Guests: Casriel, Daniel,; Kline, Nathan; Spotnitz, Hyman
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THE OPEN MIND
Host: Richard D. Heffner
Guests: Daniel Casriel with Nathan Kline and Hyman Spotnitz
Title: “Psychology Today”
VTR: 1/ 5/ 1975
I’m Richard Heffner, your host on THE OPEN MIND. Years ago I was trained in the social, not the psychological, sciences. So that my approach to our topic,, psychiatry today, and to the distinguished doctors of the mind who are my guests, is of course, of necessity, cautious and perhaps hesitant. Surely I wouldn’t play games, though in a sense the games people play do constitute our subject. So it isn’t really in a light vein that I point out that we often gain some perspective concerning the basic questions that plague us by examining first the various responsible persons offer as answer to those questions. Today then, in all seriousness, I suggest that we might gain the most useful insights into an understanding of the psychiatric problems that face contemporary America if first we identify the psychiatric solutions offered by some of the profession’s most highly respected investigators and practitioners. And now I’d like to introduce three of those investigators.
First, Dr. Nathan S. Kline, Director of Research at Rockland State Hospital in New York, pioneer in psychopharmacology, and author, most recently, of From Sad to Glad: Kline on Depression, published by Putnam.
Second, Dr. Hyman Spotnitz, neurologist and psychiatrist, widely hailed as a formulator and teacher of group techniques and principles, author of The Couch and the Circle, published by Knopf, and author too of Modern Psychoanalysis of the Schizophrenic Patient.
My third guest, Dr. Daniel Casriel, Psychiatric Director of the Casriel Institute of Group Dynamics, author of A School Away From Happiness, published by Grosset and Dunlop, past President of the American Society of Psychoanalytic Physicians.
Gentlemen, let me get back to this question of asking to get at the questions asking what the solutions are, because I have the suspicion from reading your various volumes and knowing a little bit about the psychiatric background of the panel today, that in a sense you approach the problems from a somewhat different point of view. And Dr. Kline, I’d like to begin today in terms of your book, From Sad to Glad, asking you where you identify the problem, psychiatric problems of our time to your approach through psychiatric solutions.
Kline: I think one has to distinguish between the psychiatric problems of the individual and the psychological problems in which a society may find itself. The kinds of patients with whom I deal are individuals who suffer from emotional or mental disturbances to the extent that they either suffer great pain or they’re nonfunctional, their productive capacities interfered with. And I think that some people are born with the genetic mechanism, the physiology which, as in other diseases, is more subject than that of some other people in society, the way they’re brought up, what they do may have some effect on making it manifest or not. In some individuals, their depression, their other type of psychiatric illness is going to appear regardless of what they do. In other cases, it depends on what happens to them very much. So society does play a role. But one must have a predisposition to some of these disorders. Which, to finish it off, is actually rather hopeful. Because if this is underlying it, if one can correct this physiological or biochemical disposition or compensate for it, then one has a means of treating the disorder.
Heffner: Gentlemen, Dr. Kline has begun speaking about the physiological disposition. I don’t assume that anyone is going to challenge it, but perhaps there are different approaches that you take. In From Sad to Glad, he does put his emphasis there. And I wonder you put yours, Dr. Spotnitz.
Spotnitz: I would agree with what Dr. Kline said. There is a genetic factor involved in mental illness. There is a constitutional factor, and an experiential factor. And certain conditions, to a different extent, each one of these factors plays a major or minor role. So that one has to make a careful diagnosis in each case to find out to what extent are we dealing with primarily genetic illness, to what extent we’re dealing primarily with a constitutional illness, and to what extent that we’re dealing primarily with experiential illness. And the areas in which chemotherapy is most effective is the area where it’s primarily genetic and constitutional. And the area in psychotherapy is most effective is the area where it’s primarily experiential.
Heffner: Do you feel that the boundaries between those two areas are properly defined these days? Or do you feel that there is a movement toward the chemical approach, the psychopharmaceutical approach that’s inappropriate?
Spotnitz: No, I’m very much in favor of the psychopharmalogical approach to the extent which is effective. The trouble with that approach is that it’s a very crude approach. We have a very limited number of drugs. If you compare with the number of drugs you could use in emotional or mental illnesses with the number of words that can be used with the person, you see that there is a wide disparity. You can use millions of words, thousands of different communications that influence people. Whereas when it comes to the chemical approach there is a limited number. But the big advantage of the chemical approach is that it’s very effective and it has immediate results. Whereas the psychotherapeutic approach, the verbal communication, group therapy or individual therapy, that usually takes much longer, and it’s not so easy to make a diagnosis and not so easy to evaluate what’s happened, and the results are not necessarily as clear cut as you get with a drug, drug approach.
Heffner: Dr. Casriel?
Casriel: Well, certainly there is such a thing as physiological mental disease. But I basically deal with the psychological problems, the severe behavior disorders. People who have been brought up in certain structures, certain conditions will develop patterns of behavior according to that condition. And it is up to psychologists, psychiatrists, to restructure the maladaptive people who have been brought up in substandard human conditions. I’ve developed techniques that are not psychological, per se, and they’re not physiological, per se. they’re someplace in between. They have a psychological component; they have a physiological component. I find dealing with those feelings directly can change human behavior, attitudes and feelings.
Heffner: Do you gentlemen share that notion of something in between the psychological and the physical?
