Cultural and Historical Perspective of Psychotherapy

Ellenberger: THE PATHOGENIC SECRET AND ITS THERAPEUTICS

This 1966 article, The Pathogenic Secret and Its Therapeutics, by Henri F. Ellenberger may explain why psychotherapists are bounded by strict confidentiality in their work.

Ellenberger highlights what he calls the “pathogenic secret”. This is a secret of what has happened to us, or what we have witnessed first hand, or what we have been told, that is so “heavily-disturbing”, thus unbearable for us to come to terms with. This is the secret that we keep to ourselves. Sometimes it is a secret that we keep from ourselves, out of our consciousness. Oftentimes belongs to an an event that had occurred in early childhood.

Under certain circumstances, the confession of the pathogenic secret has been known for time in memorial to have healing qualities.

The Concept of the Pathogenic Secret

Pathogenic secret manifests itself as chronic neurosis resulting in symptoms like “melancholia, neurasthenia, hysteria, or even psychosis”, i.e. what we know today as psychopathology.

“The nature of the pathogenic secret can also differ widely. In certain patients, it is the matter of secret thwarted love or some other suppressed passion, such as jealousy, hatred, or ambition. Sometimes it is a matter of physical illness or infirmity, of which the patient feels ashamed. Frequently the secret is related to some kind of moral offence which can range from petty theft to murder, but frequently also it is of a sexual nature (adultery, incest, abortion, infanticide, etc.). The secret can also be the painful remembrance of some traumatic event, sometimes connected with a secret of another person (for instance a young girl discovering her mother’s adultery).” There is often experience of shame involved in the pathogenic secret. The type of the pathogenic secret can differ widely, and it’s effect varies with how the individual attaches meaning to it.

Healing Power of the Confession

Working with confessions is not a new concept. It is observed within ancient healing practices. Confessions of sins or taboos have been documented as healing methods in ancient civilizations in places like Mexico and Mesopotamia.

In the Roman Catholic religion, confessions are practiced, as a form of the self reconciling with the social world. In Catholicism, confessions are sealed in secrecy to the point that under no circumstances is the confession revealed. Once absolved from sins revealed in the confession, the confession is free from his/her sin.

In the Protestant religion, the concept of “Seelsorge” or “cure of souls” as the result of being in the presence of another in a dialogue that can be an exchange and containing of a secret.

The Pathogenic Secret in Literature

Ellenberger also cites examples of the destructiveness of the pathogenic secret and it the healing effect of the secret’s revelation in literature like Nathaniel Hawthorne’s The Scarlet Letter, Jeremias Gotthelf’s Wie Anne Babi Jowager haushaltet und es ihm mit den Doktorn ergeht, Ibsen’s The Lady from the Sea, Marcel Prévost’s L’Automne d’une Femme (The Autumn of a Woman), Heinrich Jung-Stilling’s Theobald oder die Schwarmer.

The Pathogenic Secret in Criminology

Then there is the confessions of the pathogenic secret in criminology. The author cites 19th century literature, Philosophie Pénale, published in 1880 by Gabriel Tarde, documenting the effect that the confession of the crime has on the person who committed it.

“A problem which seems to have attracted less attention is that of the long range effects of the burden of the secret upon the criminal, should his crime not be discovered. It would seem that the secret exerts a permanent and profoundly disturbing effect on certain criminals.”

Another literature cited was that of Austrian criminologist, Hanns Gross, in his textbook of criminal psychology in 1898.

C. G. Jung (12) tells the story of a woman, unknown to him, who came to hisoffice, refusing to divulge her name, and told him how twenty years earlier she had poisoned her best friend in order to marry her husband. But the husband died soon after she married him, the daughter of this marriage disappeared in turn; even animals turned away from her so that she could no longer ride horses nor own dogs and finally she fell into an unspeakable loneliness; this was the reason why she felt that she must make a professional man share the knowledge of her crime. Jung never saw that woman again and wondered what happened to her. Actually the long-range disturbances caused by a secret of that kind in the mind of an undetected criminal are one of the least-known chapters of criminology.

Hypnosis & Pre-psychotherapy

The notion of the burdening secret became known to magnetists very soon after the discovery by Puységur of the state of “magnetic sleep”, now known as hypnosis.

