The Psychoanalysis of CBT; despite being Alternative Medicine why it is so popular; and why it is no more than a Fur-lined Mousetrap

 

What exactly is CBT, and how in a span of a few decades it has become the very face of psychotherapy? In the halls of academic psychiatry, the rout of psychoanalysis has been so complete, and the rise of Cognitive Behavior Therapy so remarkable, that any graduating psychiatry resident will not hesitate to declare that Freud is obsolete, psychoanalysis has been debunked, and though he himself has no intention of practicing psychotherapy - 97 percent of psychiatrists no longer do it and understandably so because so much more money is to be made by just writing prescriptions after listening to no more than five to fifteen minutes, with no need to examine any further than whether the patient's symptoms are less or more in intensity since the last medication adjustment, leaving the understanding of his psyche and its complexities and their healing to lesser professionals like the social workers, psychologists and other paraprofessionals of the most dubious levels of competence and training - he knows that CBT is the only scientific psychotherapeutic approach for treating mental illnesses and when asked what is so scientific about CBT, he will tell you that the psychiatric journals are replete with articles where CBT's superior efficacy has been statistically proven in a double-blind fashion, and that is the gold standard of being science.    

But can a treatment approach be called scientific just because its practice significantly reduces symptom intensity?

 Can religion be called scientific because most mentally ill find relief through its practice, sometimes outright cure - lame walk, blind see, even dead have come alive (Lazarus of Bethany did per the evidence-based case report of John the Baptist)?  What do we make out of the strange phenomenon of agoraphobics who won't go beyond their front door - in extreme cases not even cross the threshold of their bedroom - lest panic strikes, but may travel all the way to Timbuktu if accompanied by a trusted person,  even a child can fit that role as long as his presence would function as a restraining influence (upon their forbidden unconscious wishes). Recently, a patient of mine, after years of suffering from "Restless Leg Syndrome," was healed in a day. "A very special protein diet, fortified with an extraordinary 'balanced combination" of vitamins, minerals, antioxidants, and a rare mineral that my body was lacking, did the trick," she declared triumphantly. In another patient it was not lack of a rarity in her diet but the presence of one was causing all her mental ailments. She was convinced that she had a leaky gut - no amount of reasoning that a leaky gut will cause sepsis not mental issues would leak through into her skull - through which a rare alcohol was getting fermented in her bowels and then leaking into her system and triggering her "mast cells", causing severe hangover that would last anywhere from a few hours to a few weeks. Elimination of a laundry list of dietary items, virtually everything she enjoyed, under the guidance of a "Cleveland Clinic leaky-gut specialist", "stopped" the making of this "gutsy moonshine" and brought her relief not just from her "hangovers", but also from her chronic fatigue, crippling anxiety, and the ever-present simmering rage.  A young man, barely in his thirties, who suffered from chronic back pain for years, got cured of it after reading John Sarnos book "How Back Pain is Manifestation of Repressed Anger". And now, when the pain returns, all he has to do is to read a page or two from the book (like the reading of  Bible or carrying out a couple of cognition-enhancing exercises out of a CBT manual) and voila, the pain is gone.   

Just like one does not seek cessation of respiratory symptoms in lung cancer with massive doses of prednisone, nor silences the sexually-laced verbal epithets of a Tourette child by cutting his tongue off, nor quells the hallucinatory agitation of a schizophrenic by needling the frontal cortex through the orbital cavity regardless of how good are the results of such butchery on the tailored rating scales, we cannot accept a medical approach as scientific just because it brings  relief from some targeted symptoms. Any therapeutic modality to be viewed as scientific, and not Alternative Medicine, has to be backed up with at least a preliminary theory whose basic premises are not in such contradiction to the proven body of human knowledge that it falls apart on the very first examination. Science is the study of causality, and the scientific method no more than any unbiased attempt to discern true cause-effect relationships from the mass of false assumptions. The latter get established when two variables make sensory impressions simultaneously or in quick succession, and the mind, because of the compulsion to search for causality in everything it perceives because of its survival imperative, assumes its presence, directly or indirectly, regardless of there being one. If pure science, in contrast to applied, which is about favoring some cause-effect relationships over others in contrast to how they occur in natural order, is the study of causality, Psychiatry is the only medical specialty where an entire nosology (Diagnostic and Statistical Manuals of the American Psychiatric Association), came into existence as DSM III (subsequent DSMs are just the same with negligible changes) where causality is not taken into consideration - actually intentionally eschewed - in diagnosing mental problems, limiting its approach to stay within the simple clustering of symptoms. Should then it surprise us that Cognitive Behavioral Therapy emerged around the same time when DSM III was hatched, the two enterprises complimenting each other by focusing purely upon the surface phenomenon instead of understanding and manipulating the causes that resulted in the formation of the symptoms. 

DSM III was built upon a revolt against psychoanalysis's overarching contention that all mental symptoms - excluding those that are due to direct injury to the brain from trauma (which includes  overwhelming psychosocial trauma [PTSD]), neural degeneration, biochemical toxicity from substances of abuse - are the result of "neuroses" (which also at the deepest level are physiological toxicity from a tumultuous secretion of reproductive hormones). 

Neurosis as the core etiological process behind psychopathology arose from the gradually accumulating body of knowledge over the millenniums that even madness is not arbitrary but a strictly determined process with a method (logic) of its own where mental impulses (perturbations from sensory input activating the neuronal reflex arc ) which cannot proceed towards motility and discharge via their functionally appropriate pathways, due to inhibitions imposed upon them, get displaced upon neighboring functions. It is this displacement that lies at the heart of neurosis and mental illnesses. The compromise formations that are formed between the displaced mental functions and the continued influence of inhibitions cause inefficiency, irrationality, incomprehensibility and bizarreness in their execution and manifestations, giving them the mantle of madness.  Such displacements when they do not go beyond the neuronal networks that regulate somatic functions without involving cognition cause "actual neuroses" - anxiety, hypochondriasis,  neurasthenia (fibromyalgia) and perhaps even autoimmune disorders like IBS, interstitial cystitis, asthma, at their core may have nidus of actual neuroses - while those displacements that manage to reach further up in the nervous system, in the psyche (the mental representation of the external reality), they result in psychoneuroses - hysteria and obsessional neurosis and their variants.  One rarely sees pure forms of actual or psychoneurosis, for in every neurosis there is always some of each. 

From where come these inhibitions? They are the result of repression, a psychic mechanism that has evolved to keep the instinctual impulses (which psychoanalysis has termed the id) confined in to their  their unorganized, uncoordinated, unconscious versions, their entrance into the organized and coordinated part of the psyche (the ego) barred. It is not towards all instinctual impulses repression comes into play. Only towards those that the ego - the outer layer of the id which adapts itself to the two sensory surfaces, one facing the external reality, and one the id, mediating between the two, as the latter seeks union with the former - considers dangerous. In other words repression is instituted towards ego dystonic instinctual aims. Without entrance into the ego, these aims cannot become purposeful actions. For the coordinated motility can only be reached by the id when it is in cooperation with the ego. What is the raison d'etre  of repression?  For many instinctual drives in their raw forms - that were serviceable to different degrees in our phylogenesis - are no longer so, without subjection to modifications and sublimations, in our current state of cultural organization, and if allowed expressions in these earlier versions, will  not only destroy the organization of the ego as they traverse through it, but the whole organism itself from retaliation by the outside forces for their aggressive aims. The external world, besides providing everything that we need for our survival, is also an ever present threat to our existence. The objects that nourish and enable our reproduction also author our injuries and traumas and ultimately our disintegration. The world has to be interacted with caution, often requiring putting our  needs on the backburner till they are modified enough to escape counter aggression.  Repression by inhibiting the movement of the id impulses gives them opportunity to make compromises with the ego, such that when these altered impulses are expressed to find the object that they need they do not  invite counter aggression. The processes by which the ego extracts these compromises are called ego defenses.    

The prime mover of repression* (see the footnote for the metapsychology of repression) is the  agency of pain. When the ego, the core of which is the sensory surface of the organism, including the kinesthetic feedback it receives from its motility (motor behavior), is subjected to pain, it puts inhibitions upon whatever is taking place. An across the board first step of dealing with pain, including the threat of it. Ego assesses the source of the danger/pain, and if it is due to the movement of an id impulse towards action and discharge, if it considers that such a satisfaction, based upon its familiarity with the external world, will provoke retaliation, and, quantitatively, the retaliatory injury and pain will be greater than the pleasure that would accrue from the satisfaction, then it will inhibit the id impulse's further progress. Which will be accomplished through the affect of anxiety, generated by the neurochemical and neuroendocrinal secretions, reflexly released when harm is anticipated. Alongside these physical components of anxiety, there is activation of psychological processes, memories of the  similar anxiety situations and the steps that had been taken to end it. Counter-cathectic memories of which we will hear more later. The anxiety and the psychological processes activated by it, bar the id impulse's entry into the ego. This is what repression is. Pain inhibits motion, pleasure accelerates it. Repression occurs at the border of the unorganized id and the organized ego. How does the ego learn to generate anxiety to institute repression? It is through phylogenetic memories - the species inherited history etched in its DNA  The memory traces of the traumas that countless generations of our ancestors had encountered when that particular impulse had succeeded in getting acted out towards others without sufficient modification. These inherited memory traces reactivate the affect of anxiety, pain and the resultant repression.  It happens even in the absence of any fresh injury. Though fresh ontogenetic infliction of pain by parents, and parent substitutes, also plays a significant auxiliary role in strengthening the inherited repression. The id impulse repulsed by this repressive pain now finds itself deviated from its original path, with no choice left but to seek forward mobility through camouflaging its intentions. 