Kline: Well, I think it’s just a matter of formulation. I think we agree in principle, because actually emotion is primarily, to a certain extent hormonal, to a certain extent physiological, to a certain extent psychological. And there are different areas of the brain that are involved in emotions, and different areas involved in intellectual functioning, and different areas involved in purely nervous functioning. So that when Dr. Casriel mentions this borderline area between physiology and straight psychology, intellectual communication, he’s talking about the emotional area, and that’s a very important area, and a very important area to approach. And it can be approached through emotional communication. It also can be approached through drugs. It also can be approached through intellectual practice. But the most effective approach known today is through emotional communication. I would agree with him on that.
Heffner: Dr. Kline, you started by talking about the psychopharmacological approach when you said it was an optimistic approach. If the notion of a higher degree of psychological, psychiatric difficulty due to chemical disposition is to be accepted it’s much more optimistic. Do you think that’s true in terms of what Dr. Casriel is saying, taking this emotional area? Why is the chemical approach more optimistic?
Kline: Well, I think for two reasons. First, let me distinguish between the fact that part of my life is spent as a researcher up at Rockland with a staff of about 250 people and budget of about 4 million a year, where we spend a great deal of time trying to investigate the causes and the development types of treatment and to relate these to the patients that we have. The other part of my life is spent in treatment here in Manhattan. And I think the reason that the psychopharmacological approach for many reasons is at least the most practical is that if, let’s take depression as one condition. As a rule, if someone is depressed and they’re given medication, it takes about three weeks before you begin to see some improvement. If you’ve been unfortunate and for one or another reason selected the wrong medication, it may take another three weeks. But we’re talking in terms of three weeks to a month or two months at the outside before you begin seeing improvement.. and I would certainly agree that the treatment does not cover all cases. But in the area of depression it’s probably somewhere around 80, 85 percent of the patients do respond. If they do respond, the treatment is not only more rapid, it’s certainly less traumatic. And anyone who’s undergone psychotherapy knows that it’s a rather arduous process as a rule. So it’s rapid, it’s less painful to undergo, and it’s certainly much cheaper than other types of treatment. So that there is actually a kind of primacy. If you’re in doubt at all, then certainly it is reasonable to try a medical approach, that is using medication. If it doesn’t work, then one has to consider other things. There really is no antagonism between the two approaches. I think that in a way there’s a temptation on the part of many people to try to pit those who are psychotherapists, practice psychotherapy, against those who, where the stress is on physiological or pharmacological factors. As you know, I was trained as a psychotherapist, and had Paul Sherder, who was one of the great psychotherapists himself, as my teacher. So that there certainly is no antagonism between the two. It’s a question of when do you apply one, when do you apply the other. And very often the two treatments can be very successfully combined.
Heffner: Yes, but Dr. Kline, we’ve known each other for a good many years. And 20 years ago, when we sat at a roundtable like this on a program called The Open Mind, I wasn’t pitting a more orthodox psychoanalytic approach against your own. I found it there in the person of someone who was appalled at your psychopharmacological approach. What’s happened to that division? I didn’t create it then. I didn’t pit one person against the other. Has that all disappeared?
Casriel: Not entirely.
Heffner: Is the mood that exists at this table really all-pervasive?
Casriel: Well, I too deal with depression, but on a purely physiological, emotional approach. As a matter of fact, to me, depression isn’t a feeling, it’s a symptom of a feeling. The underlying feeling is either pain, really emotional pain, or the inability o express, usually, anger. And I have techniques to get to this feeling of pain immediately within the first group in most cases. Or anger with the first group in most cases. And their depression lifts right then and there. Now, it doesn’t stay lifted, because many of the attitudes which cause the depression in the first place has to be restructured. But the first thing a person feels when they get down to their feelings is they feel better. Their depression lifts right then and there. Frequently it stays lifted. Frequently it will tend to come back because the attitudes…for instance, if a person feels, thinks, “I’m not lovable,” or, “I’m not good enough,” it’s pretty depressing. And they’ll walk around feeling depressed. I can remove that depression. They’ll feel better. But I have to restructure their thinking which gave rise to the depression. Their depression to me is a symptom. It’s telling me something is wrong. It’s not a sickness any more than if a person says, “I haven’t eaten in three days, and I’m hungry.” To me that hunger is not a sickness. It’s telling me something. And I treat why haven’t they been eating in three days, or I give them food. In this case I find out why are they depressed. The first thing I do is remove the depression, and then second thing, you start to look for the reasons that they have these pathological attitudes which gave rise to the depression.
Heffner: And you don’t make the connection between what you call the pathological attitudes and an imbalance of the chemistry of the human mind?
Casriel: There are people, there are definitely people who have an imbalance of chemistry which causes an apathy in the depression. There are some people that are obviously organic. Dr. Kline’s patients. There is another group that are obviously my type of patient. And there is a group in between that I don’t know. I try it my way, and if they don’t respond right away, I’ll send them to a doctor that deals with medication, or occasionally I’ll give them some medication myself to see if it carries them over.
Heffner: Is that the end of the road?