Moritz Benedikt (1835-1920) in the late 19th Century was already able to explain how symptoms like hysteria was cured with revelation of a pathogenic secret in the individual’s “second life” and thus “inner life”.

Freud’s Psychoanalysis and Psychotherapy Today

Freud’s earliest publications illustrate the curative process of revealing of innermost difficult-to-bear secret to a trustworthy professional in a therapeutic dialogue, or “talking cure”. In psychotherapy, this pathogenic secret is something in the unconscious that is revealed in the course of therapy. This revelation is the curative change that occurs in therapy.

With the further development of psychoanalysis, the concept of the pathogenic secret became gradually absorbed into the wider frame of reference of traumatic reminiscences and of repression, and later in the concept of neurotic guilt feelings.

Psychotherapy Law of Confidentiality

It is law in Europe that psychotherapists are committed to confidentiality in their work with clients. This means that whatever the client tells his/her therapist is bounded to confidentiality. The therapist has duty and also the right to maintain this secrecy. The therapist cannot be forced or tricked by anybody– regardless of power or authority– to reveal information given to him/her by his/her client.

This professional code of conduct (in German) for psychotherapists in Austria can be downloaded here: Berufskodex für Psychotherapeutinnen und Psychotherapeuten

The only consideration to break confidentiality is when it concerns the welfare of children and if lives are at risk. Even so, the therapist would consult their counsel of psychotherapists for advice and support.

Being trained in Austria, I am not sure at this point if this rule is applicable to other parts of the world. However, in this article, I would like to highlight the importance of confidentiality for the effectiveness of psychotherapy itself. The wish is that there is a worldwide recognition of the special role of psychotherapy as a profession, and respect for the autonomy of psychotherapists in keeping confidential the material obtained from their clients. As a therapist in Austria, I am committed by the license and by the law to keep all information of my clients secure. Documents are locked up, and information are encrypted so that no client information is compromised. When doing research or case studies, the information that is provided is altered in such a way that no person can be remotely identified in the work. All this is monitored by ethics commissions and peer groups.

This code of the psychotherapeutic profession, it’s protection by law of the therapists and clients, in countries like Austria, creates an environment safe for people to use psychotherapy as a means of healing.

Bibliography

Ellenberger, H. F. (1966). The pathogenic secret and its therapeutics. Journal of the History of the Behavioral Sciences, 2(1), 29-42.

Fruehauf: Wang Fengyi’s Emotional Healing in Traditional Chinese Medicine

“All disease comes from the heart” writes Freuhauf (2006). With this statement, he refers to a traditional Chinese concept of illness.

The Five Element Theory of Chinese Medicine

Chinese medicine evolved in relative isolation, with little outside interference, and has held its own through time. Documents of Chinese medical writings date back to 1500 BC. Chinese medicine is based primarily on the theory of the five elements or wuxing (五行) and the concept of yin-yang (balance) and the idea of correspondence between organism (microcosm) and its environment (macrocosm). It is dependent on the natural rather than the supernatural. Hence there is belief in the connection between the body and nature. Human emotions are considered the “vital air” in the body, and are viewed as equivalent to nature, and that, which in turn connects the body with nature. The organs are considered to affect emotions (Tseng, 1973).

The wuxing is used to describe almost everything that is tangible and intangible in the universe. In the above diagram, the elements are represented by organs. Emotions are also allocated elements. We can see from the table below how the wuxing is used as metaphor to explain the flow of relationships between objects and concepts.

Wang Fengyi uses this principle as a guide to connect the illness affecting particular organs with emotions and relationships, etc.

Psychopathology and Chinese Medicine

The Chinese character for madness, feng 疯, is etymologically composed of two parts: wind 风 and illness 病. This indicates that such illness is brought about by extraordinary “wind”, a word which also implies emotions.

It is no accident that the modern Chinese term for psychosomatic medicine is xingshen bingxue, literally the science of how (primary) physical form and (secondary) spirit relate in the disease forming process. (Freuhauf 2006)

Since traditional Chinese medicine is characterized by the concept of visceral organs, patients frequently describe their psychiatric problems in terms of organs, like “exercised heart,” meaning apprehension, “injured heart” to mean sadness, and “elevated liver fire” to mean agitation and tension (Tseng, 1973).

