studied in controlled trials. There is obviously a world of difference between saying that a treatment has not been extensively researched and saying it has been empirically invalidated. But academic researchers routinely blurred this distinction. A culture developed in academic psychology that promoted a myth that research had proven manualized CBT superior to psychodynamic therapy. Some academics and researchers (those with little regard for actual scientific evidence) went so far as to assert that it was unethical to practice psychodynamic therapy since research had shown CBT to be more effective. The only problem is that research showed nothing of the sort.

This may shed some light on why the authors of the study I described above could so cavalierly assert that clinicians should adhere to CBT treatment manuals to give patients the best chance of recovery—and how such an empirically false assertion could sail right through the editorial review process of a prestigious research journal.

Where is the Evidence for Evidence-based Therapies, Part 2

Stay tuned. In the next installment, I will discuss whether “evidence based therapies” help people. The answer may surprise you.

Hal Arkowitz and Scott O. Lilienfeld - Are All Psychotherapies Created Equal?

That is the big question in the world of psychotherapies - and the answer is yes and no. They are equal in so far as all good therapy is about the relationship between the therapist in the client. They are not equal in that some models do not spend much effort in building that crucial relationship.

The other part of it is that some therapies are better suited to some issues than others. There is no model that works for all issues equally.

Are All Psychotherapies Created Equal?

Certain core benefits cut across methods, but some differences in effectiveness remain

By Hal Arkowitz and Scott O. Lilienfeld

 

Image: MARIO WAGNER

As a prospective client searches for a psychotherapist, numerous questions may spring to mind. How experienced is the therapist? Has he helped people with problems like mine? Is she someone I can relate to? Yet it may not occur to clients to ask another one: What type of therapy does the clinician deliver? People often assume that the brand of therapy offered is irrelevant to the effectiveness of treatment. Is this assumption correct?

Psychologists do not agree on whether the “school” of therapy predicts its effectiveness. In a survey in 2006 by psychologists Charles Boisvert of Rhode Island College and David Faust of the University of Rhode Island, psychotherapy researchers responded to the statement that “in general, therapies achieve similar outcomes” with an average score of 6 on a 7-point scale, indicating strong agreement. In contrast, psychologists in practice averaged a rating of 4.5, signifying that they agreed only moderately with that position.

As we will discover, both camps can justify their point of view. Although a number of commonly used psychotherapies are broadly comparable in their effects, some options are less well suited to certain conditions, and a few may even be harmful. In addition, the differences among therapies in their effectiveness may depend partly on the kinds of psychological problems that clients are experiencing.
 
Tale of the Dodo Bird

At least 500 different types of psychotherapy exist, according to one estimate by University of Scranton psychologist John Norcross. Given that researchers cannot investigate all of them, they have generally concentrated on the most frequently used approaches. These include behavior therapy (altering unhealthy behaviors), cognitive-behavior therapy (altering maladaptive ways of thinking), psychodynamic therapy (resolving unconscious conflicts and adverse childhood experiences), interpersonal therapy (remedying unhealthy ways of interacting with others), and person-centered therapy (helping clients to find their own solutions to life problems).

As early as 1936, Washington University psychologist Saul Rosenzweig concluded after perusing the literature that one therapy works about as well as any other. At the time, many of the principal treatments fell roughly into the psychodynamic and behavioral categories, which are still widely used today. Rosenzweig introduced the metaphor of the Dodo Bird, after the feathered creature in Lewis Carroll's Alice in Wonderland, who declared following a race that “everyone has won, and all must have prizes.” The “Dodo Bird verdict” has since come to refer to the claim that all therapies are equivalent in their effects.

This verdict gained traction in 1975, when University of Pennsylvania psychologist Lester Luborsky and his colleagues published a review of relevant research suggesting that all therapies work equally well. It gathered more momentum in 1997, when University of Wisconsin–Madison psychologist Bruce E. Wampold and his co-authors published a meta-analysis (quantitative review) of more than 200 scientific studies in which “bona fide” therapies were compared with no treatment. By bona fide, they meant treatments delivered by trained therapists, based on sound psychological principles and described in publications. Wampold's team found the differences in the treatments' effectiveness to be minimal (and they were all better than no treatment).

One explanation for the Dodo Bird effect is that virtually all types of psychotherapy share certain core features.

Read the whole article.

Support SACASA - Survivor Support Network

The Southern Arizona Center Against Sexual Assault exists purely on grants, donations, and fundraisers - if you can help or know someone who can, we are hosting an Open House on Wednesday, September 19, from 5:30-7:00 pm.

As always, you can donate online.