Casriel: No, that’s only the beginning of the road. They then have to restructure all their thinking about themselves which gave rise to depression. For instance, I find that most people are depressed because they’re basically not getting their emotional needs met. As adults, we can meet all of our needs. We can feed ourselves, we can clothe ourselves, we can support ourselves, we can even masturbate for sexual relief. But there’s one thing I feel we need another human being for, and that’s the feeling of emotional closeness, what I call bonding. A feeling of warmth and closeness and sharing intimate, tender, open honest feelings. If we don’t have that, we’re going to get, quote, “depressed.” And what I do is find out why a person hasn’t been able to reach out and feel close to somebody. They usually don’t feel good enough or they don’t feel lovable, or they feel the price is too great, or they feel that they’re doing something wrong, or they’re guilty. There’s a million different pathological attitudes that prevent a person from getting their emotional needs met from other significant human beings. And what I do is to deal with those pathological attitudes, not intellectually, per se, but emotionally first, and then talk about it intellectually.
Heffner: But you seem not very much to make the connection, or at least not very often, between those attitudes and this chemical imbalance that Dr. Kline has concerned himself with.
Casriel: No, well of course, our patients are almost preselected. The patients that see Dr. Kline see Dr. Kline for various reasons. The patients that come to me are usually referred by other patients. They’ve seen the change in other patients. And usually they’re birds of a feather flocked together. So I might be getting a kind of preselected patient. I very rarely see the organic depression. But there are, such a thing does exits, the inpollutional depressive. However, I’ve seen changes even in those on an emotional level.
Kline: I think the thing that makes it very difficult is that if an individual is depressed – and as I mentioned to you, my concern is more with treatment as a practitioner than it is with the research, which is a separate part of my existence – but the symptoms which Dr. Casriel describes are very much the symptoms that an individual who has a depression no a physiological, biochemical basis has. And I think the problem arises to know whether it’s the cart or the horse that’s going first. Because if an individual has a depression on a physiological or biochemical basis, the most common symptom is interestingly enough not depression, but as I bring out in the book, the lack of joy and pleasure in existence, to which I think all of us are not entitled but would come to naturally. And it was Hamlet who put it very nicely when he said, “How weary, stale, flat and unprofitable seem to me all the uses of this world.” He doesn’t say he’s depressed, he just says that everything is blah. he’s not interested. He has no pleasure in things. But this can arise on a physiological basis as well. It may,, since I only see rarely any of Dr. Casriel’s patients, as I’m sure he sees some of min since we tend to see the failures of, each other’s failures rather than each other’s successes. But the point is that there’s a great difficulty sometimes in distinguishing. We do not yet have adequate biochemical blood tests in order to distinguish who belongs to Dr. Casriel, who belongs to Dr. Spotnitz and who belongs to me.
Heffner: Well, Gaul may have been divided into three parts, and you gentlemen seem to feel that there isn’t any basic conflict here. You have your individual categories of patients with whom you deal. Would it be fair then to say that less sophisticated people, including myself of course, but that by and large less sophisticated people do see a split between and among the approaches that you take and for that reason that split, that presumed split, becomes what is current in the minds of most other people, and that your polite assumption that you have three valid approaches to different kinds of patients or for different reasons kind of bypasses what seems to be an increasing conflict between those who want the immediate relief that you suggest, Dr. Kline, those who take much longer, those modalities of treatment that take much longer. And I would ask Dr. Spotnitz, with what result? What’s the difference? What’s the bottom-line difference between the person who experiences something other than chemical treatment?
Spotnitz: This tendency to see a split here can be a very severe handicap in the field. As Dr. Casriel said, there are certain patients that will respond primarily to his approach. Dr. Kline said there are certain patients that respond to his approach. And I’ve had the experience with both types of patients. But I also want to present another type of patient which respond to the combined approach. And if you have the split then you’re in trouble. You have a patient I once had who was an amazing man, very depressed, suicidal. I treated him a couple of tears and then he told me that he was going to have to commit suicide. He didn’t believe that there’s any way out of this feeling of terrible depression, lack of joy of living. Life meant nothing to him. His father committed suicide, now he had to do it. Well, I sent him to a specialist in Dr. Kline’s field who gave him a drug for one week, and his depression disappeared. And he said, “I’m never going to have to be depressed again.” And he continued treatment for a short time afterwards, and as far as I know, this is ten years later, he’s a cured man, never had another depression, Is functioning very well in the field of his profession.
Heffner: You say, “ a cured man.” What do you mean by that?
Spotnitz: I mean he never had, as far as is known,, he never had another depression, nothing significant. I mean, he has temporary feelings of unhappiness and so on, but the danger or suicide has completely disappeared. This man’s life and the danger and his inability to function has disappeared. He holds a highly respected position in life and does the work he wants to do very successfully. But if one would separate the field out and say certain patients you only use drugs, certain patients you only use a psychotherapeutic approach, then this kind of patient couldn’t be helped, because he needed a combined approach to really make him into a well-functioning person. I think this area of psychotherapeutic influence and pharmacologic influence needs very carefully study and investigation, because we don’t’ know which patient will only respond to the pharmacological approach, which patient needs the combined approach. But if we are open to all three approaches, that’s why I favor this program of The Open Mind. If we have an open mind, and then we are available for all these approaches, then we can pick an approach which is specific for that patient’s needs. But if we make a real split, then we’re not necessarily going to be able to help the patient who needs the combined approach.
Heffner: Is there a difference perhaps, nevertheless, in your assumption about what your objectives are with a patient and perhaps Dr. Kline’s? are you going to be satisfied with that immediate relief that comes in three weeks or eight weeks or ten weeks? He has relief and he moves on. Is this what you would accept too as your colleagues would?