Psychological problems are therefore deemed somatic- and organ-based, the Chinese never separated psychiatric disorders from other medical illness. Mental illness was never of particular pre-occupation in Chinese culture as it is in the west. Large mental asylums therefore have never been known to exist in pre-modern China (Ng, 1997).

Wang Fengyi’s Emotional Storytelling as Treatment for Somatic and Relationship Problems

When Wang Fengyi passed on in 1937, he left behind followers of his technique; one of whom is featured in the video above. The method of treatment is story telling. The practitioner sits among a group of people and tells a story (or something like a story). His story induces emotions in the individuals. From the video, we can see how the group dynamic plays an important part in the field. Even as a observer, emotions are induced in us. People laugh and cry at the same time. Some even throw up.

The explanation is that locked-up painful feelings (the practitioner in the video terms it poisonous feelings) are the cause of disease. These poisonous feelings (hate, blame, anger, judgement and annoyance are described here) arise from relationships with others because there are things that we feel but aren’t allowed to come to terms with or say.

The negative emotions are part of the wuxing (five-element cycle) and blockage to this flow causes a blockage to the organs that are also part of the wuxing.

Releasing these negative emotions, free up the flow, and hence improves overall well-being of the person. In the video, we can see the cathartic effect at the end of the session.

Emotional Story-Telling and Gestalt Psychotherapy

Wang Fengyi’s concept of releasing painful emotions is concordant with the gestalt therapy. We do not call the emotions poisonous, but the emotions that we encourage to be expressed in the therapy sessions are nonetheless painful.

In gestalt therapy, therapists do not need to tell the stories. The stories come from the client. The therapist’s job is to support the client with the feelings that emerge from his/her narratives. Using the two chair technique, and “acting out” works in this way.

Gestalt therapy is also focussed on the somatic aspect of emotions. Very often we ask clients to locate the feelings in their bodies. Checking with the feelings in the body, brings the client to the awareness of the mind-body oneness.

The work of Wang Fengyi is very much relevant to me as a therapist. I gain much inspiration from this traditional wisdom.

Bibliography

Fruehauf, H. (2006). All disease comes from the heart: The pivotal role of the emotions in Classical Chinese Medicine. na.

Ng, C. H. (1997). The stigma of mental illness in Asian cultures. Australian and New Zealand Journal of Psychiatry, 31(3), 382-390.

Tseng, W. S. (1973). The development of psychiatric concepts in traditional medicine. Archives of General Psychiatry. 29:569-575.

Psychotherapy Case Studies of the 18th Century: Das Magazin zur Erfahrungsseelenkunde

Karl Philipp Moritz‘s (1756-1793) das Magazin zur Erfahrungsseelenkunde (translated as the Magazine for Empirical Psychology) could be the first published books (or journal) of modern psychotherapy case studies. The magazine is unfortunately, still not translated into English.

100 Years before Freud…

When we think of the dawn of psychotherapy, we think of Sigmund Freud, the father of psychoanalysis. Freud’s writings are filled with case studies of people’s lives, narrated by the persons themselves or by people who are in contact with them (e.g. family, doctors, etc.). Psychotherapy (and psychoanalysis) was born out of the realization that through the talking about, the narration of one’s inner life stories, the narration one’s experiences in relation to one’s society / culture / beliefs etc., one achieves and awareness of the self through the sharing of these “stories” with another. Therefrom comes a process of psychological healing. The term “talking cure” is coined by Freud’s first documented psychoanalytic patient, Bertha Pappenheim (Freud et.al 2009 /1895). Freud’s writings were, however, created more than a century after Moritz’s Magazin.

The Magazin, das Magazin zur Erfahrungsseelenkunde, was published in the years 1783-93. Edited by Karl Philipp Moritz, it is thought to have also anticipated the 19th century development of fields of psychology, pedagogy, criminology, etc. Each Magazin was published triennially and was roughly 125 pages long. There are in total 10 volumes, each in 3 parts.

18th century crowd-sourced material

Somewhat like the Wikipedia of today, das Magazin is also (to a certain extent) a crowd-sourced. There is no one author to this journal. The readers were encouraged to make public “the secret history of own thoughts”, record behavior of neighbors, students, and friends, publish their earliest childhood memories and write case histories of criminals, madmen and other misfits. It was a collaboration of lay people which included also educators, judges, etc.