What exactly is this camouflaging - distortion in psychoanalytic terminology - and where does it come from? It is simply a continuation, into the psychological dimension, a quintessential behavior of all  living organisms - from plants that blend with their background to escape herbivores, to flowers that devour insects hiding their blood-sucking intentions behind their lovely exterior, to the chameleons that match their profile with the colors of their surroundings to escape predators, to the complex give and take game playing humans - to deceive their surroundings from noticing their sinister motives by putting a front of innocuous ones.  Amidst the abundant bountifulness of this universe, lies endless masquerading and counter-aggression. Its sustaining dimension is Eros, the Life Instinct,  its destructive dimension, Thanatos, the death instinct. The internalization of these two pillars of the universe - the will to combine and the will to disintegrate  - in humans is played out as libidinal id impulses pressing for union with the outside from which it got separated and entrapped into individual organisms, and the destructive impulses inhibiting this union through the mechanism of repression. 

The camouflaging (distortion) is achieved through displacements.- the id impulse making a common cause with the neighboring, or related, ones. This hides their true nature, but the distortion introduces illogic (madness) in its further movement and inefficiency in its functioning.  This displacement is what mental illnesses are about. Incidentally, it may be mentioned, that displacements being upon related functions  helps us in undoing these distortions in therapy For example it is easy for us to decipher that the disorders of intestinal tract often are displaced genital sexuality. Hysterical vomiting being an expression of disgust at the impulse to seek satisfaction through the psychosexual organization of the oral phase, with the mouth substituting for vagina. The Ancient Greeks were right therefore when they nailed hysteria as wandering uterus. The excessive mucosal secretion of colitis (Irritable Bowel Syndrome) is the other end of the intestinal tract taking over the role of the genital passage. The subsequent constipation representing obstructed labor. The former being a substitute satisfaction for passive genital excitement and the latter being the oppositional defiance reaction to undo the yielding. Making common cause with other impulses (condensation in psychoanalytic terminology), even with ones that are diametrically opposite in their aims, in order to combine their energies to overpower the repression, adds further distortions. Other mechanisms,  to introduce incomprehensibility and make the displacements successful, are symbolism where objectionable psychic structures are replaced by less objectionable ones, and making one's own self the object of the impulse instead of seeking its satisfaction in others. - sort of cannibalism. Herein lies the germ of the disorder of Narcissism and other LGBTQ adaptations.  Without going into details of these mechanisms - a most penetrating and enlightening account of them  is given by Anna Freud in "The Ego and the Mechanism of its Defenses" - it can be said that they operate outside the conscious will, and their movements,  proceeding  nonlinearly, separating and rejoining multiple times before emerging in the ego,  are not easy to fathom. They require inferring. Something that a novice in science assumes that since these processes occur in the unconscious, which by definition is not perceptible, its study cannot be scientific. It is interesting that this objection, so vehemently invoked towards the study of the mind, is never levelled against the sciences of astronomy and paleontology which too are primarily inferential. Emotional resistances against touching anything that will successfully uncover sexual motives underneath the surface phenomena has to be the factor as to why such double standards exists with psychoanalysis versus other disciplines, and as to why CBT, which does not take sexuality into consideration in its conceptualization and healing of mental illnesses, is such a darling of not just the mental health professionals and the mentally ill (the two are often difficult to tell apart), but also of the funding agencies (health insurance industry) and the governmental agencies.  One notices wryly that how it has become fashionable even for regulatory agencies, such as governmental courts nowadays to mention when meting out counseling as a punishment to specify it be  CBT.  At this point it also occurs to us that the rapid fire adoption of  DSM III, not just in the US, but across the world, owed not a little to keeping its nose above "the smut of sexuality".   

More complexities exist in understanding neurotic displacements, Not only it is achieved through  undergoing distortions, condensations, symbolizations, turning against the self (parts of one's own self becoming substitute for the desired attributes of others) but also with regression to lower levels of  psychosexual organization; from more mature to earlier ones; from genital to  pregenital. Expression of genital sexuality, in contrast to  pregenital, can invite greater censure and greater infliction of traumatic retaliation. Seeking genital sexual satisfaction is fraught with competition from the rivals and its original form requires extensive modification during the Oedipal phallic phase of psychosexuality sexuality to become serviceable in adulthood without inviting annihilation.  These modifications occur through the internalization of parental authority into one's own self, with one part of the ego, behaving like the parent (the superego/the conscience), watching over rest of the ego.  The fear of the parental authority in the form of castration anxiety becomes the engine of cultured behavior. In females the castration anxiety manifests as having been unfairly and traumatically deprived of this important piece of anatomy and which she deduces, and correctly, that it will keep her handicapped in all her endeavors through life. Her life to a significant extent will become a protest against this unfairness. However, with the actual memory of it having happened being absent, it is dealt with developing a conviction of  having been done wrong but without a clue as to when and where. The subsequent revenge impulses and feelings of compensatory entitlement will predominantly emerge as antagonism towards men and for the most outlandish reasons, inviting epithets of femme fatale, inscrutability of the female character, and borderline personality disorder.  Castration anxiety owes its origin to the phylogenetic reality of the practice of castration in hands of the despotic primal father for challenging his sexual hegemony in the Primal family constellation [see Freud's Totem and Taboo for a comprehensive exposition of this epoch of human phylogenesis]. It manifests as ever-present dread in men and the fear of loss of love in women 

 It is easier to disguise amorous intentions as non-sexual when they are expressed through the anal and oral psychosexual conduits than when the intentions are clearly genital. But expression of sexuality through pregenital outlets has its own drawbacks. Such sexuality is viewed pejoratively and contemptuously labelled as perverted.  And when one is not in the throes of extreme passion, is felt by oneself and others as disgusting. Smell as an alluring sensations may be highly prized in dogs but in humans aesthetic appeal resides more in visual appreciation from a distance than in messy genital contact. The presence of such impulses in oneself, even if not acted out with others, and limited only to fantasies (conscious or even unconscious), causes recoiling, not just on part of the patient, who out of shame and embarrassment rather hide and make a show of condemning it in others, but on the part of  the therapist as well, and the two, unless the therapist is well versed in psychoanalysis, make a common cause in finding a solution for the patient's illness by every therapeutic mean except through analysis of its sexual roots. And herein lies the main reason for CBT's popularity. It ignores the factor of regression in creation of the symptoms just like the official diagnostic and statistical manuals of Psychiatry (the DSMs) do too, satisfied with clustering them into meaningless groups. The patient who is already prejudiced against his symptoms, exasperated by their irrationality, wholeheartedly takes refuge in CBT. And CBT is more than happy to join hands and declare yes, yes, your symptoms indeed are gobbledygook and if those bizarre involuntary sexual thoughts and imageries that are intruding into your consciousness,  don't worry as to whence and why they come. Just rebuke them in the name of Aaron Beck. For these "automatic thoughts" have no need to be addressed. Forget their sexual underpinnings, they have no standing to exist in the mind. Instead deal with them with this silver bullet of ours, the mantra of  3 C's -catch them, check them and change them. That will rid you of these intrusions which had no right to be in your mind in the first place.  And to replace the vacuum we have have these manuals, full of wholesome thoughts, unassailable by any logic, laboriously searched by us so you wont have to scroll through the Internet.  And selling of this mantra is all that is to psychology. Just identify and get rid of the bad and fill it with good stuff. Mankind's fondest hope to be able to reason with mad people, at last has come true through the 3 Cs of CBT. As to why in this God's world, where not a single blade of grass stirs without strict causality, the Almighty will allow irrational nonsense to pervade its finest creation, the human mind, CBT tells us nothing.   

Another challenge which makes the study of neurotic displacements so difficult is that the transformations do not take place in the ego's reality-oriented logical secondary process thinking but through its admixing with the unconscious mind's primary process immediate-discharge seeking pathways. There is less resistance to the movement of the mental impulse through the associations existing in the primary process which is not influenced by how things are actually associated in the external reality. The primary process network is the earlier organization of the nervous system where if two phenomenon were perceived simultaneously, or in quick succession, or have physical similarities, or are conceptually related, then one replaces the other in facilitating the movement of the mental impulse towards action and discharge, regardless if the two have a causal/functional relationship with each other in objective reality.  To prevent such an easy passage of the mental impulse, and dissipation of its energy through goalless discharge instead of lining up in the psyche a course of associations that when converted into physical action will procure the object desired or the object that is causing discomfort removed and thus stop the generation of the disturbing mental impulse,  secondary process developed.  Secondary processes are more specialized practical neuronal networks that developed from a long series of successes, big and small, starting from our crying for our mother's breast and her action of putting her nipple in the mouth, to listening to and successfully analyzing a patient's dream where the essence of his whole neurosis lays hidden, that were reinforced by neurochemical processes, perhaps through the agency of dopamine system. Networks that have much higher level of energy (charge/cathexis)  than other associations that got connected with each other through the inherited reflexes or through having randomly occurred together by chance. Primary and Secondary Processes are in a continuum, and the latter can be conceptualized as oasis of human settlement in a dense unorganized chaotic rain forest of associations. Incidentally, even what looks like unorganized and chaotic for human survival in a rain forest  is completely purposeful and organized for other ecosystems. At the primary process end of the spectrum, under the affect of relief (pleasure), everything becomes interchangeable as one notices in the pathological condition of mania, or induced iatrogenically as when one takes psychedelic drugs, or at the height of sexual gratification as with one's partner, or in orgiastic fusion with a group as in Tantric Yoga, or in spiritual practices such as devout chanting where the boundaries between the self, others and the divine disappears. Under the influence of painful affects, the Primary Process interchangeability works in the reverse with a single thought or perception or emotion replacing all others mental activities as in depression where preoccupation with poverty or self injury can exclude all other concerns of life, or in other mental illnesses, where an obsession or an affect of anger or hate can suppress all other thoughts processes and emotions. On the extreme end of Secondary Process spectrum, thinking becomes so free from desiring objects that only their mathematical abstractions are left for thoughts/associations to traverse upon. Hence mathematics is the purest form of secondary process thinking, unbending in producing results to all wishful distortions and affects. 

A clinical example is in order to illustrate how primary process operates in the formation of mental symptoms.  