Spotnitz: No, I wouldn’t be satisfied with that. But I don’t work with patients for my own satisfaction. I work primarily for the patent’s satisfaction. If a patient says he wants immediate relief and he wants immediate relief with drugs, it seems to me he’s entitled to that. If a person wants the personality changed, Dr. Casriel is mentioning, a complete change of intellect and personality, he’s entitled to that. It depends on what the individual wants and it depends on what he wants is good for him. I agree with him. I’m willing to help him get the approach which is most effective and most meets his needs. The big disadvantage of the pharmacological approach is the person may remain dependent on that. The primary goal of the psychotherapy approach is to make the person eventually totally independent of drugs and the psychotherapist.
Kline: Well, first of all, the drugs do not create dependencies. Dr. Spotnitz is using it in a somewhat different sense, as I’m sure he’ll agree that, as compared with heroin or amphetamines. And we’re not talking about that. The drugs which are used in treatment do not produce addiction or drug dependence in the usual sense. I think what Dr. Spotnitz raises as a point is in the individual, should there be a recurrence, would obviously turn to the more rapid treatment. I think what you’re trying to get at is to stir up the question of whether Dr. Spotnitz and possibly Dr. Casriel get at the causes of things, and therefore obviate the possibility of recurrence whereas has been accused I stress the relief of symptoms. There was a French surgeon, Paret, who lived in the 16th century and made a great statement. He said, “ I treat, and God cures.” And in a sense, no physician ever cured a patient of anything. All that the physician can do is maximize the possibilities of self-healing. And I think this is what Paret meant, and it’s just as true today. Dr. Spotnitz and Dr. Casriel do it in terms of dealing with either psychotherapy, with the mind or with the emotions. The approach which we do primarily is in terms of the biochemistry. There are patients whom we also refer for psychotherapists. We have two very good psychologists working with us. So that it’s not that we look down at, reject this type of treatment. But psychotherapy, we don’t’ know any more really about how psychotherapy works than we know how pharmacotherapy works. The objectives of the psychotherapists is the same objectives as we have, and that is relief of the pain and suffering, and increasing the individual’s productive participation in what’s going on.
Heffner: Dr. Casriel.
Casriel: No, I think I slightly disagree. First, I think my previous goal was getting a patient from sick to well. But that’s no longer my goal. I find that most of the people that come to me are not sick; they’re malprogrammed, they’re maladapted, they’re unhappy. And I’ve changed my goal from sick to well to unhappy to happy. Now, I find out that most of my psychotherapeutic endeavor is not getting a person from sick to well. That’s easy. The hard part is getting a person from well to happy. Everybody feels entitled to take their hand away from a burning stove it if pains them. Nobody has any problems about trying to remove pain. But it’s amazing the conflicts and the distortions that people have when you say, “Reach out for happiness. You know, don’t settle for a lack of pleasure. Don’t’ settle for just being well.” You should be able to feel a sense of well-being and joie de vivre about yourself. Not all the time, but the capacity to feel it when it’s appropriate. To really feel good about life. And that’s a different state than just well.. that’s a state of well-being and happy. And people feel, have a lot of problems about reaching out for pleasure. They don’t trust it, it’s hedonistic, it’s immoral, it’s unethical, it’s, you know, “what do you mean, happy? Like, I’ll settle for God shouldn’t strike me down and I should be well.” Well, that’s not enough. That’s not enough as far as I’m concerned. But I agree with Dr. Spotnitz. You can’t tell every patient what is enough. What I have is not so much a medical process but an educational process. Like every educational process, some people say, “Well, I graduate from grammar school. That’s well, and that’s enough.” Some people want high school, some people want to go a higher step to college or graduate school. Amazingly, the people who come to me who have higher educational levels stay the longest. Not that they’re the sickest, but they have a higher capacity and they want a greater amount of pleasure out of life. So the people that stay the year or more are the people with their, basically the professional, the people with more than a college education.
Heffner: You know, it interests me that you are using some of the, you and Dr. Kline use the same words here, and I think Dr. Spotnitz did too. Dr. Kline calls his book, From Sad to Glad. You say, “I learned the business from sick to well. A person’s happy.” That’s an interesting development. And I think it is a development, you may totally approve of it as you seem to. But is our objective the production of sad to glad people, happy people? Or is there some larger framework – call it moral, call it anything you want, call it social – in which our concern is for well people who may not at all moments have smiles on their faces and may not say, “I’m happy. I’m glad rather than sad,” but who fit into a pattern of what we consider an appropriate relationship to society at large, the emphasis upon glad rather than sad, happy as you suggest? Isn’t this mark a change in our attitudes toward the well-being of society, where we now put our emphasis on the well-being of individuals only, we produce happy people? That’s what you seem to want.
Casriel: Yeah, well that’s great. And they’re not nonproductive. They’re very productive people. They’re very socially productive. Give me a group of happy people and I’ll show you a very productive group of people.
Heffner: Well, what about those people who we read about in Brave New World? Happy people, I presume, who weren’t sad. They seem to have been glad.
Spotnitz: I think you are hitting on an area where we most disagree.
Heffner: Well, go ahead, develop it please.
