Ego Damage and Repair

Toward a Psychodynamic Neurology

J. Allan Hobson

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781782201700
• eBook ISBN: 9780429913082
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

As a psychiatric trainee at Harvard in the early 1960s, Dr Allan Hobson was taught commitment to psychoanalytic theory that was already suspect and is now almost entirely obsolete. Via a series of clinical case reports, the author first apologizes for the arrogant ignorance that he adopted from his teachers and then replaces Freudian doctrine with a scientific alternative called Psychodynamic Neurology. The new approach is solidly grounded in sleep and dream science and restores hypnosis to its rightful place in the therapeutic armamentarium. A central precept of Ego Damage and Repair is that the self and its subjective experience (including symptoms) are natural accompaniments of spontaneous and prenatal brain activation that persists throughout life as REM sleep dreaming. Far from being the nonsense theory that psychoanalytic opponents mock, Psychodynamic Neurology views the unconscious as a hyper-meaningful set of predictions about the world that constitutes a virtual reality model which is continuously updated by personal experience. To showcase the changes in psychotherapeutic practice that are recommended, the self treatment of Dr Glen Just is described in detail.

PART I
The power of suggestion

A key assumption of the approach to psychotherapy that is taken here is that the most powerful environmental force for change is suggestion.

Hypnosis—yes or no?

As a resident, I was taught that suggestion imposed truth upon a subject and that suggestion was the enemy of insight, the discovery of the deeply buried unconscious impulses that truly drove all behavior. Consciousness was, therefore, positively misleading. Only the dynamically repressed unconscious was truly true. Thus, hypnosis was vilified as the devil that kept the unconscious demons from liberation by suggestion-free psychoanalytic psychotherapy. In retrospect, these psychoanalytically inspired injunctions were themselves suggestions of an intellectually numbing kind.

My first psychiatric boss, the late Dr. Jack Ewalt, went so far as to drive the professional hypnotist and prestidigitator, Dr. Martin Orne, out of Harvard. Martin moved to Philadelphia, where he pursued his career in the more eclectic and more tolerant Department of Psychiatry at the University of Pennsylvania School of Medicine. With Martin’s departure, we lost what little chance we had of recognizing and manipulating the suggestibility that might have empowered ourselves and our patients to more positive and useful ways of thinking and being. Whether we were psychiatrists in training, or patients, or just normal human beings, it was in my opinion a major mistake to outlaw suggestion.

Shame on you, Jack Ewalt! You were very tolerant of my dissent from the psychoanalysis that you espoused and you encouraged my interest in the brain. As my department head, you helped me enormously to develop an experimental career. But you exiled suggestion from my clinical education. I had to find out about this most important and potent force by myself, almost by accident. This book is a testimony to the negative effects of this error of omission as well as a screed against the falsity of other aspects of psychoanalysis.

The double-bind hypothesis of schizophrenia

When I was a resident in psychiatry at Harvard in the early 1960s, the leading theory of the supposed psychogenesis of schizophrenia was a double-bind injunction attributable to mothers who confused their children by saying, for example, “Be independent but don’t ever leave me.” In 1960, the evidence was already strong that genetics played a large part in the determination of schizophrenia, but the psychodynamic model of Sigmund Freud was being extended far beyond the bounds of scientifically sound application. Freud himself inveighed against this practice. Psychoanalysis may have been justified in the case of Viennese and Parisian hysterics, but Freud’s theory was probably flawed even in those ostensibly neurotic cases.

The assertion by my American teachers, most of whom were Freudian psychoanalysts, that schizophrenics were psychotic in part because their mothers raised them in a climate of mixed messages seemed dubious to me on its face. I nonetheless went along with this hypothesis because I was young, impressionable, and cowed by my professorial instructors. I feel now that I was intellec tually and emotionally abused by them and it has taken the better part of a lifetime of self-reliance to overcome this early intellectual trauma.