A four year old child developed an intense fear of his father. The fear appeared out of nowhere. He had not experienced any unusual trauma or threat, just intense sibling rivalries with his older brothers and recently the birth of a sister. These variables by themselves should not have risen to the level of trauma unless one takes into account the fact that he was also being simultaneously inundated with the Oedipal psychosexual impulses that biologically reach their peak around that age. Under the influence of these impulses, biochemical in their origin, but psychosexual in their impact,  libidinal and aggressive fantasies were being generated which could be broadly placed under four categories: to love his mother erotically; to love his father erotically; to contemplate disappearance of his father to love his mother uninhibitedly, to contemplate disappearance of his mother to love his father uninhibitedly. In short he was in throes of a complete positive and negative Oedipus Complex, with all four of its components raging fully.

In this package deal, the fear of the father was the most powerful. It was backed by the fear of castration. At perceptual level it was experienced as an apprehension of something dreadful happening,  like running into an accident. At night anxiety dreams of unknown dread  began waking him out of sleep. He developed an intense curiosity to see his mother undressed and one day he managed to follow an aunt of his, a mother substitute, right into the bathroom, where she had lifted her skirt all the way up to sit on the toilet seat to urinate, exposing the side view of her buttocks. While the aunt was no means overweight, nevertheless a shiver had run up his spine like a bolt of lightening as to how massive were her buttocks.  Fifty years later, in analysis, it emerged that the fear of the buttock size was actually a reversal of the shock of seeing the absence of penis. It had ended for good his having assured himself many a times before,  while playing doctor-patient and other sexually tinged curiosity games with neighborhood kids, that absence of penis in little girls is because it is still too small to be visible but will grow up once they become adults. Through the mechanism of reversal,  the dread that penis can be absent in grownups too (castration does happen) had got displaced upon how large buttocks can be. The psyche had attempted to mitigate the horror of castration through the consolatory thought "so what if she does not have a penis, look at those huge buttocks instead." But this compensatory assurance had not done the job quite fully. It repressed the vision of the absent penis but could not keep out the fear that had seared through him. 

The four cross-purposive Oedipal aims were now in an impasse. If he dared to love his mother, which would be active/masculine expression it would  be equivalent to stealing the mother from his father. At that stage of development the whole world is the father's property - similar to how later in life he would respect the eminent domain of the state and the religious doctrine of everything ultimately belonging to heavenly father.  And such a stealing if he did attempt by invoking the father's wrath would result in castration.  If he gives into the impulse to love his father passively and tenderly it would entail identifying with the mother and replacing her relationship with him, which would be castration too. For cultivation of femininity in a man occurs at the expense of his masculinity and vice versa in women. Actively loving the father, demanding passivity from him for discharge of his aggressive erotic impulses,  entailed provoking counter-aggression, defeat and castration. Passively loving the mother had obstacles too. She lacked penis. With all the pleasurable sensations and erotic fantasies that were arising on stimulation of that organ, especially  in the wee hours of the night when he would wet his pajamas with enuresis to calm down these fantasies, absence of that source of pleasure (absence of the penis in the mother) was unacceptable. She was just not right as an erotic partner for phallic pleasure through mutual enhancement (something, later in life, in highly masculine men, would lead to the rejection of females as sex object altogether, in favor of masturbation in company of similarly minded men, the now widespread practice of circlejerking in the surreal world of LGBTQ). Also libidinal attachment to her was felt to be dangerous in that with her envy aroused, she may try stealing his to compensate for it being absent in her. Incidentally, if I may be allowed another digression, the distrust of women, to the point of punishing them even with murder, as serial killers do, because of the feeling that they have been betrayed by the female sex in this regard [recall Boston Strangler who would murder matronly women and then make a bow around their neck as if to fetishistically compensate for the absent penis] and "femicide" in various forms. including killing of female baby as a disappointment for it not being  male in primitive cultures, including that of the ancient Greeks, and the sacrifice of young girls to the altar of Hindu Goddess Kali, arises from this complex.  

All roads led to castration. And this was the fault of his father, the four year old boy's cognition deduced. For it was the fear of him that these fantasies had become so complex and mutually antagonistic and could not  proceed towards fulfillment and discharge. (Herein lies the germ of mankind's preoccupation with conspiracy theories and as to why we hold our leaders [father substitutes]  responsible for all our woes. It is our own hostility towards them that we project as their hostile preoccupations about us). Retaliatory aggression emerged, culminating in scenes of his father's disappearance. Disappearance and demise is equivalent at that early stage of life. Herein lies the germ of  mankind's endless fascination with whodunnit murder mysteries and the plot of all our action movies where the hero is in mortal combat with the father who appears as villain in endless forms. He had preserved a screen memory from that time. He saw his father driving away from home. The meaning of that screen memory could only be deduced if one adds "to never return". Another time he saw a vivid picture of his father meeting a road accident. He had a dream of his father getting chopped up into bits by bandits on the highway.  Alongside seeing the father meeting a terrible fate was a rising devaluation of the mother's worth. A welling up of a contempt at her "inferiority". Decades later in analysis it was revealed that the devaluation arose from his feeling that she had betrayed him by conceiving another child after him, the recently born sibling. But more so for not fielding a phallus especially since this absence served as a warning that the vague dread of castration and other misfortunes were not all that vague but did happen to those who played with their penis. He had around that time ran into a psychotic child, whose nonsensical speech and bizarre behavior had horrified him, and which he had interpreted it as a punishment for being a bad boy. He also was periodically exposed to a beggar with ulcers all over his body which would fill him with revulsion and pity for the unfortunate man , equating the ulcers with castration.  To harmonize all these contrary oedipal impulses with each other, his causality based secondary process logical thinking - rudimentary and without adequate repertoire of memories to model upon  - was grossly inadequate. Furthermore these fantasies were occurring in a child whose body was not mature enough to execute them. 

The boy's ego (organized part of the mind) did what any organism would do when dealing with an insurmountable problem that is threatening its integrity. Like the proverbial ostrich it turned its back upon all these Oedipal fantasies, banishing them out of his consciousness. A developmental process which is the fate of all human children during that phase of psychosexuality. And it starts the human species endless ambivalence, if not outright hostility, towards all things sexual  But simply turning one's back upon something does not necessarily means its disappearance.

Boy's fantasies submerged into the unconscious where they regrouped in a subterranean existence, working upon themselves to find new entry points into the ego, primarily by covering their true intentions with disguises that would fool the repressive forces from recognizing and freshly repressing them. Meanwhile, in the ego, the vacuum was filled by thoughts and behaviors with contrary aims. As if by pursuing opposite goals, the prohibited impulses would be doubly barred. What were these contrary thoughts and behaviors whose occupation of the ego including its executive motor components would crowd out the libidinal impulses from finding outlets? These are what we term as virtues, the counter-cathectic measures. They are thoughts and motor behaviors that pursue aims that postpone, or altogether do away with, the satisfaction of erotic instincts. They are our aesthetic strivings, our altruism, our spiritual in contrast to material strivings, ascetism, pursuit of law and order, social justice and above all religious practices (Obsessive compulsive rituals). In short all that goes under the rubric of civilized behavior and inhibits direct sexual expression. 

From whence come these countercathectic measures? What is the source of their energy? They are the cultural acquisitions of mankind, passed intergenerationally, primarily from identification (mirroring). Their energy is derived from the instinctual impulses themselves. At their core they are still libidinal, but stripped of their original sexual aims of satisfying one's own self, now displaced upon satisfying the needs of others, primarily the parents, and then the members of the larger society's, who are at bottom extension of the parents and siblings, who because they are dear to the parents deserve our gratitude. Satisfaction of parents libidinal needs through working towards providing them the preliminaries that would facilitate their genital union, at the expense of the satisfaction of one's own erotic needs is what cultural activities are all about. Darshan, the most prized religious ritual of Hinduism, in which one views the bedecked images of paired Gods and Goddesses, is seeing in displacement the parental sexual union.  Such an inhibition of the individual's original libidinal aims, through channeling it into facilitating others sexual union, has become possible in humans because of our remarkable ability to identify with one another and vicariously satisfy our needs through their actualization in others.     

And when this transformation of the ego dystonic libidinal impulses into culturally approved behaviors does not happen sufficiently and they prematurely break into the ego despite the latter's objections and manage to convert themselves into motor behavior, they are deemed as mental symptoms. Mental illnesses are no more than failed altruism, insufficient transformation of direct sexual aims into culturally approved sublimated sexuality; triumph of narcissism over loving others.

What transformations of the (oedipal) libidinal impulses took place in this boy? The father's mental representation got split up into a number of other conceptually related entities. One outcome was development of fear of, and simultaneously fascination, with dinosaurs and dogs. One may ask why the human child chooses an animal as the substitute for the father? Phylogenetically our fear of the external reality was less with darkness and natural forces like thunderstorms and lightening, than other  animals, especially carnivores. They were our direct competitors and willfully attempted killing and eating us. Dangerous animals therefore are not only apt symbols of the strength of the external danger, primarily that of the father, but also the strength and dangers of the id impulses if allowed free reins and not kept from challenging the father. Dinosaurs stupendous size and power became the bridge that transferred his overvaluation of his father's majesty onto them. The father ceased being as important as he was previously, opening the door for emulating other adults, and transitioning from family being everything to the infinite world taking over that role. By repressing the intense cathexis (energy) that was going into Oedipal conflict the family relationship returned to their original dynamics, no longer colored by the Oedipal fantasies that had temporarily hijacked his psyche, and he stopped walking on tippy toes as if he was an intruder in his own house. Now he feared the dinosaurs more than the flesh and blood father.  He watched dinosaur shows, collected their paraphernalia, and made a game of  roaring from one end of the house to the other, admiring himself as the mighty Tyrannosaurus Rex among other dinosaurs. His identification with his Oedipal father was complete, becoming the nidus of his superego.