Spotnitz: I think that the objective that we all have we disagree on. For instance, I’m not interested in making people happy at all. When I work with people I want to help them become mature personalities. I want them to be able to function to their maximum capacity. I think he may want to make them happy. He may want to relieve symptoms or have some different objective. We all have different objectives. But none of us insists that the patients go where we want them to go. And Dr. Casriel described it very well. Some patients only want to graduate from grammar school, some high school, some college, graduate school. So we take them to different stages of emotional development and maturity. But I, when I work with a patient I want to help him become the best kind of person he can be from his own point of view and function in the best way he can function. Now this may take me 5, 10, 15 or 20 years, you know, even longer. So that’s the price one has to pay for a very deep emotional education. But some doctors aren’t interested in that type of work. So the patient who wants to get a brief education, a brief change, has to pick out the kind of doctor who will provide that. The patient who wants to have a longer education should go to one who wants to give him a longer education. But it doesn’t mean that any one of us is doing any better work or any worse work. It just means we have different objectives and that we have to evaluate eventually which patient should to go which doctor for which objective.
Heffner: As a layperson, of course, I have always assumed that the objective of a physician is to heal his patient. Now you seem all to be telling me it’s not to heal a patient, it’s to give him what he wants. He wants to be glad, we make him glad. He wants to feel better, we help him feel better.
Kline: I haven’t said that.
Heffner: I thought that’s what you said.
Kline: No. the point is that I think that people have a capacity if they’re feeling well to get some enjoyment out of life. The other two doctors have also stressed the fact that anybody who goes around happy all the time is sick. This is not a normal state of affairs.
Casriel: Send them back to Dr.
Kline: If they’re too happy, it’s no joke. The manic patient is so euphoric that he gets into all kinds of trouble. They’re very unrealistic, because the world is not that happy a place. But I think people have the normal capacity for enjoying at least part of what they’re doing. If you eliminate the sadness and the anxiety, you’re eliminating a lot of the things that all of us value. A great part of the world’s literature, art, and music is based on the capacity to feel and to suffer. So I don’t think any of us are advocating that. But the point possibly wherein we differ is I fear that, one, that individuals have this tendency to self-healing if you remove the impediments. Now, the kinds of patients I treat are the ones who hopefully are the ones where it can be removed by biochemical means. Once it’s removed, very often these patients go on spontaneously and in a sense cure themselves, as any patient has to do regardless of what he’s being treated for. So that that part of it is no great disagreement, I think. And the other thing is, in terms of even maturation, I think there are people who would go to someone like Dr. Spotnitz who have a need for a very interesting kind of maturation which is different from the usual, and who have the need and who benefit from such a relationship. In general – as you know, we’ve discussed this in other areas – I’m more for allowing people to develop spontaneously. Sometimes they develop in ways you don’t like. But that’s another problem. I think that individuals should be given the opportunity, unless they have a need and wish it, to go ahead and develop how they choose to. In other words, no censorship unless obviously they’re going to become engaged in criminal activities or they’re going to cause suffering to someone else, or undue suffering. We all cause people suffering. This is unfortunately part of our fate.
Heffner: You know, we’re going to do a program on The Open Mind sometime in the near future on the legal establishment and on the degree to which perhaps lawyers become today less and less officers of the court and have some assumption about legality and appropriate legal behavior and more and more extensions of their clients. A client wants to do this, that’s his business. We do it. And that’s why I raise the questions about healing as opposed in a simple way to me to the matter of from sadness to gladness. I didn’t mean to praise m myself as one who would say this is a shocking shift in medical ethics. In fact, it seems to me that what has been happening here, let’s say, in the 20 years, Dr. Kline, since we first discussed this subject with a psychoanalytically oriented psychiatrist who was appalled at what you were doing, I suppose it would be more difficult today to find such a sense of total shock and total rejection. Maybe some shock and some rejection…
Heffner: But not quite so totally. Isn’t that a response to the notion that what you gentlemen are doing with groups, with chemistry, is in response to a greater and greater felt need, greater and greater demand on the part of more and more people which can’t be met with more traditional, or through more traditional methods? And now the need comes to develop nontraditional methods and to rationalize them. I don’t mean to explain them away, but develop a philosophy for them. And I wondered whether you’re not simply responding to the fact that there are so many, many, many more people crying for it.
Casriel: No, I don’t think, that is certainly not my response. I think I found a better way to do the process. I’m not apologizing for my way in terms of, well, we’ve got so many we have to dilute the goal of analysis. I think the process that people are developing of giving somebody a pill to make them compensate, brain compensation, is not an apology to psychoanalysis, because we don’t’ have the time to analyze them. I think it’s a better and a new way. And I think the past 20 years has really seen a revolution in psychiatry in terms of drugs. I think we’re about to see a revolution in terms of psychiatry, in terms of psychological treatments, because I think we are finding better and better ways and quicker and quicker ways to treat the problem, or to educate the problem. One thing I wanted to…I don’t overlook the growth and maturation of the personality. You can’t be a happy adult person without being an adult person, mature and responsible. And certainly a lot of the people that I treat in my residential facility, AREBA, are severe behavior character disorders. Drug addicts and kids who’ve been in a room for seven years or a compulsion of washing their bodies, with scabs. And these people, I found out, were not organically a problem, but psychologically extremely disturbed, extremely disturbed. And we are able to reeducate them emotionally, behaviorally, and attitudinally o they come out a fairly healthy human being. Not in years, but in 5,10, 15, 20 months.