As dubious as was the double-bind theory of schizophrenia was the arrogant and insensitive way that the theory was often promulgated in my day. Mothers at their wits’ ends, with offspring who were unhinged, were made to feel guilty for causing states of mind over which the mothers had no control or responsibility whatsoever. I vividly remember one particularly exhibitionistic and sadistic hazing of a psychotic patient’s mother by a senior psychoanalyst. Such teachers were simply ignorant and should have admitted it. From them I did learn how to talk with such patients and how, by psychological means, to help them live their lives, but I never found a modicum of evidence for a theory that was, like most of Freud’s own ideas, nothing but speculative philosophy.

Like so many other theories, the double-bind hypothesis was probably entirely false. Because evidence could not be found to support it, it was, in fact, put out in the pseudoscientific trash long ago. The later studies of Paul Wender and Seymour Kety, who studied identical twins reared apart, showed that it was genetic inheritance and perinatal insult, not later environmental misadventure, that was at the root of the psychopathology in schizophrenia.

Many psychoanalysts believed then (as some of them still believe now) that they had transcended the rules of science. In fact, it was arrogantly claimed that a new science had been discovered which was free of the need for experimentation. All that was needed for a scientific psychology was psychoanalysis itself. Any doubts about psychoanalytic veracity were dismissed as psychological resistance to truth. Such resistance was thought to emanate from the neurosis of the doubter. I was sadly subjected to such outlandish and politically incorrect hazing. I remember being dismissed by Professor Ewalt as a “believer” in science; my retort was that science was our only hope for the correction of misguided belief.

What had been discovered in psychoanalysis was little more than a new religion from which the intellectual world of the West has yet to escape. This is still another reason for challenging David Spiegel’s joke about the triviality of academic disputes (which are so acrimonious because there is so little at stake!). Spiegel’s bon mot turns on the ironic intensity of academic disputes. But the argument over psychoanalysis is anything but trivial. At stake here is nothing less important than a deep truth about ourselves. We are brained creatures who still do not see ourselves at all accurately because of our still profound ignorance of the brain.

I now resort to a discussion of some of the cases that helped me to reject psychoanalysis and to reach a humble consensus regarding self-reliance. These case vignettes are designed to make two reciprocal points: one is that theoretical and practical errors can be harmful and even fatal; the other is that common sense and open support are more likely to be helpful than subtle insight about parental behavior.

First, I consider ten patients whom I followed in individual therapy. I try to balance the good that I might have done with frank acknowledgement of the harm that I am afraid I may have inflicted in the name of the psychoanalysis that I was taught. Then I tell about ten more patients that I saw in groups who helped me further to realize the pompous delusions of Sigmund Freud. A more positive point is made about the great efficiency and surprising efficacy of group psychotherapy, a modality thought by my psychoanalytic teachers to be greatly inferior to individual treatment.

In presenting these cases, all of which were supervised by psychoanalytic faculty members of Harvard Medical School, I might, out of anger at what I consider to be deception, overly emphasize my inadvertent negative interventions. A paradoxical truth is that the intellectual weakness of my treatment was a cover for an almost devout adherence to clinical responsibility. At the same time that we residents were being brainwashed about the scientific probity of psychoanalysis, we were being sworn to the care of our patients for life. I am as proud to have taken the ethical charge seriously as I am ashamed to admit that I was gulled into confusing theory with fact. The irony of this contradiction of intellect and ethics is profound.

Individual therapy case vignettes

Derrick Sutter: Did I kill him?

Derrick Sutter was a thirty-five-year-old man who wished he could fly. Mr. Sutter’s problem was that he did not restrict his flying to his dreams or to his waking fantasy. He enacted his conviction in waking. His mother was understandably concerned about him and kept him on a very short leash lest he hurt himself. “Typical double bind victim” I thought to myself and began to pry Derrick Sutter loose from the source of his troubles, his benighted mother.

One day, after a session with Mr. Sutter and his mother in which I recommended their separation, Derrick ran from my office and launched himself into space in the first floor corridor of the hospital. He aimed his head very accurately at a small window in the metal fire door that separated the corridor from the front lobby of the Massa chusetts Mental Health Center. He hit the window with his head and broke the glass but tore his scalp apart with the wires that reinforced the glass in that fire door’s tiny light aperture. Because he had severed his left temporal artery, Derrick Sutter bled profusely and by the time his mother and I got to the scene of his failed flight, he had been whisked off to nearby Brigham and Women’s Hospital for emergency surgery. He recovered quickly and was sent home with his distraught double-binding mother. Two weeks later, he committed suicide by hanging himself in a stairway of their home.