We do education and outreach through our prevention program, we provide Sexual Assault Response Services for survivors in the hours following an assault, we provide crisis advocates to help those who are reaching out for help for the first time, and we provide free therapy for survivors and their loved ones (secondary survivors). We do a whole lot more than I can even list here.

Robert Stolorow - Blues, Trauma, Existential Vulnerability

Robert Stolorow is one of the co-founders of intersubjective psychoanalysis (along with Donna Orange, George Atwood, Bernard Brandchaft, and Jessica Benjamin, among others). Deeply influenced by Hume, he moved Kohut's Self Psychology into the post-modern. All of which is to say I am a huge fan.

The fact that he and his son have written an article on the therapeutic value of the blues is even better. Classic blues has always been a balm for the soul in my life - Lightnin' Hopkins, Howlin' Wolf, Blind Willie McTell, and of course, Robert Johnson.

Louisiana Red is the musician they discuss in this article - I couldn't find the exact song, but this one is hauntingly beautiful - "Blues for Ida B."

Blues, Trauma, Existential Vulnerability

The therapeutic power of the blues.

Published on April 14, 2012 by Robert D. Stolorow, Ph.D. in Feeling, Relating, Existing

"I can't stand living, but I'm scared of dying, but Old Man River, he just keeps rolling along."—Jerome Kern and Oscar Hammerstein II

[This blog was coauthored with my son, Ben Stolorow, who is a working jazz pianist performing in the San Francisco Bay Area, both as a solo artist and together with his sister Stephanie under the name “Stoli Rose”].

With roots in African music, the blues was born in the Mississippi delta as a distinctively African American musical genre in response to the de-humanizing traumas of slavery and its aftermath. It has origins in spirituals, work songs, field hollers, etc., all of which are types of music associated with enslaved people attempting to deal with their painful situation. Although blues is a uniquely African American music, it has a uniquely universal appeal. There is something in the blues, and in music with qualities that derive from the blues, that people can relate to. What are these qualities? Irrespective of whether people who relate to the blues are truly able to relate to the collective historical trauma of African Americans, there seems to be something expressed in the music that strikes an emotional chord in people from a wide range of ethnic and cultural backgrounds. What is this something? And why is the blues universally compelling? That is the mystery: that people of many different cultures respond to the blues and to the “bluesy feeling” prevalent in other music.

In this blog, we try to show that there is something about the blues that allows us to come face to face with universally traumatizing dimensions of human existence. Indeed, the music itself may be seen as a process of working through such trauma (musicians use the phrase “working it out”). How does the blues put us in touch with the universally traumatizing aspects of the human condition? We will look for answers both in the blues’ lyric aspects (such as themes of irony and the absurdity of existence) and musical qualities (such as pitch-bending and the bluesy sound produced by shifts and ambiguities between major and minor keys). First, however, we must explore the nature of emotional trauma itself.

Emotional trauma
Emotional trauma is an experience of unendurable emotional pain. In his book Trauma and Human Existence (link: http://www.psychoanalysisarena.com/trauma-and-human-existence-9780881634679) Robert Stolorow has claimed that the unbearability of emotional suffering cannot be explained solely, or even primarily, on the basis of the intensity of the painful feelings evoked by an injurious event. Emotional pain is not pathology, it is inherent to the human condition (we will have more to say about this later). Painful emotional states become unbearable when they cannot find a “relational home”—that is, a context of human understanding—in which they can be shared and held. Severe emotional pain that has to be experienced alone becomes lastingly traumatic and usually succumbs to some form of emotional numbing. In contrast, painful feelings that are held in a context of human understanding gradually become more bearable and can eventually be woven seamlessly into the fabric of whom one experiences oneself as being.

Trauma's existential significance
Having discussed emotional trauma in terms of its context-embeddedness, we turn now to its existential significance: how it is implicated in the human condition in general. Robert Stolorow has proposed that the existential meaning of emotional trauma lies in the shattering of what he calls the "absolutisms of everyday life"—the system of illusory beliefs that allow us to function in the world, experienced as stable, predictable, and safe. Such shattering is a massive loss of innocence exposing the inescapable dependence of our existence on a universe that is unstable and unpredictable and in which no safety or continuity of being can be assured. Emotional trauma brings us face-to-face with our existential vulnerability, our vulnerability to suffering, injury, illness, death, and loss, possibilities that define our existence and that loom as constant threats. Because we are limited, finite, mortal beings, trauma is a necessary and universal feature of our all-too-human condition.