Interest in the Individual’s uniqueness

Moritz’s project was driven by the question: how can we find a mode of writing that does justice to the idiosyncrasies and detours of the individual’s life? How do we describe the individual-ness / uniqueness of the self?

Interest in the Individual in relation to society

Moritz’s interest was also in social deviants, and case studies from the judicial system (criminal cases). Theses case studies forces us to think about how the individual responses to societal influences. The “cases” are in fact the link between the individual’s soul and the socio-political power that is imposed on it.

In other words, the work is an initiation of the notion of psychopathology, which is actually a symptom in which a person develops as a result of negative reaction to his environment. This environment can be physical or social. With such an attitude, Moritz’s concept mirrors the gestalt therapy approach of seeing the client in a holistic manner.

Description of cases without making judgement

The premise behind das Magazin was to portray these case studies as it is. There was interpretation or judgement of the cases presented. This is of course, different from Freud’s work.

In 1798, influential psychiatrist, Alexander Crichton, described the magazine to be a kind of publication he has not before come across since it was filled with “well-authenticated cases of insane aberration of mind”, narrated in a full and satisfactory manner, “without a view to any system whatsoever”. This means no added interpretation from higher order.

This was and still is a unique concept in writing. It is a way of sharing knowledge without controlling the reader.

These cases are narrated and described, providing as clear and complete information as possible, so that the reader gets a full as possible picture of the subject. The reader is also able to freely make his own interpretations and associations.

Moritz’s motivation

The Erfahrungsseelenkunde raises the ancient injunction to know thyself to the level of a public scientific project. Just as an individual, through self awareness can mature and live fully, so would the collective awareness bring about positive social change. Moritz says:

“If only there existed moral doctors who, like the physical doctors, were more concerned with individuals, and would publicly report of their cures, to the betterment of all…” Moritz

Moritz alludes to the need for a profession that works with the individual in the way of guidance through unique personal issues. He uses the word “moral”, which is not meant to be the same a morality imposed by culture or religion. Moritz belonged to the radical enlightenment movement that was against religious control. What “moral doctor” likely means is the healer to bring the individual to a point where he can integrate peacefully with society. This is a good goal to make in psychotherapy.

“On the basis of the combined accounts of many careful observers of the human heart one could build an empirical psychology which in practical use would exceed anything our ancestors have done on this field.” Moritz

We have many examples of psychotherapists (like Irwin Yalom who writes amazing books) who have done this: studying their patients and sharing their observations with the world. From them we have learned a great deal about our society as it unfolds.

We also gain much from people who write honest memoirs, or share their lives with others on the internet.

“In the beginning, all these observations must be collected in magazin under certain rubrics, without reflection until a sufficient amount of facts is there, and then at the end all of this must be ordered into a purposeful whole. What an important work for humanity this would be! This would be the only way how the human ace would com to know itself, swing itself to a higher level of perfection, as a single man can perfect himself through self-knowledge.” Moritz (Galius 2000)

Moritz was very careful to leave out any form of premature theorizing or moralizing in the magazine. This was to offer a moral- and censor-free space for people to learn about being a person.

We learn of Moritz’s political aspiration for creating this project in his statement in which he implies that criminals should be studied, and not simply judged and executed (Galius 2000, p. 81):

We witnessed the execution of a thousand criminals, without considering worthy analysis the moral damage of these limbs, which were cut off from the social body. But these limbs are as important for the moral doctor as they are for the judge, who must perform this sad operation.//

He alludes to the fact that it is important for society to understand what led to deviant behavior, how to prevent it, how is society responsible for this behavior, and how could the process that had led to it have been overlooked. Moritz writes metaphorically:

How did the inflammation of the damaged limbs slowly increase? Was it possible to prevent the growth of the evil, to cure the damage? What negligence in observing or dressing this wound caused it to spread until all antidotes (Rettungsmittel) were ineffective?

Moritz also makes clear his stand on the concept that people are born healthy but become deviant as a result of life experiences. This is a controversial idea, since at the time, the belief was aligned with the Judeo-Christian doctrine that man was created sinful.