At night just before falling asleep a bogey-man began appearing. This bogey-man, clearly a father substitute, would ominously climb up the steps - the boy slept in the attic - and menacingly stand over him, sometimes spinning his bed around. Fifty years later in analysis, he swore the bogeyman was not a dream but an actual person who came every night at bedtime. Sometimes bogeyman was replaced by a gorilla. Analysis showed the bogeyman had been conjured up to scare him out of giving in to the temptation of masturbating in the solitude of the night. Alongside these frightening transformations gentler father surrogates found expression too.  Impulses emerged to tenderly love animals, chiefly dogs. Towards these pets he took the role of the father, treating them as if they were his sons. He became a big animal lover, with keen interest in rescuing them from death. This sublimation muted his wish to bear children from his father. His passive homosexual libido, to sexually submit himself to his father, got transformed into his identifying with pets and through them submitting to himself as their father - a double identification, playing himself and his father simultaneously. In the process of making his dogs becoming good boys, he identified with them and started pleasing everybody, becoming a good boy to the whole world, finding an excellent sublimation of his homosexual libido. This was a reversal of his earlier irascible phase of aggressive defiance and opposition to whatever was demanded of him. The Oedipal relationship with the mother got transferred on to a fascination with and exploration of mother nature and its myriad manifestations, mastering it through understanding and not erotic subjugation, which his original Oedipal fantasies were impelling him to do with his real mother. His hostility towards her, by the mechanism of projection,  changed into belief in witches, ghosts and goblins, who could cast spells on humans and make them murderously evil. One must be reminded that all these modifications of the Oedipal impulses and the representation of the objects they were aiming for were taking place in the unconscious primary process network, without any report of these changes reaching the ego's perceptual consciousness, where only the end results of these transformations could find representation.   

From the above case history it is obvious that our currently approved scientific methodologies cannot be applied to studying the primary process zone of the psyche. For here the variables change their measurable properties at the drop of a hat. The father becomes a dinosaur, then a dog, then a bogeyman alternating with a gorilla, and God knows what else, while the mother becomes mother nature and its myriad manifestations, and the transformational march not satisfied with the objects of this world, enters the paranormal, turning into witches, ghosts and goblins.  How do we bring the science of cause-effect relationships into such a field of measurements.  It is obvious that currently accepted scientific methodologies can only be applied to the physical dimensions where the variables, unless they are palpably acted upon by other variables, remain the same from the beginning of the experiment to its end.  But does that mean the qualitative dimension of our existence is beyond science? Or worse still since aspects of qualitative phenomena also have physical correlates just measure the latter and declare that that is all there is to the science of qualitative existence? This reductionist approach is best exemplified in the study of dreams where instead of analyzing dreams the sleep experts go around pretending to each other that the only thing that matters about dreams is as to measure such variables as how long the person takes to enter into it [Rapid Eye Movement (REM)] -incidentally a patently false scientific myth, which they all know is false but they all pretend it is the truth to keep their fake science alive, for dreams happen in all stages of sleep and not in the REM phase alone, with the only difference in the latter being that the discharge of tensions occurs in bursts of condensed motor activity through the muscles of the eyes, not unlike how the muscles of the toes curl up in the throes of orgasm, and how children unable to surmount Oedipal conflict show isolated bursts of motor activities in tics and other manifestations of Tourette's, or how libidinal discharge blocked by antidopaminergic drugs finally find its way to discharge through [Tardive] dyskinetic motor movements, especially through the mouth muscles, the conduit for the oral phase of sexuality -  how long he stays there, and if this phase of sleep is prevented from happening how it adversely affects his memory and other cognitive functions (duh). All wonderful measurements no doubt, but are they of any real value except for drafting multiple choice questions for Board Examinations? As for the qualitative dimension of sleep, these sleep scientists have found an easy way out. They have jointly decided that dreams are simply nonsense, mental froth, and all that counts is the electric potential that is generated through the night that can be picked up by electrodes. But if dreams are mental froth how can they bring  such exquisite joy and sadness, dig out memories from the very dawn of our lives, and often leave us thinking about them for days. Perhaps our conceptualization of what science is itself is wrong. We are so bogged down with the babble of double blind, p values, falsifiability, sufficiency of "n", matched cohorts, interrater reliability etc. that we have forgotten that science is not capturing essence of phenomena in mathematical terms but any unbiased attempt to understand the world.  Studies of qualitative dimension of the mind without turning the results into mathematical terms is still science and can be practiced by endopsychically resonating with the subject's psyche. What is going on in the subject's unconscious can be correctly inferred by the observer's psyche by being qualitatively in tandem with him.

This has to be illustrated with an example. A patient of mine, a severe obsessional neurotic, came to the session inconsolable, convinced that in the colonoscopy which was scheduled in three weeks will reveal cancer.  He had woken out of his sleep with this obsession, and had not been able to shake it out of his thinking. The scanty associations that occurred to him threw no light on this hypochondriacal preoccupation. But fifteen minutes later, in some other context, he reported that a few days ago, his neighbor, who lives in the flat downstairs, and with whom he shares the same hot water tank, had started showering couple of minutes after him, shocking him when the hot water had suddenly turned cold, and the curse had come to his mind with great force for the neighbor to die a horrible death. As soon as he narrated this information,  I asked if this shower debacle had occurred on the day before the obsession had woken him out of the sleep. The patient, incredulous, said yes that is the night when the obsession had taken hold of him. In my endopsychic perceptual apparatus, in tune with his unconscious, I had correctly inferred how the wish for his neighbor's death had ended up with the fear of his own death. The wish which he had forgotten  in the course of the day had returned in the sleep but with the object of his wrath displaced from the neighbor to his own self. The correctness of the analysis was confirmed by the immediate resolution of the obsession on its interpretation. Such empathic understanding when it occurs leaves no doubt in the observer's mind as to its validity and should not be discarded as unscientific simply because nine out of ten therapist are incapable of making such observations correctly. For just like one does not reject the theory of relativity because Orangutans, 100 percent of them, in fact virtually 100 percent of humans too, are incapable of understanding it, we cannot reject the study of qualitative phenomena as unscientific because only rare people can correctly infer it.  

But the absence of quantitative measurements to give us certainty that what we are inferring is precise is not the most difficult factor in studying qualitative phenomena. In material sciences, the subject under study does not have an ego, a sense of self, which acts as a biasing filter between the observer and the observed. In qualitative studies what we can observe has to percolate through the person's ego (his individuality), which is evolutionarily designed to hide, through camouflaging, its troublesome intentions instead of revealing them. The ego censors what it considers embarrassing and puffs up what it considers will enhance his standing. In other words it is an unreliable reporter of its own processes. As a rule, impulses that he views will get him in hot waters with others or his conscience, but which he must pursue nevertheless, he disavows them to his conscious mind and to others, while performing them, often failing to recognize his hypocrisy, attributing his motives as applicable perhaps to others but not to him when pressed directly. Furthermore he gets defensive if not outright defiant and hostile when the scientific enquiry touches his repressed complexes and the sexual motives behind them, considering such questioning as an aspersions on his uprightness.  And often  despite its avowed intention to be honest with the scientific observer does just the opposite, weaving deceptions in his reporting, believing in his lies, and fronts false explanations to account for his behaviors to deflect his own and others attention from the truth.  

To handle this degree of complexity it requires a scientific method which is a departure from the one applicable to the physical world.  A methodology that requires not just theoretical knowledge from reading of textbooks and didactic instructions, but also by simultaneously psychoanalyzing one's own self. For one cannot understand another's psyche without having had significantly analyzed one's own and having come to terms with one's own  past traumas and unmodified libidinal impulses.  that skew one's observations and thus the understanding of others. Without an unbiased understanding of one's own self, which very few can do without help of an experienced analyst, one cannot become familiar with the play of mental forces in the human own psyche. For one can properly observe in others only what one has already correctly observed in one's own self.  Without making the undoing of  one's own repressions which can only be done if it becomes a life long passion one cannot work upon undoing the repressions of others. As long as one's own self is a puzzle to oneself one cannot solve others mental riddles. But dynamically understanding one's psyche through such a  preparatory psychoanalysis is no easy task. Only individuals with an unquenchable thirst to know themselves succeed in this endeavor. Most contemporary preparatory psychoanalysis fails miserably in achieving this aim.  And herein lies the primary reason why psychoanalysis has earned the reputation of being non-scientific. It has become a discipline where poorly trained analysts are passing on the baton to even more poorly trained aspirants - a proverbial example of the blind leading the blind. In qualitative science since there are no measurements for the veracity of one's observations - this does not mean the observations are necessarily impossible, it only means replication of the scientific finding is more difficult -  others are totally at the mercy of the observer's/reporter's honesty and it is easy for the field to get flooded with nonsense masquerading as scientific findings. And it should not surprise us therefore that total incompetence has infiltrated psychoanalytic training institutes.  Far from replicating each others work, certified psychoanalysts cannot even replicate Freud's findings, whose accuracy is beyond reproach. This is not because his work was unscientific but asking modern psychoanalysts to replicate Freud's findings in their own work is like asking baboons to replicate Mona Lisa. At best they will paint a Picasso. 

A further difficulty in utilizing the psychoanalytic technique for scientific exploration is that it can only be applied while the subject is in a therapeutic relationship. The psyche reveals its intimate secrets only when it is in a libidinal attachment with another, whom it trusts will not seek prurient satisfactions and other unsatisfied libidinal needs, when he drops his guard and exposes his past wounds, and thus inflict fresh trauma instead of helping find better resolutions.  Only in love we bare our soul. Repressions are grasped  through free association, yes, but even more importantly through enabling the affects associated with the ideational contents of the repression to find release in the transference.  The distortions that the traumatic memories impose upon thinking can be straightened only through their reanimation when recounting their ideational contents with the therapist. This unique requirement has no counterpart in physical sciences. Mountains do not reveal the secrets of their geological age while emotionally singing their history though the multicolored layers of their rock formations and the rustle of sand holding it together though it may feel like that to the geologist, if he really loves his calling.  Humans however will reveal their intimate fantasies only after creating the illusion of having a special emotional relationship with the therapist. In studying matter the data emanating from the subject does not have to be conditioned by love while it is indispensable in studying the psyche. Yet study of the qualitative world is not unscientific and fundamentally the same.  Science being observing without bias. 

With such difficulties existing in studying neurotic processes (symptom formation), it is not surprising that the architects of DSM III, under pressure from the so called "Biological Psychiatrists" - a euphemism for such ineptness in observing the mind that they take the absurd position that the treatment of psyche requires no understanding of it, a corollary of the Hun doctrine of destroy what you don't understand. everything was chemical imbalance and the mind could be healed by drugs alone -  decided that there was no neuroses either and diagnosis could be made just by whatever the patient was saying without going any further as to why he was saying so.  And there was some grounds for such a point of view.  