Why his mother did not sue me for malpractice, I will never know. Derrick, forgive me; Mrs. Sutter, I was only following orders. But I should have known better, shouldn’t I? In retrospect, I was guilty of Derrick Sutter’s death. I had applied a theory to his care that was unproven and implausible on its face. As a result he gave up and died of despair.

Derrick Sutter was not a schizophrenic, although we diagnosed him as such. He was not bizarre, withdrawn, or odd in any way. We got the diagnosis wrong because, at Harvard and similar institutions influenced by psychoanalysis, diagnosis was not held to be very important, since all patients received the same treatment: talk. Obstreperous patients got Thorazine to calm them down (and sometimes knock them out) but we were confident that it was the talk that really mattered.

Today, Mr. Sutter would probably be diagnosed as suffering from major affective disorder and treated, possibly successfully, with one or another of the drugs that directly play upon the same brain stem neurons that Robert McCarley and I, working in a basement laboratory just below Mr. Sutter’s launch runway, discovered to be key regulators of sleep and dreams. As I will later explain, the clinical efficacy of drugs such as Prozac is related not only to their antidepressant action, but also to their more fundamental role in conscious state stabilization.

The link between sleep and both mood and psychosis is now biologically clear and I am proud to have been a part of such small but genuine scientific progress in this field. This is not quite as great an advance as we might want, but it is certainly better than the gratuitous double-bind hypothesis that was my accomplice in facilitating Derrick Sutter’s death. I am deeply sorry that Derrick Sutter died before a possibly helpful treatment could be tried.

Of course, Derrick Sutter really killed himself. I was just an unwitting accomplice. How can our new view of the ego and its imputation of ego damage deal with the reality of suicide? Consider a variation on the theme of suicide, as is so commonly attempted by taking an overdose of psychoactive medication. Unpacking the language we use to describe suicide may help us understand this increasingly common event. It occurs not only in patients like Derrick Sutter, but also in people who want to die because life is no longer tolerable to them.

I can only kill myself if there are at least two me’s: one me kills and that part, plus the rest of me, dies. The pills themselves might be procured by a relatively healthy me (now) who contemplates the day (then) when I will be too unhealthy to want to go on. Thus, there is one me now and another me then, not so much two half-me’s as one me that changes state over time. When I finally do take the fatal pills, I might not be depressed at all (as psychodynamic theory has tended to assume). I might actually be happy, relieved to suppose that I can make it out of life with dignity and freedom from pain.

Of course, if I were to commit suicide, I would be vilified by those who believe that any willful taking of a life is a sin. It is such people that prevent the legalization of an act that the atheists among us con sider rational and even noble. More Anglo-Saxons than Latins favor freedom in this domain, but many fundamentalist Anglo-Saxon religionists join with the Catholics in opposing voluntary death as part of their battle for the right to life.

The implications of the Derrick Sutter case, thus, go far beyond my mea culpa regret about trying to separate him from his double-binding mother. Mrs. Sutter was, for all I know, a good woman who was doing her best to cope with a disabled son.

The change in psychiatric thought and practice has now reached a new level of sophistication that may be obscured by the disenchantment with psychoanalysis that has brought the field down so low in public opinion. As irrational as was the optimism of 1960 is the pessimism of today. It is not just that the Derrick Sutters of today have a better chance at symptom relief. It is also that we are beginning to piece together a picture of how accurately the activity of the mind reflects the activity of the brain. A major reason for the low status of psychiatry is that we are understandably impatient. We want a quick fix for our woes and we want it now.

As I will further recount in Part III, it is in large part the inappropriate use of effective drugs that is aggravating psychiatry’s current credibility problems. In truth, the same pills that college students take to improve test performance might also help today’s Derrick Sutters. Not just mood, but psychosis and sleep are today much better understood than in the 1960s and 1970s. Today, arousal, attention, and other cognitive faculties are falling within a genuinely scientific purview for the first time in human history. And life itself is increasingly seen as a secular privilege rather than a sacred obligation.