Spotnitz: Well, I think what we have to take into consideration is that the trend in the field of psychiatry is toward greater specificity. Originally there was the idea of only one approach to my work, which was the psychoanalytic approach. But as the years have gone by, the psychoanalytic approach was encompassed to be effective only for certain patients. Psychopharmacological approach is only effective for certain patients. The emotional approach is effective for certain patients. We have to make a careful diagnosis as the years go by. We’re going to see in the future many different conditions. In my own experience, every individual turns out to really be an individual. He doesn’t respond to any routine approach. Even psychopharmacology, where you think you can just give anybody any drug, you have to match the drug to the patient. And when it comes to the emotional approach, you’re going to have to match the feelings with the patient. The same with the analytic approach. So we’re going to see many new techniques developed, many new methods, many new drugs are going to be on the horizon. My anticipation is I’m going to see more and more specific interventions for specific patients.
Heffner: With the same objective?
Heffner: The objective that you…
Spotnitz: Yeah. I think we’re all aim, all psychiatry is aiming eventually at helping people attain their maximum emotional potential as human beings. Yeah.
Kline: One of the interesting things is in a way my area of my approach is the least controversial rather than the most. Because the Food and Drug Administration requires that before a new drug is put on the market one must compare it either with a placebo, that is a blank, or with a standard drug which is already on the market. So that any kind of therapy which I did was subject to very rigid examination and scientific requirements. In a sense, the psychotherapy, I’ve often wondered why the Food and Drug Administration doesn’t subject psychotherapy to these same criteria and make the therapist demonstrate that what he’s doing is superior to doing nothing or is superior to standard treatment. It’s a wild, maybe not so wild fantasy. But I think this would help clarify which patients would do well with which kinds of treatment. I can only tell you that among the patients that we see which, as Dr. Spotnitz points out, which medication is likely to work best on which type of patient. How one determines, since the psychotherapists don’t set up these double-blind experiments or trials, how one would know which type of psychotherapy would be most useful. We do it by clinical means, obviously. You have an, there are patients I’m sure which Dr. Spotnitz knows intuitively that he wouldn’t handle. He mentioned one that he referred for pharmacotherapy. And Dr. Casriel points out he’s more interested in a sense to take the patient from being well to being happy. Whereas my concerns with the individual who has depression or has what’s called anhedonia, lack of joy and pleasure, can’t concentrate, insomnia, underachievement, ruminates about the past and all the things he didn’t do that he should have done and all the things he did do that he shouldn’t have done, and so on. So that in a way it’s true we’re treating a different group, which makes it in a sense very difficult for us to argue with each other because we’re treating different kinds of individuals under different conditions in different ways, which as far as I can tell is now I think compared with 20 years ago a generally accepted approach to the field.
Heffner: I certainly can’t disagree with you three gentlemen, because you’re saying what you do. I do have a sense, as I read what each of you has published, that somewhere there is that sense of not quite here it is to the exclusion of anything else – I don’t’ mean that, and I’m not trying to say let’s you and they fight – I’m suggesting that there does seem to me as a layperson again a kind of basic difference in the approach that there will be more of a resolution of the problems we face in this regard. In Dr. Spotnitz’s book, The Couch and the Circle, he points out that he uses both. And yet I had the feeling as I read that there was a kind of sense of joy in the accomplishments of the circle. And Dr. Spotnitz, I was, you said here, “It would be fascinating to form a group of highly aggressive personalities, top dogs in various fields, with conflicting interests. A police chief interacting in a therapy group with a gang leader, or industrial tycoon with the head of the labor union could certainly stir up a great deal of hatred. If they also develop love for each other and learned how to prevent any of their feelings from seriously interfering with their functioning in the sessions, I would know that they were having a therapeutic experience together. This could be the supreme test of the power of group psychotherapy.” Maybe that test that Dr. Kline was talking about. I had the feeling that there was an enormous sense of joy on your part in writing about that circle rather than the couch, and that you were, if not pushing an approach obviously to the exclusion of others, that there is a division, there is a feeling that here is a more, all in all, by and large, setting aside the individual differences, a more effective modality of treatment. And I guess you’re saying…
Spotnitz: Well, I wish it were true that I could say that, but I really can’t. I can’t say that group therapy is a more effective modality or that pharmacology is more effective, or that individual approach is more effective. I told you it’s specific. The individual patient may require sometimes one modality, sometimes another. And we can’t say that penicillin is the ideal drug for any condition, or terramycin or any other drug. The trouble with the field of medicine is that we don’t have the wonder drug for every disease. Every disease is different. And not only is every disease different, but every patient is different. So that treatment in the field of medicine and in the field of psychiatry is an awfully complex process. And it’s necessary to really understand the patient to see how he reacts to whether you’re giving him a drug or giving him a psychological intervention, and then to determine what is the most effective approach for that individual. And unfortunately we don’t even have the proper diagnostic tests today yet. We’re still working on that.
Casriel: Correct. I think he’s pointing up a very important…We don’t have a diagnostic test that can say, “Okay, you go here or you go here.” I think an ethical practitioner physician who has a total spectrum of treatment available, either in himself or by referral, will probably, if he thinks it’s possible, try his approach on the patient. If he sees he’s not getting the type of result he expects within a period of time that he allows, he will then refer them to a Dr. Kline or a Dr. Spotnitz. And I think this is really the safeguard of the patient is to go to the hands of a physician who has this open mind and how’s willing to say, “Hey, you know, I think Dr. Kline might do you more good than I can.”