Beginning in the early 1950s drugs were coming out of pharmacological labs that were fundamentally changing the world of madness, and liberating the insane from its shackles as never before, and not just with the ubiquitous anxiety and depression but with stark lunacy as well. The pharmaceutical industry saw that if these drugs were marketed with the right fanfare, dressed up to be no different than medications for physical illnesses, they had the potential to make the stockholders unimaginable profits. Stealing a term, and the concept behind it, from Sigmund Freud, who called the approach of understanding mental functioning through the lens of their adaptive value for survival as Biological Psychology, altering it just slightly to Biological Psychiatry, these henchmen of Pharmaceutical industry created this new branch of psychiatry with their most unifying factor being denunciation of Freud, the very man who had given them the idea and the moniker by which they defined themselves. 

But the task was not that easy. The first hurdle was how to get them approved by the  FDA in the same fashion as medications for regular medical illnesses. Despite knowing that mental problems were fundamentally different than medical illnesses - the latter are primarily disorders of the bodily tissues - and the elicitation medical symptoms is straight forward as there is nothing wrong with their reporting apparatus - their speech and cognitive faculties - while elicitation of mental symptoms pried out of a mind that is unsound mind to begin with is unreliable if not outright false as to with what ails them,  more interested in hiding than revealing true state of affairs, a big effort was launched to rename  psychiatry as Behavioral Medicine and push the idea that these two fundamentally different dimensions of human misery are identical. and the method of understand their symptoms is the same. And this required gutting the concept of neuroses.  For the theory of neuroses sees mental symptoms as displaced manifestations of what is wrong and therefore rating the symptoms as reported is worthless. But FDA would approve drugs only if the symptoms showed quantitative changes on rating scales. So was born diagnosing of mental problems through checking boxes of prefabricated questions and rating scales. And anyone who did not practice psychiatry in this manner risked getting delisted from their university posts, insurance companies and even losing their license.  

There was also another and a more sinister motive behind discarding the concept of neurosis. Along with these new highly effective medication new technologies were emerging in the fifties that could gauge neurochemical and neuroanatomical changes (the so called "biological markers") in the brain, without cutting it open. And if mental problems could be transformed into discrete diagnostic entities and then correlated with these biological markers the potential to churn out journal articles was limitless. Above all psychiatry could be shifted from a qualitative science, which is nebulous to begin with, into a quantitative one, into a hard and not a soft science, and thus bring to its practitioners the respectability that humans accord to the material over the mental. The veneration that is accorded to the proctologist who cuts open your rectum is infinitely more than what is given to a psychiatrist who dissects your dream into its minute component bares your soul instead of your crotch.  And in this quest  the concept of neurosis was once again a bugger. For if all mental symptoms were displaced sexuality, and the mind a unitary network then these biological markers were epiphenomena, the result of mental problems, not their cause. On the other hand, if  symptom clusters were declared as valid medical diagnoses, and the sexual causality behind them simply ignored, diagnoses could be made hand over fist and the biological markers correlated, making everyone tenured professors with hundreds of papers to their name. And not to appear specially hostile to psychoanalysis, one could go a step further and declare that this new diagnostic classification ignores not just the concept of neurosis but all causal concepts in making diagnosis. It made the architects of DSM III look so white, favoring no one theory over others.  The DSM III spawned 300 diagnoses. And then added five axes to each one of them.  Every medical professional was stunned with so much profundity coming into psychiatry all at one.   The psychiatric practitioners and researchers were literally in diagnostic heaven having so many diagnoses to play with and so much respect coming their way.  It is ironic that in the last 50 years, with hundreds of thousands of publications, and billions of dollars spent, correlating these biological markers to virtue everything under the sun, not a single piece of theoretical advancement has occurred in the understanding the basic principles of mental functioning than what the masters of 19th century neurology had not worked out by simply pondering over the anatomy of the brain, doing simple physiologic experiments, and observing human behavior as it is.      

Contrary to the very definition of madness being something absurd, and to accept mad man's complaint  on equal footing with those of the medically ill beyond absurd, such common sense did not put off   act  the Biological Psychiatrists from spawning plethora of structured interviews and rating scales where - without any interest in what the patient had to elaborate on his own  - same rote questions were asked of  everybody, and their responses accepted as unvarnished truth and then pigeon holed into a few predetermine categories. If a melancholic declared that there is a hole in his stomach from where all the food that he eats leaks out,  the Biological Psychiatrist approach was to rush to order a Cat Scan to rule out if the food indeed was not actually leaking into the peritoneum instead of exploring if this was not a metaphoric way of complaining that his depression is so profound that whatever edible (good) experience comes his way the pleasure that should have followed is instead swallowed up by the black hole of his depression. If a person out of panic is scared to breath fully and as a consequence complains that he cannot catch his breath, the correct thing is to order blood gas analysis, if not biopsy of the carotid body in the neck artery, if such a thing could be done, to see whether the Carbon dioxide receptors in it have not gone awry.  If a person claims that there are pin worms under his skin, because he was a dirty pig as a child and would scratch his anus and then touch the other parts of his body, do a skin biopsy to search for the parasites if per chance they were still not having a party there instead of analyzing if it was not a symbolic complaint that his ego has become so weak and porous that the raw id impulses are overpowering it and disintegrating his sense of identity. If the agoraphobic complained that the world outside her house is  dangerously sloped and she will fall if she walks out the front door,  refer her to the ophthalmologist to get her eyes examined, and then to Dr. Scholl's for inserts. If we take the analogy to another field of medicine it would be like treating high fever by turning the hospital thermostat down to zero  It is astonishing how fast the mental health practitioners from Timbuctoo to Kalamazoo,  in a jiffy dropped  incorporating causality in conceptualizing mental problems, making DSM III the alpha and omega of psychiatric nosology. 

The architects of DSM III, and subsequent DSMs, will argue that that is not their problem. They gave the most comprehensive and "reliable" system of diagnosing,  keeping the factor of causality unaddressed, for it was better that way with so many etiological theories floating around. The individual practitioner could supply his own favored etiological theory in treating the diagnosis he was faced with. And why blame us the authors of DSM III for doing away with etiology. There was hardly any discussion of them in a meaningful way in the DSM II either, and exclusively derived from psychoanalysis, and that is exactly what we were out to bury. So be glad that we gave you the most comprehensive and egalitarian system of diagnosing, where every mental complaint had a niche.  Rejoice for that and thank us that here is a medical diagnostic system which a Voodoo doctor of Haiti to the Primal Scream therapist of LA to the Professor of psychopharmacology out of Harvard can make use of in whichever fashion he wishes with full confidence that he is practicing evidence based science. 

By selling symptom clusters as diagnosis, with the rationale that if they occur together they must have caused by the same thing, the validity of the nomenclature of mental illnesses for therapeutic purposes took a nose dive. For in mental illnesses each symptom has its own unique etiology, its own unique course of neurotic displacement. Mental symptoms when taken up together have no etiology and searching for it would be like searching for the tree on which all the fruits on a supermarket aisle grew, just because they were being displayed together.   

CBT, coming into its own around the same time when DSM III was hatched, and taking its cue from the latter's total disregard for causality in diagnosing, applied the same shortcut for treatment. In therapy too the patient's insane complaints now were accepted at face value, without any need to check if what was  verbalized was not just a camouflage for more complex hidden disturbances.  Above all, as in DSM III, in CBT too, there was no room for "the unconscious" and "sexuality". Everything was above board. No yuckiness of sexuality, no sense of inadequacy, dealing with things unconscious. There was no anxiety over missing out on hidden issues since there were none. What you complaint about is what you get treated for. Complaints that were too ambiguous or outright crazy were declared as of no consequence, just "automatic" thoughts, deserving of getting swept under the rug. If the patient cried that he was miserable, misery was his problem not what was causing the misery. Therapy was to convince him that there is no place for misery in a sound mind, so if you want to get well, here is our ironclad logic as to why feeling such an emotion is bad for you. It is from your tendency to misperceive and it is high time you perceive things under a rosier hue.  The long established principle of psychoanalysis that mental problems originated from adverse experiences of childhood was retained, in fact made into the cornerstone of CBT, but without any intention to address these experiences by asking the patient to talk about them,. They were part of the theory but only to vilify them, not to give them any place in the treatment scheme. There was no interest in examining in individual cases as to how the "negative core beliefs" and  "cognitive distortions", the other metapsychological pillars of CBT theory, arose out of these childhood adversities. we immediately know what was behind such radicalism.  Limiting treatment to simply replacing bad with good thoughts was a huge relief in that one could become a mental health expert without knowing a whit about psychology and madness. 

One can convince a novice that yes depression and panic are due to distorted thinking and all that is required is for the patient is to snap out of it with "cognitive tools". But when that novice ventures a little further and faces truly mad psychopathologies such as to why a necrophiliac wants to eat the dead, the coprophiliac feces, and the fetishist serial killer wants to strangle matronly looking housewives out of dread that something crucial is missing in them which must be dealt with by killing them and then the ribbon used to kill them be made into the missing fetishistic penis (the Boston Strangler's signature style), then only it dawns upon him the inadequacies of the psychological theories like the "Cognitive Triangle of CBT" in understanding real human psychology. And the list goes on. The most bone chilling being that of a patient of mine who had shot his mother and father to death because he thought they were interfering with his wish to defecate millions of babies  Fortunately having studied the Three Essays on the Theory of Sexuality, and knowing the infantile sexual theory of anal birth and its corollary that men can therefore deliver babies too which grips the child during the Oedipal phase, an age when the existence of a genital passage separate from the intestinal tract is shrouded in mystery,  the patient's command hallucination to kill his parents were not as horrifying as they could have been.  