We are living at the dawn of the greatest renaissance of all time, the understanding of the human brain–mind. When I say that 500 to 1000 years is the time that it may take to realize this renaissance at all thoroughly, I mean only to counter the unrealistic enthusiasm evinced by those who beg politicians for money to do the scientific job right. We will spend far more on brain research than we have already spent on cancer, but the cure for cancer is still optimistically said to be “just around the corner.” Until we know much, much more about the brain, we would be wise to obey Shakespeare when he said, in Hamlet, “Take physic pomp”, by which I suppose he meant be humble and be honest, physician. Heal thy self.

Sarah Sage: Did I maim her?

Sarah Sage was another of my double-bind-as-folly teachers. At age forty-seven, Sarah was more schizophrenic than Derrick Sutter. She was also higher functioning, perhaps because her very traditional Anglo-Saxon family believed so strongly in self-reliance. Sarah lived alone in an apartment in Boston and worked as a copywriter for a major publishing house. She kept to herself because she often had the feeling that her co-workers were talking about her in an unflattering way. They probably were!

The paranoia that she sometimes felt was responsive to small doses of Stelazine, a phenothiazine cousin of the pioneer antipsychotic drug, Thorazine. Hers was a bland, somewhat humdrum existence, but Sarah was admirably self-reliant and socially useful. Books were still being read in the pre-digital era that spawned both Sarah Sage and me.

When Sarah told me that she was thinking of quitting her job and going home to live with her aging mother, I reacted with inexcusable horror. A part of me realized, appropriately, that she might not do well at home, but a part of me was misled by my fear of the probably nonexistent double-binding mother into whose grips she would inevit ably fall. A prolonged power struggle between me and Sarah ensued and a standoff settled in. Sarah ended the standoff when she jumped in front of a tram as it pulled out of a downtown Boston subway station. Mercifully, she survived, but two broken hips and a broken pelvis were her ticket home to her double-binding mother. Naturally, Sarah never consulted me again.

I like to think that today I would be more lenient with Sarah and wiser about the limitations of my knowledge, but these stories and recent personal experiences make me wonder. A relationship with one’s mother is better than no relationship at all and easily beats talking to a psychiatrist like me once a week for fifty minutes or so. In retrospect, it might even be that Sarah Sage realized that her aging mother needed her as much as she needed her aging mother. I am now embarrassed to admit that what Sarah really needed was a good social worker and a protected living situation (something like a halfway house) to provide her with shelter and a limited and controlled set of peers to keep her company. She might have rejected such a solution out of a mixture of pride and diffidence, but it never even occurred to me to recommend it.

This kind of social splint has helped keep much sicker patients than Sarah out of the now mostly closed mental hospitals. Halfway houses and group homes liberate the likes of Sarah Sage from parents who might be unhelpful whether or not they emitted the dreaded double-bind curse. The halfway house concept is used well in eldercare housing, too, where it is called, euphemistically, “assisted living.” People of all ages and of all character types need each other as much as they need a job or self-reliance. The subsequent section on group psychotherapy will make this point crystal clear.

Human beings are powerfully driven to seek closeness to others. Our self-esteem grows as we are perceptibly helpful to one another. This, as much as science or religion, keeps us alive. We are born close, we need closeness to make it to school, and we need closeness to keep us first at school and then at work. Social bonding must be a biological imperative that grows out of the same soil as our primordial contact with our mothers. Sarah Sage vitally needed that contact and had to outwit me to get it. I didn’t quite commit ego murder in her case. Just ego assault and battery! My teachers should have had the common sense of a social worker, not the self-congratulatory sophistication of a Harvard psychiatry professor.

William Hitchens: Did I do more th...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ACKNOWLEDGMENTS
• ABOUT THE AUTHOR
• INTRODUCTION
• PART I The power of suggestion
• PART II The brain basis of normal and abnormal ego states
• PART III Psychodynamic neurology: sample cases
• PART IV Self-reliance and psychotherapy
• PART V Ego repair: what every psychotherapist should know
• APPENDIX I: Glen Just's altered states timeline
• APPENDIX II: Glen Just's new self-observation experiments
• GENERAL BIBLIOGRAPHY
• REFERENCES
• INDEX