Heffner; Yes, but the question that I would raise again is, do you more good, how? What’s the bottom line? Is it happiness? Or is it wellness? And I guess you keep coming around this circle in that way.
Casriel: Well, if I refer them to Dr. Kline, it’s not for happiness, it’s for wellness.
Heffner; Okay. Good enough. Good enough.
Casriel: Either you think you’re enjoying this or doing this to me for happiness.
Heffner: You’re serious. You’d rather think in those terms. You’d rather be identified as someone who is concerned with happiness than wellness.
Casriel: Well, I don’t stop at wellness. I mean, I see people who are very depressed and then get well. I like then to go on to be happy.
Heffner: You mean the first is wellness, and the second one is, the second step is happiness?
Casriel: Yes. Is happy. I see a lot of patients that would never see Dr. Kline. In other words, they come in and they say, “I’m not sick. I’m not depressed, I’m not anxious. I just don’t feel that I’m getting enough out of life. You know, I’ve got a good business, I’ve got a wife that loves me. I’m okay, the kids are okay;. But I’m bored. There must be something more. I’ve taken up golf, I’ve done this. And you know, there’s something missing. Can you help me find out what it is?”
Heffner: You mean there’s really this other thing? If you are well –whatever in the world that means – still there is this other thing that well you may be, but now we’ll try to get some happiness for you?
Casriel: Yes. You know, a beggar on the streets of Calcutta with a loaf of bread under his hand and you say, “are you well?” and he’d look at you and say, “well, I’m not only well, I’m happy. I’ve got a loaf of bread under my hand.” That’s the most he’s ever known about happiness. But would you and I say we’re happy if that’s how we had to live? So living, you know, can be rather different degrees of pleasure. Some people will settle for being well. And if they want that, fine. I’m not here to say you’ve got to be better than that. I’m not going to take this beggar off the streets of Calcutta and say, “You don’t know what you’re missing. Come to New York. Or better still, you know, go to a nice beautiful climate.” I wouldn’t do that. But if a person says, “I’m functioning. Here I am, a New Yorker. And you know, I got the loaf of bread, the equivalent,, under my hand, and I’m not physically ill, but I’m just not enjoying enough.”
Heffner: Well, we are soon going to celebrate the 200th anniversary of that life, liberty and the pursuit of happiness. But I guess I had always been under the illusion that that happiness really was equated with wellness, that happiness really meant the capacity of a society to permit people to be well, to grow well, to stay well.
Kline: I would say, Dick, that anyone who is well is happy at least part of the time. Anyone who is not well…and somebody who is well is also sad part of the time and is anxious part of the time and is depressed part of the time. But happiness or this feeling of euphoria, we all have it from time to time if we are well. If you don’t’ have it at all then by my criterion there’s something wrong, because I think man is born to be happy. And I think this is a natural state of the human at least part of the time to get enjoyment out of life.
Spotnitz: I want to give you an example of this problem that was very dramatically presented to me by a young man one day. I treated him for about two years for a gastric ulcer. And the ulcer disappeared and he was getting along fine. But he was a stock boy in a major company here in New York City. And he had ambitions to become president of the company. And he had the intellectual ability and the potential personality to get there. So I said to him, “would you like to continue, to develop your personality and become head of the company?” He said, “How long would it take?” I said, “ It would take several years possibly if you achieve it.” He said, “No thank you. I just came here to get rid of my ulcer. I’m happy to spend the rest of my life as a stock boy.” And then he left treatment. Now, he was happy. He didn’t have to become president of the company. He eventually got married and as far as I know he lives happily. Every now and then he sends me a patient. But this man had the potential to be of great social value. He didn’t want to achieve it. It’s not my job to make him get there. If he wants to remain a stock boy all his life, that’s his choice. Ad I went along with him and helped him with that choice. But as Dr. Casriel said, he could have gone a long way ahead. He could have gone to graduate school and become president. So we don’t know what we should do under those conditions always.
Heffner: But the question wasn’t one of success or being well.. would you consider him well?
Spotnitz: Well, by his likes, by his standards, he was well. By my standards, he hadn’t achieved his full potential. But he doesn’t have to live according to my standards, and I wouldn’t impose my standards on him.
Heffner: Okay. Let me go back to a question that was stirred up by something Dr. Casriel said. He talked before about psychological revolution. He talked there was a chemical revolution and now there is a psychological revolution aborning. What is it?
Casriel: Well, as far as I’m concerned it’s a different approach to the person who’s unhappy and not well. I’m currently being subsidized by a couple of states to deal with their problem adolescents, the kids who’ve been abandoned, the kids who’ve been on drugs, the kids who’ve been in police courts. They’re now putting them all together. These are the problem children. And many of them have never had any mothering, no loving, no nothing. They’ve just been raised as weeds, human weeds. And they have to be cultivated. They have to be reeducated, rehumanized. Now, I think the previous type of psychiatry would never be able to deal with the drug addict, for instance. The classical one-to-one, three times a week or five times a week.