It dawns upon us that something is wrong when we try to  push the idea that defective cognition lies behind the physicist who complains that the CIA is sending radio waves to a metal antenna implanted inside his head by aliens or why a stunningly beautifully girl becomes a scarecrow because whenever she looks in the mirror she sees a fat woman staring back at her leading her to give up eating altogether.  Even if correction of the distorted thinking (ego defects) is the end step of psychoanalysis too,  psychoanalysis harbors no illusions as to how foolish it is to start the treatment with changing the ego functions, which were fine till the id went awry and the illnesses struck. CBT in every sense puts the cart before the horse. There is no long term change of the ego before simultaneously addressing the id.   

 Let us examine the CBTs Cognitive Triad, their founding manifesto. When stripped off its verbiage all it tells is that mentally ill have dysfunctional thinking. Without quite tracing as to how this dysfunction comes about or even what dysfunction of thinking means, they go to the end result of this dysfunction it being people with cognitive dysfunction think poorly of themselves, are  pessimists,  perceive adversities as more threatening than warranted. They find others as critical, if not outright ill-intentioned, with even their neutral gestures interpreted as ominous.  Every putdown, no matter how slight, is built up to be catastrophic and reacted with different shades of panic, and the process is also used to explain the cause of all other disorders including shutdown of one's zest for life (depression). And all this happens because mentally ill selectively focus on stimuli that validate their negative assessment of themselves and filter out whatever would have made them look or feel good. Self appreciation and appreciation of one's accomplishments is out of question,  no matter how well deserved. And all this is due to "negative core beliefs". When asked as to what are these " negative core beliefs" we are told they are the product of  "negative self-schemas". When we dig our way out of this substitution of one mouthful with another, and ask what in the world are negative self-schemas we are told they are "faulty life themes" because of "childhood adversities". Putting aside ones wonderment as to what  clinical data led to the coining of such dazzling terms and limiting ourselves to enquire further only upon childhood adversities from which everything else flows as to why all this leads to depression in some, panic in others, eating disorders in the third group, and all kinds of abnormalities from mild to the outrageous in yet others, we draw a blank. CBT literature beyond paying lip service to childhood adversities has no  developmental wing to their theory. And when we push the envelope a little further we are astonished to notice that while CBT claims to be a cognitive science, Aaron Beck was a physician, and had no background in cognitive psychology. In fact in all of CBT literature there is no attempt to correlate their clinical theories with the basic cognitive psychology. The latter has centuries of rich tradition of exploring the nature of cognition; its origination and development in children, and  its transformations and influence upon the human behavior through the life cycle. All CBT does is to substitute the more high sounding word "cognition" for "thinking" and manipulation of thinking as some kind of great cognitive-science based treatment enterprise. As for the Behavioral part of CBT. in the beginning there was no behavioral part at all. Just addition of that word to their enterprise as Cognitive Behavioral Therapy sounds more substantive than simple Cognitive Therapy. There was no reward and punishment for behaviors as original behaviorists had been doing for decades and are relentlessly rebottling it as new branches of psychology, the latest in the series being Applied Behavioral Analysis.  Subsequently realizing that exhorting to think right is not much of a science to keep beating one's breast over as a great enterprise and manipulating behavior directly (without the middleman of thinking) entered into CBT too as exposure therapy, encouraging good enjoyable behaviors over bad boring ones, and psychoeducation. Though being too lazy doing it without giving actual rewards and punishments as the hard core Behaviorists do. And while on genesis of cognition it may not be inappropriate to add here that while depression does strike those who had troubled childhood it does so even more upon those who were well brought up, in whom  high ethical standards were inculcated, and whose superego demands more out of them than their natural abilities are capable of achieving. People who grew up in adversities and who were abused, who suffered deprivation, who had poor role models, who have as a consequence defective superegos, they suffer from depression alright but in actuality less from it than from aggressive personality constellations,  acting out their bottled up anger upon others and in sociopathy. The hurt is externalized as destructiveness, not internalized in sadness, inhibition and depression.  

Far from providing a credible metapsychological underpinning for cognitive triad, CBT does not even make use of the psychoanalytic metapsychology properly. The latter relying upon the similarity of depression with that of mourning  tells us that behind the feelings of sadness and across the board withdrawal from concerns of life there is always a loss. Loss of a person that one valued and therefore loved,  or loss of something valuable in the person one loved so he ceased being worthy of one's love,  or some loss of value in one's own self, even loss of some valued possession, or membership in a group, or separation from one's country or profession or enterprise that gave meaning to one's life. Such loss unleashes rage. Rage being the emotional necessary for undoing the adversity and restoring what was lost. And when one fails to reverse the loas and fails to find discharge upon those who the mind holds responsible for the loss, it turns the rage against one's own self. But man's self love is so great that only by undermining one's cognition such that one does not notice that one is being self destructive can one one punish one's own self and work against one's own self interests and thus find satisfaction (and discharge) for that rage. It is this undermining of one's interest outside of one's consciousness is what depression is. It is not disturbed cognition that causes depression but depression that undermines cognition (cognitive distortion).  It may be of value to point out at this juncture how CBT originated. Per CBT mythology, Aaron Beck, their founding father,  while trying to treat depression using the psychoanalytic theory that it is "anger turned against one's own self" that causes it and failing to  confirm it abandoned psychoanalysis and invented his Cognitive Triad theory. CBT aficionados love to emphasize that CBT arose because Aaron Beck, a psychoanalyst, found psychoanalysis does not work. This is taken as a proof that CBT works and psychoanalysis does not. The more parsimonious explanation is that Beck was a lousy psychoanalyst and that is why psychoanalysis did not work for him. 

While CBT rests its case of causation on adverse childhood experiences, in CBT's repertoire there is not a single case history even remotely like that of Freud's "Little Hans", whose phobic/anxious diathesis developed from losing his mother as erotic love object out of the fear of castration by his father, which got displaced upon horses, or that of "the Wolf-Man" - a Russian aristocrat who developed phobias of wolves after waking out of a dream in which he was wishing for sexual satisfaction through the agency of his father, opposed by his narcissistic pride in his masculinity refusing to accept passive homosexuality as the price for love, turning the father into wolves in the land of the primary process dream state.  Passive homosexuality is castration too. In both cases it was not adverse childhood experiences but rather difficulties in surmounting the Oedipal Conflict. Both had excessively strong  libidinal drives coupled with equally strong castration complex objecting to it. It is these two factors and not any significant defect in upbringing or traumatic experiences that had resulted in their anxiety, phobia and depression. It is the human species traumatic phylogenetic past more than individual ontogenetic experiences that lies behind the cognitive and emotional difficulties, and simply exhorting their sufferers to mend their way through better cognition may work for a while thanks to the personal authoritative influence of the therapist, but the true cure lies in bringing these phylogenetic memories to the consciousness so they lose their stranglehold and find their own way to integrate themselves in to the secondary process structure of the psyche enriching the personality. Both, the phylogenetic memories and the adverse childhood experiences, require extraction from the unconscious but neither of them can be achieved by exhorting the patient to simply think and act better to get out of his impasse.

 Far from giving us actual case histories, where step by step account of the transformation of  normal thinking and the associated affects into the psychopathological had occurred,  CBT gives us only schematic case examples, composites of many, and done in this manner, per their authors, to simplify the complexity of their efforts. But this is a cop out and nonsense.  CBT's theoretical foundation are ridiculously and anybody with a GED can grasp it in its entirety if he refuses to be daunted by their pompous psychological neologisms. Mastering its contorted practice is another matter. It is a rocket science. Listening psychoanalytically is a piece of cake in comparison. The bottom line remains that CBT cannot give any comprehensive account of the development of a mental disorder from beginning to its full fledged form because their theory has nothing to do with how its partitioners get therapeutic results. The dynamic factors that causes improvement with CBT is better explained by psychoanalytic concepts for there is total disconnect between what CBT practitioners believe what they are doing  versus what they really do. In fact their concepts as to what brings about healing are so simplistic that the world of social media is awash with self proclaimed CBT experts espousing its virtues without any   formal training in psychology. Alternative Medicine (snake oil) sells not for its effectiveness but for its salesmanship. And this schematized way of describing their fake cases, tailor made to prove their point, is to hide their feet of clay. For forget about monumental cases like that of Little Hans and Wolfman, which one may argue that only Freud was capable of writing, there is nothing in CBT literature which matches the short clinical vignettes one finds in the works of psychoanalytic stalwarts like  Anna Freud, Karl Abraham, Sando Ferenczi, Otto Rank and other early psychoanalysts that illuminate us with penetrating nuggets of insights. It is another matter that current psychoanalysis has lost its way and its theory and practice has become a mass of confusion. But two wrongs do not make a right. 

CBTs achievements have to be compared with the best achievements of psychoanalysis before passing judgment whether the claim of CBT that it works while psychoanalysis does not as was the experience of psychoanalyst Aaron Beck, the father of CBT.  Also it is time for us to burst the myth and propaganda that CBT is evidence based. What is evidence-based is that CBT when compared with equally bad, or worse, psychotherapeutic approaches, with the use of reductionist rating scale, that are designed to gauge only a few cheery picked variables without touching deeper aspects of the psyche, in a double blind fashion, administered by half-baked clinicians, it shows better results in 16-20  weeks. Agreed that in some the brain washing done by CBT that it worked for them lingers for years but beyond this narrow symptom wise improvement there is not a whit of enlightenment to be had from CBT as to how cognition, ego functions, reality testing, psychosexuality unfolds from birth to death, in normalcy and pathology. There is no psychology in CBT, just mildly superior therapeutic results which any other Alternative Medicine would have yielded if it had been applied with so much fanfare and dedication as CBT practice has managed to garnish for itself. 