On which thorn did the healthy finger scratch itself, which little unnoticed splinter remained in it, inflamed, and gave rise to such a dangerous tumor?

The parallel of Moritz’s ideas to the work Psychotherapy

From the above quotation of Moritz, we see how he uses the metaphor of the splinter, which is something very small and often overlooked. He encourages society to pay attention to details without judgement. To observe like this allows one to see beyond pretenses of society, and to observe the underlying human condition / “secrets”– which one can say, alludes to the conceptualizing of the term, “the unconscious”.

The emphasis on “thinking in cases” is very much the foundation of the psychotherapeutic profession, in particular Gestalt therapy:

*to see a case study as an individual phenomenon;
*to unearth the hidden chain of events in an individual’s life history that leads to the symptoms;
*to see the individual not in isolation, but as part of a whole (including his society, status, life-cycle, biological and psychological etc);
*to avoid making generalized diagnosis;
*to share and listen to one’s stories without theorizing or moralizing;
*to tolerate the tension of situations that are unsettling to the society, so as to achieve awareness,
*to be able to integrate this knowledge.

Bibiliography

Breuer, J., & Freud, S. (2009). Studies on hysteria. Hachette UK.

Gailus, A. (2000). A Case of Individuality: Karl Philipp Moritz and the Magazine for Empirical Psychology. New German Critique, (79), 67-105.

Moritz, K. P. (1978 /1783). Gnothi Seauton. Magazin zur Erfahrungsseelenkunde. Berlin 1783-1793. Retrieved from: http://telota.bbaw.de/mze/

Pinel 1754-1826 on Treatment of Illness from “Moral Causes”

Out of the era of the post French Revolution, we learn about Philippe Pinel (1754–1826), one of the founding fathers of what would later become psychiatry and psychopathology.

“Pinel is important because of his method: he was the founder of the clinic, that is to say, of the determined and systematic approach through which mental illness acquired its distinctive status, institutions, and treatment.

With regard to theory, he took a rather peculiar stance: he remained skeptical of any form of theory that, as far as he was concerned, moved too rapidly away from observation. Hence one cannot talk about Pinelian theory. Rather, he proposed a pragmatic approach, a form of know-how (savoir-faire) that enters history under the name of the “moral treatment” (traitement moral). This approach accords with his views on etiology. (Verhaeghe, 2008. p 93)”

He distinguishes between three groups of pathogenic factors / causes of illnesses:

• Physical causes (trauma, organic diseases);
• Hereditary causes (debility);
• Moral causes.

Deeming the first two practically incurable, he concentrates on the third group, which can be inferred to as describing psychological pathology. His ensuing treatment model recalls the Hippocratic idea of illness, in which illness is the body’s healthy defensive reaction to an imbalance, and whose normal result is health. This is not unlike much of the philosophy of traditional medicine which we also embrace today.

It is clear that such a conception of illness has important repercussions for the way the person who was then called the “alienist” responds. Pinel sums this up in three basic rules:

• He has to wait;
• He has to avoid any intervention that disturbs the natural course of the illness (because its ultimate goal is health);
• He must help the illness progress.

It is precisely this last that constitutes the “moral treatment.”

This principle of “waiting” instead of leaping immediately into trying to “cure” or “treat” or solve a problem” or to “eliminate the pain”, with regards to working with mental issues was also clear in the decades prior to Pinel. The creation of the 18 century Magazin by Moritz, das Erfahrungsseelenskunde, centered also around the same premise of observing without premature judgment, or looking for explanation. Moritz also wrote about the need for “moral doctors” to work with individuals seen as societal deviants.

This is also in line with the principles of the Paradoxical theory of Change in Gestalt Therapy, written by Arnold Beisser in the 1970s.

With regards to psychological health and working with patients with psychological and psychosomatic issues, this attitude of being patient, of observing and understanding the client’s symptoms, and allowing the client to understand his/her situation in order to support the change process, without premature intervention is crucial for therapeutic change in psychotherapy.

The magic pill that solves the problems immediately, does no magic in helping the client work through with the goal of dealing permanently to alleviate the symptoms of depression, anxiety and other inter- and intra-personal issues.

Bibliography

Verhaeghe, P. (2008). On being normal and other disorders: A manual for clinical psychodiagnostics. Karnac Books.