The therapeutic power of the blues
The working through of painful emotional states requires a context of human understanding in which they can be held. Central to this process of helping us to bear and live in our emotional pain is the bringing of the visceral, bodily aspect of emotional experience into language. Such visceral-linguistic unities, unities of bodily sensations with words, of “gut” feelings with names, are achieved in a dialogue of emotional understanding, and it is in such dialogue that experiences of emotional trauma can be transformed into endurable and namable painful feelings. The blues are a wonderful example of such dialogue. The lyrics, of course, provide the words that name the particular experience of trauma. The more formal aspects of the music seem universally to evoke the visceral dimension of emotional pain. In the unifying experience of the blues, songwriter, performers, and listeners are joined in a visceral-linguistic conversation in which universally traumatizing aspects of human existence can be communally held and borne. In experiencing the blues, we are joined together in an experience of our existential kinship-in-the-same-darkness.

The role of lyrics
We have claimed that emotional trauma puts us in touch with our mortality: we all know that we will die, but we don’t know when. These facts about our existence evoke conflicting feelings, and such ambivalence about our mortality often plays a central part in the lyrics of the blues. As one of countless possible examples, consider the first verse of the blues song by Louisiana Red, Too Poor To Die:

"Last night I had a dream
I dream I died
The undertaker came
To carry me for the ride
I couldn't afford a coffin
Embalmin' kinda high
I jumped off my deathbed
Cause I too poor to die
I's in trouble
And I'll tell you the reason why
I'm just too poor people
I'm too poor to go lay down and die."

The absurdity of our finite, mortal existence is clearly captured in these lyrics. Louisiana Red, obviously traumatized by the suffering of poverty, anticipates his death in his dreams. But the poverty that traumatizes him renders him “too poor to go lay down and die”—he can’t afford a coffin, embalming, or in subsequent verses, gravediggers, or to grease the devil’s palm—so he jumps off his deathbed and evades death. In a twist of tragic irony, the very same poverty that puts him in touch with his mortality provides him with the means for escaping it, and simultaneously it becomes the focus of his lament.

Musical characteristics of the blues
The blues has musical qualities that communicate the visceral aspects of emotional trauma. In music, one of the most important expressive devices is the use of tension and release. The tension and subsequent release can be melodic, harmonic, or rhythmic.  Emotionally expressive music tends to have a greater degree of musical tension, which makes the release more effective. One of the ways in which tension is created in the blues is called “pitch-bending.”

Pitch-bending is a technique that is used by both vocalists and instrumental musicians. It plays on our ear being accustomed to hearing melodies composed of pitches, or notes, that relate to a key.  A key is comprised of a series of usually seven adjacent notes (as in the major scale) that are fixed.  Blues musicians will slide up or down in between pitches of a key, thus “bending” the notes and creating tension.

Pitch-bending gives rise to an ambiguity between major and minor keys. Blues musicians intentionally sing or play around the pitches of the key to create tension. Then, at just the right moment the musician will resolve the tension created by the pitch being out of tune by sliding up or down to the “correct” pitch. This technique is an enormously effective expressive device. 

Because of this ambiguity in the blues between major and minor keys, the music is not really in either key. We suggest that this ambiguity is one of the elements of the music that gives it its power to capture viscerally the emotionally traumatizing quality of human existence. This is so because we typically associate music in a major key with happy or joyful emotions and music in a minor key with sad or painful feelings. Blues music gives us both at the same time, paralleling the way the lyrics can convey the tragic irony and absurdity of our existence, as we discussed earlier. Contradiction and irony are built into the structure of both the music and the lyrics of the blues, just as they are built into the structure of our existence.

Concluding remarks
We have tried to show that in the unities of its music and its lyrics, the blues provide a therapeutic, visceral-linguistic conversation in which universally traumatizing aspects of human existence can be communally held and lived through. Therein, we have suggested, lies the blues’ universal appeal. But, to grasp the profundity of the blues, we must return to its origins in African American history and in the traumas of slavery.

Why was the need for such a visceral-linguistic conversation especially powerful in this context, so powerful as to give rise to a musical genre with such universal appeal? LeRoi Jones suggests in his book, Blues People, that the birth of the blues was linked to the circumstances of newly freed African slaves having to establish their identity as African Americans. Having endured generations of brutal enslavement, these former Africans were faced with having to figure out their identity in a land where they and their ancestors were forcibly brought to work, and to do so amid the bleak conditions of post-slavery and post-Civil-War America. They needed a form of dialogue through which the devastating nature of their experience in America could be conveyed and shared in their English and, at the same time, that could capture viscerally the traumatic suffering entailed in that experience. It was in this context, claims Jones, that the blues came into being.

In the blues there is a quality of acceptance of the way things are, however miserable. The conditions under which the creators of the blues brought this profound music into being show a remarkable resilience of spirit. The world owes an incalculable debt of gratitude to the creators of the blues, who endured unimaginable suffering while bringing forth this powerful music that continues to help people face, own up to, and cope with the human condition.

Copyright Robert Stolorow and Ben Stolorow