Interestingly, if one begins to peruse their basic theory one realizes that even their concept of negative self-schemas (core beliefs) is not an original contribution of Albert Ellis and Aaron Beck, the self declared fathers of Cognitive Behavioral Therapy. The term coined by Kant, was introduced into psychology by Sigmund Freud while explaining the primal fantasies, and for its introduction in CBT, the credit goes to Ron Hubbard, the father of Scientology, who started his own branch of psychology in the fifties, which is basically CBT with some fringe overtones.  People suffering from ego dystonic latent homosexuality, which is on the verge of making inroads into the ego (consciousness),  defend themselves from realizing it  by creating their own grandiose unassailable theory of the mind. It acts as a way to  prove their greatness to themselves and thus counter the fear that they could be homosexual.  Hubbard was paranoid to the boot, and his theories were a defense against his homosexual panic which he pandered as the new science of Dianetics and which in all fairness is the real Mccoy of CBT, For the CBT of Ellis and Beck came upon the scene a decade later. In Ron Hubbard's CBT, "core beliefs" were given the moniker "engrams" - memory structures permanently ingrained  in the psyche because of  "adverse painful experiences of childhood". It is the same concept as that of "adverse childhood experiences", "negative self schemas" and "negative life themes" which makes the foundation of CBT. If Albert Ellis and Aaron Beck are fathers of CBT then Ron Hibbard is the grandfather. But on a little further reflection it dawns upon us that  the antecedents of these fragments of "ego psychology" were more comprehensively dealt with in the works of  Alfred Adler, and before him in that of Sigmund Freud and Theodore Meynert.  All these fancy terms "core beliefs", "self-schema", "life themes", "engrams" they are no more than recycling of Meynert's, and subsequently Freud's concept of "individuality"/ego, though stripped of all the complexities and richness that the earlier masters had achieved. It is Meynert who first elucidated the concept of Individuality, every now and then interchangeably calling it "the ego" and "the character", and defining it as the sum of all those impressions which due to their frequent occurrence together become the indissoluble core of our being and which became with Freud the ego of psychoanalysis.

Ron Hubbard's engrams, in contrast to the core beliefs and life schemas of Ellis and Beck, has much more psychological meat to it. Engrams, Hubbard tells us, are conglomerations of memory traces of all the perceptions that were simultaneously present at the time of the childhood trauma that made the person mentally ill.  And any one of these perceptions, even if innocuous on its own, because of its associative presence at the time of the trauma, later in life can act as a trigger, causing reactivation of the same negative affects that were generated at the time of the harm. For example if a woman is given a blow on the face, and as she falls into semi-unconsciousness or unconsciousness, is told that she is fake, shifty, good-for-nothing and simultaneously hears the faucet running in the kitchen and a car passing by on the street, in the future, just  on hearing the noise of the car, or of running water, or on being called a fake, will be beseeched by the same painful emotions that she had experienced from the actual blow upon the face. The irrationality or madness in the woman has arisen because such an innocuous event as running of the faucet in the kitchen can make her experience the pain of the blow upon the head and make her swoon into unconsciousness. This psychological mechanism behind the irrationality of mental symptoms was first described by Meynert in his neurological theory of induction, where he proposed that if a man sees a lamb and simultaneously hears it bleat then in the future, because of association fibers having been developed between the two,  if he hears a bleat, it will by itself induce the visual image of the lamb upon the perceptual consciousness, even if the lamb is not visually present. The corollaries of this induction theory of Meynert was recycled (without giving the credit to its source) by Pavlov as the phenomenon of Classical Conditioning, and later, combining  with it another wing of Meynert's theory of Aggressive (assimilative) and Repulsive (avoidant) behaviors being strictly determined by the emotions of pleasure and pain, Edward Thorndike would recycle it as the Law of  Effect  (Skinner's Operant Conditioning being continuation of this plagiarism) without giving credit to its source. 

Scientology too believes in rationally dealing with the illogical thinking of madness. And attempts to do so by altering "the painful engrams" which lie behind "the irrationality". And that is not fundamentally different than the CBT folks using rational arguments to alter the patient's illogical negative core beliefs. However Scientology is superior in that it at least makes an attempt to bring the memories residing in the core of the engrams from unconscious to the conscious mind to "air" the affect entrapped within them, before influencing them rationally. It calls the process changing of the "reactive mind nature" of the "unconscious engrams".  Reactive mind nature is nothing but a rudimentary formulation of "primary process thinking" and "reflex action" which underlies our irrational hasty behaviors. And unconscious engrams with entrapped affects are recycling of the psychoanalytic concept of "repressed memories" and "strangulated affects".  Scientology while steals, hook, line and sinker, from psychoanalysis to build its metapsychology - though we must not fool ourselves into believing that Scientology is a good substitute for psychoanalysis and  does anything more than provide temporary psychological relief from the cult-camaraderie -  it nevertheless should be praised for being faithful in its broad outline to the script that it steals. Ellis and Beck's plagiarism guts everything about psychoanalysis as a depth psychology, holding on to only parts of the psychoanalysis' ego psychology, finding it sufficient to push their agenda. Instead of following the dictum "where id was, there ego shall be" CBT has made it the alpha and omega of their approach, "where patient's defective ego was, there therapist's superior ego shall be [and to hell with his id]". The whole world of self-help literature and TV shows, podcasts and infomercials, dieting and yogic exercising, religious and spiritual discourses, they are, when carefully considered, CBT in endless forms, attempting  to heal mankind's neurotic disturbances through simply rebuking the id and strengthening the [falling apart] ego by high minded thinking and iron-fisted determination. 

Even the assumption that mentally ill have negative self schemas as their core belief,  by the way, is not correct. At the core of their being all men believe they are God's gift to the world. The best thing that ever happened to mankind. Women have even higher opinion of themselves. Mentally retarded of course have the grandest self esteem of them all,  the result of their getting praised to high heaven for every little thing they do. This of course does not mean that humans do not co-harbor 50 shades of inferiority alongside their megalomania. The narcissistic injuries that we sustain on a daily basis, and the great Oedipal defeat that all of us undergo, which is a necessary milestone in human development to tear us away out of the bubble of the family of origin and take cognizance of the larger society and become like our parents ourselves, makes us a husk of what we had once believed our importance to the world was.  But all these narcissistic scars of inferiority are miniscule in comparison to the man's immense self love, with the sense of inferiority taking centerstage only when depression, or rather any neurotic process, overwhelms the ego. So the negative core beliefs about one's self worth, the very cornerstone of CBT metapsychology, is not the cause of the depression but its result. 

Another cornerstone of CBT that depressed folks perceive only what confirms their low opinion of themselves, filtering out all that contradicts that assumption, begs the question as to why would anyone, depressed or not,  perceive only that which increases suffering (pain)?  CBT should be ashamed of itself as a Behavioral Science for coming up with such an anti-Behavioral hypothesis. The very premises of  Behaviorism is that all behaviors are about pursuit of pleasure and avoidance of pain. It is never the other way around.  If avoidance of pain is the guiding principle of all biology, why would any human, a biological organism, choose to perceive himself as worthless, his future as bleak, his world as ominous, and every trivial defeat as catastrophic? It does not add up. The CBT theorists will counter that this is because depressed folks misinterpret what they see. Which simply begs the retort why a biological organism would misinterpret its perceptions to its own sorrow. Perceptual apparatus evolved to interpret, not misinterpret. One can understand misinterpreting reality for feeling good - actually that is what CBT is all about, it teaches to ignore reality to improve your mood and lessen your fears - but why misinterpret to feel bad? We don't hide our victories, we trumpet them. And if others won't listen to our achievements, we replay them in our head over and over again till we get the credit we think we deserved. We do not exaggerate our defeats but cover them with alternate narratives. Even the mind of the depressed cannot override this inexorable law. Nor is it capable of misperceiving reality no matter how twisted was its childhood experiences unless by doing so it gets pleasure in some part of the psyche that is quantitatively more than the pain generated in the other parts from that misperception. Even the self-flagellation of the religious fanatic is not for the pure joy of suffering but for the eternal heavenly bliss in the afterworld as a payback. All the self-flagellation of the depressed, all those condemning and self-defeating automatic thoughts, and all the cognitive distortions that are handicapping him, when properly listened to, instead of rushing to convince him to drop them in favor of rosier thoughts, is an attempt to come out of the depression and not the cause of it. Depression is an across the board shutting off of all functioning, mental and physical. It it a sledge hammer approach by the psyche to nip the  person's aggressive (angry) impulses towards others. Not dissimilar to how the agoraphobic's unruly sexual impulse, under whose influence she dreads stepping on the street lest she solicit like a prostitute for its satisfaction, causes paralysis of locomotion outside the familiar territory. The negative view of one's self worth created by focusing only upon those aspects of the environment which further confirm it, avoiding success in the present, and anticipating none in the future, at bottom are the former aggressive (competitive) attitude towards others now turned against one's own self. A loss of a loved person, or the loss in their significance for us, or a loss of some ability in one's own self, factors that had enabled one to discharge one's aggressive drives upon others with confidence that one would be able to handle the retaliation effectively with that resource, now no longer available due to the loss, the aggression has to be turned against one's own self. And upon one's own self it rages till it is discharged sufficiently to no longer pose the threat of getting acted out against others, ending the inhibitions imposed upon one's thinking and actions, sometimes so massively that the pendulum swings into euphoric mania.  Beck's contention that he developed his CBT theory because he could not confirm psychoanalytic postulate that depression is anger turned against one's self and therefore could not work effectively with depressed patients, on deeper examination tells us that psychoanalysis failed him because his observations were not deep enough. It also dawns upon us that  depressed patients misperception of environmental cues is not due to the perceptual apparatus having gone awry from some mysterious adverse childhood experiences, but from a purposive narrowing of attention to selectively perceive only that information from the world which will justify self-deprecation. It is not misperception but selective focus. Paradoxically it is people who have had cultured upbringing (grew up under a demanding parents/superego) and were protected rather than suffered from adverse experiences and as a result developed into high achievers, who get depressed due to insufficient fulfillment of these ambitions. It is insufficient triumph in life, provoking envy and rage towards others, which through the affect of guilt - anticipation of punishment in hands of the superego (internalized parents) - getting turned against one's own self  that lies behind depression. The criticism of others now finding outlet in  self-deprecation - the much made intrusive thoughts of CBT. It is not cognitive disturbance arising out of misperception of others intentions that does a number on one's self-worth, it is a purposive (though unconscious) condemnation of self that was originally meant for others that lies at the heart of depression.  Those who grow up with real adversities and raised by genuinely mean parents, they are the ones who have negative life schemas and poor core beliefs, and who aim not for high achievements, getting depressed on failing to achieve it, but for retaliation against those who they consider as the author of their misfortunes. True childhood adversities cause character pathologies (personality disorders) and inhibitions of functions from actual harms perpetrated upon the ego's abilities rather than depression.