Casriel: Because it was a very inefficient process. It would be like Dr. Kline giving an aspirin for schizophrenic. It just wasn’t enough. I found that we, you know, I started the therapeutic community movement in this country. I started Daytop about 12 years ago, and now I have AREBA. And I was the first psychiatrist to take Synanon seriously. I wrote the first book on Synanon. And these people need a totally restructuring, a total reeducation, a total new culture, a new family experience, to reeducate themselves and to develop their potential. And that’s what we do. And we do have standards and we do have value systems. And when they graduate from AREBA there is a sort of mark or a stamp on them. They look for something similar, as you would if you graduated from Harvard or Annapolis. There’s a mark. Within six months or a year that mark fades out and you can’t tell that they graduated from Harvard or AREBA. But we do give them standards, just as they did with any educational system. Ours is an educational system. We give them values. We say “Two and two is four, and that’s right. And these are the things that are right.” We teach about relationship and responsibility and reality testing and being concerned for others, because if you’re not, nobody’s going to be concerned for you.
Heffner: You say “teach.” You mean train or teach?
Casriel: Teach, train. That’s right. Educate.
Spotnitz: Teaching and training, both.
Casriel: Let them experience it. Now, we do this with different types of group processes. We have the emotional group that I evolved. We also have attitudinal groups, we have behavioral groups, we have the classical encounter of Synanon and Daytop. We have educational groups, a whole, it’s amazing what they have to learn in terms of sex education. You know, if a boy grows and he feels that to be a man he has to have 47 erections and be able to have a woman lie in a pool of sweat and then, you know, shake on the chandelier, that’s a man. Well, you know, if he really feels that, you know what he does? He avoids that. He becomes homosexual. Because it’s amazing the distortions that people grow up with feeling this is what a man is supposed to be.
Heffner: You used the phrase “psychological revolution.” You said it will bring about better and better results. And then you said very quickly, “faster and faster.”
Heffner: Would it be fair to say that the faster and faster looms particularly large because of the very problems that you’re dealing with, crime, drugs?
Casriel: Well, it’s realistic. It takes time to reeducate and resocialize and rehumanize a delinquent who might be shooting dope or shooting at the cops or stealing, whatever. It takes us about a good year, maybe a year and a half. But we’re turning out a pretty healthy human being. And in terms of their functioning, they function better than the average adolescent as a group who’s never had the need for therapy. They’ll get better grades in school, they’ll get the better girlfriends, they’ll live up much closer to their potential.
Heffner: So this is a kind of behavior modification?
Casriel: Well, it’s behavior modification,, it’s intellectual modification, and it’s emotional modification. AREBA stands for Accelerated Reeducation of Emotions, Behavior and Attitudes. We reeducate not only the behavior but the attitudes and the feelings of the individual. We reeducate them morally, ethically, culturally, socially, vocationally. We have people coming in…of course, AREBA was originally started for middle- and upper-class kids who had the best schools and who were illiterate. They were uneducateable in the best schools because they had such emotional blocks. And we remove those blocks and they learn their four years of high school in about a year.
Heffner: Now, if I were a pusher of summa, if I were concerned about the huge numbers of people young and old who are in need of some kind of rehabilitation, do you think I would find in what you’ve suggested and in more traditional approaches – it seemed funny to talk about this as traditional approaches – but the groups, intellectual or emotional, would I find enough satisfaction, would I find the speed that is necessary to bring about change in our times, would I find sufficient relief from the giant social problems that are created by neurotic or psychotic persons?
Casriel: I honestly and sincerely feel I have tools now to deal on this social level. I think some of these tools that are developed, as a physician, should much better be applied in the school system. I feel that we should add three additional R’s to the reading, writing, and arithmetic: relationship, responsibility, reality testing. I think we can teach these things from kindergarten right on through college. I think it should be part of every school curriculum in the country, every classroom. Teach a person do you really be human and mature.
Heffner: Dr. Spotnitz, are you sanguine about that approach?
Spotnitz: Well, not only am I sanguine, but I’m very much in favor of that approach. I’ve been advocating that for many years myself. But the school system is totally lacking in what it should provide for the children of this country. That providing intellectual education and not providing for an emotional education is a very unhappy approach. I mean, it leads to all kinds of disastrous consequences. I remember one headmaster of one of the most illustrious schools in the country saying, “we’ll help your children get into college, but if they have a mental breakdown it’s not our fault.” And it’s because the schools do not accept responsibility for the emotional education, the reality testing, and the other considerations Dr. Casriel said. Children do need a thorough education in every aspect of life. And there is this trend going on to give it to them. And the field of psychiatry it’s our responsibility to provide the tools which should eventually be introduced into the school system so that children can all be helped to become mature people and realize their potential.
Heffner: Those are very happy thoughts. Do you think they are possible of realization within the context of the size of the nation we have?
Spotnitz: Yes, I think it’s possible, but I think you’re going to find tremendous opposition, and that for that reason, it’s going to take many years to accomplish it. but it certainly is possible to do it.
Heffner: And I suppose because of that our position because of the difficulty we may turn more and more to Dr. Kline his rather faster approaches.
Spotnitz: There’s even opposition to his work too.
Kline: No, no, I think the problem is we…
Heffner: In 15 seconds.
Kline: …unfortunately we don’t really know how to do these things. It would be interesting to subject them to vigorous scientific tests, whether one can produce a sense of responsibility, a sense of reality. I think we’re all for it. It becomes a question of can you accomplish it.
Heffner: And that’s the point at which I’m sorry to say our program is at an end. But I do want to thank you so much for joining me today. Dr. Nathan s. Kline, Dr. Hyman Spotnitz, and Dr. Daniel Casriel. And thanks, too, to you in the audience. I hope you’ll join us again next time. Meanwhile, as another old friend used to say, “Good night and good luck.”