The next pillar of CBT, and more so of REBT (Rational Emotive Behavioral Therapy), is that thinking determines emotions and emotions determines behaviors, and one has to just straighten one of the three out to straighten all three out.  As Albert Ellis declared, "Thoughts are the source of negative emotions that lead to self-destructive behaviors." Aaron Beck's  CBT theory echoes the same: It is not what happens to you that matters, it is how you think about what happened to you that determines you will become sick or not.  If your core beliefs about yourself are negative you will think of yourself as worthless, and whatever happens to you you will distort its perception to confirm this sense of worthlessness, and the world will then appear to you as bleak, with no possibility of it changing in the future, generating automatic thoughts, self-condemnation, and dysregulation of affect. 

But it strikes us as soon as we hear these brilliantly put together theories, which so smoothly explain everything, that it is speculative and not evidence based.  All the clever terms 'cognitive distortion', 'automatic thoughts', 'dysregulation of affect' are meaningless phrases, "wise nonsense", gratuitously thrown in to hide CBT's ignorance as to the true nature of affect, the origin of automatic thoughts - for nothing is automatic in God's universe but based upon inexorable cause and effect - and of  cognition itself? If it is not what happened to you but how you think about what happened to you that determines you will fall sick or not, then why even if have the concept of childhood adversities as part of one's theory?  Declaring that adverse childhood experiences result in negative core belief, that distort perceptions to confirm this bias, that produce automatic thoughts that pop in and out of psyche without rhyme or reason and ultimately end up in dysregulated affect is not a scientific theory. Mentally ill people, unless they are psychotic, have no cognitive distortion. They perceive things like everybody else does. Only difference being that their emotional reaction to them is either excessive or blunted because their normal pathways to discharge is impeded or outright blocked due to interpsychic conflicts. Mental illnesses are emotional disorders;  not disorders of cognition. Mentally ill are not low IQ people. And their affects are not "dysregulated", they are just more or less than the context expects because their damning at one point causes their overflow at another. 

It behooves us now to answer as to how did CBT come up with the idea that thoughts, emotions and behaviors are interconnected and curing one automatically cures the other two - CBT's celebrated Cognitive Triangle. What could have been the motive behind this theory-making? A very practical one. CBT's entire armamentarium rests upon the premise that bad thinking is the villain behind all our woes and all one has to do is to alter it one way or another.  A claim that every Tom, Dick and Harry immediately resonates to. For thinking is our main tool for survival and which, under temptation to take short cuts, we are always converting to action prematurely instead of waiting till the most optimal course of action presents itself,  and therefore we are always kicking our selves for not thinking  enough before letting immediate gain highjack it into failure, pain and guilt. This guilt, which in mild forms is felt as self criticism and in severe version self destructiveness and depression. is what is exploited by the self help industry and Alternative Medicine, including CBT. All these approaches with slight variations start with blaming your defective thinking for your miseries, and then promise to provide you the  method to straighten it out. And since we feel guilty about our thinking all the time anyway, we lap it up.  Every advice on improving one's thinking no matter how trite sounds like a nugget of wisdom.  Even such inanity as to tell people to repeat forty times a day, "Every day, in every way, I am getting better and better" once had tens of millions of followers.

 CBT being limited to manipulating thinking but purporting to be a complete psychological science had to say something on dealing with the co-existing distressing emotions and disturbing behaviors. For psyche is not just about thinking, and though one can wax eloquent on how to change defective thinking with sound reasons no amount of glibness works with disturbed emotions. One can hardly reason with someone in emotional meltdown or has stubbornly sealed himself off from others.  No amount of convincing the multimillionaire who is sobbing his heart out in your office that he is going to poorhouse that his stock portfolio speaks the opposite will make a dent in his depression. Once pathological emotions grip you no amount of cleverness practiced out of any CBT manual makes a dent. They dissipate only after extracting their quota of pain.  And while pathological behaviors may appear to be quasi-deliberate and not knowing how to behave better, they are primarily displaced repetition of the past traumas with the aim to undo them.  While the patient will humor the efforts to psychoeducate mentally ill are not stupid and ignorant as to how to behave properly, they do it because their heart is in   the past. Realizing one can fool all the people just some of the time, and beating the drums of  restructuring thoughts can only take you so far, CBT concocted the concept of Cognitive Triangle- not to be confused with Cognitive Triad, though no doubt the latter must have played a role in deriving one from the other without there being nothing in common between the two.  Without backing it up with any true clinical material or existing scientific literature on cognition and emotions they came up with the idea, as if pulled out of their rear end,  that thinking begets emotions, emotions beget behaviors, and behaviors beget thinking and right thinking can cure all three.  What an extraordinary lifting of the burden of addressing the problem of irrational emotions and behaviors! Ignore emotions and behaviors altogether, just double down on thinking to cure all three.  

The only problem with this beautiful formulation is that thoughts do not beget emotions. They do not even have that much influence upon emotions. Emotions arise from unsatisfied needs and the trauma that comes from the external world while attempting to satisfy them. While thoughts mitigate, blunt, even override one set by overlaying contrary ones, emotions are primary. Developmentally it is emotions that begets thinking. In the beginning there are only emotions and  reflex behaviors without any thinking wedged between the two. Thinking evolves gradually and as the end point of a cascade of other preliminary cognitive processes like conversion of sensations to perceptions, development of associative networks between the perceptions arising from different sensory modalities. Thinking comes considerably later and as a tool to mediate between emotions and reflex behaviors. Its purpose is to rehearse in the psyche, multiple behavioral options, before putting the most expedient one into action. What exactly are emotions? They are neurochemical and endocrinal signals from the interior of the body to the nervous apparatus  that the homeostasis of the body is deviating from the stable state and action is required to reestablish the baseline.  Bodily needs - oxygen, food, water, warmth and craving for touch (which will later blossom into endless forms of loving) - are the primary disturbers of  homeostasis. These biological needs to begin with are barely felt, but then through  summation becoming more pressing start reaching the perceptual consciousness as emotions (impulsions to act). If relief does not arrive, the tension gradually moves from an awareness of mental load to frank oppression, restlessness, unpleasure, anxiety, pain and convulsions. Unsatisfied bodily needs are the original source of negative emotions. But there is yet another source  of negative emotions, and in human animal of far greater significance. The traumas we are subjected to by the external world, primarily by other people - starting from our parents (for upbringing is mostly teaching moderation and austerity) -  to prevent the satisfaction of our needs. The resources are finite, competition for them infinite. In this competition, the outside world is not just the source of everything we desire but also the source of endless pain. The negative emotions that are generated from the obstructions of love needs are longing, jealousy, mourning, pain, mortification etc. while the retaliatory aggression aroused from frustrations are irritation, hatred, anger, rage and fear. A defining feature of these negative emotions is that once generated, even after the traumatic event is over, any new perception, or thinking that has associate link with the original trauma, can induce recollection of the event, mostly unconsciously, but nevertheless enough to provoke the release of the same neurochemicals, the same stress hormones, and the same feelings, as the ones that were released when the actual trauma had occurred. The intensity of the emotions generated through such mental association may even be stronger than when the actual hurt took place. And while such painful emotions usually do become less and less provocative - get tamed, become bound - by countervalent thinking, proving that soothing thinking is required to take the bite out of past painful memories, it is nevertheless incorrect to postulate that "thoughts are the source of negative emotions" as done by Albert Ellis, one of the fathers of CBT. The source of negative emotions are our pressing biological drives waiting to be fulfilled and the injuries inflicted upon our body integrity by external forces while pursuing satisfaction of these drives, not thinking. One can persuade the mind to divert one's thoughts away from painful memories for temporary respite, replacing  the negative by positive emotions by indulging in happy memories from the past or by daydreaming of a rosy future, but to claim that thinking generates emotions is wrong.

A newborn is bundle of emotions. The threshold for sensations to become overwhelming and therefore painful is very low in it. The first emotion it experiences is of anxiety. A negative emotion by which we mean that it belongs to the painful side of this great mental divide and generates "avoidant behaviors". The anxiety results from cutting of the umbilical cord and cessation of the placental oxygen entering the body giving a jolt to the central nervous system causing a sudden rise in brain activity to initiate a whole slew of physiological activities to reverse the situation. This massive stimulation is felt as anxiety - anxiety being a rise in brain activity with uncertainty whether one will succeed or not in reversing the situation that is causing the agitation.  The anxiety initiates gasping/crying and the first breath. The inhalation restores the oxygen supply, reversing the heightened brain activity which is felt as relief  - the first  positive emotion. Our penchant for reversing all our woes - the pranayama of yoga and the staple of host of other Alternative Medicine practices,  and the common advice to take a deep breath when feeling overwhelmed,  has its origin in this relief with our first breath from the first fear of impending death.  As other bodily needs, hunger, thirst, warmth and craving for touch, press for their satisfaction, taking hunger as their prototype, the following sequence of events can be hypothesized to occur. The homeostatic instability from falling nutrients in the blood stream causes a rise in mental activity (tension/anxiety) and a rise in cardiovascular activity (the forerunner of the high blood pressure due to anxiety,  the father of all metabolic syndromes) impelling the child to scream/cry, flail its arms and legs. The crying is modelled after how respiratory distress and the associated anxiety had ended with the first cry for breath. Flailing of arms and legs and other muscular emotional expressions are the rudimentary movements to reach out for outside objects to incorporate them in to oneself to satisfy the need and bring an end to the rising tension and its counterpart, the running away from the distressing situation by treating the internal source of stimulation as coming from the outside that can be ended by simply walking away from it (the forerunner of Restless Leg Syndrome). At first these actions, uncoordinated, can bring no change in the external world and get the object one needs to end the distress. But they do alter the external world in that they attract the attention of the mother, who by undertaking the specific action of putting her nipple in the mouth, activates reflex motor behaviors of sucking, swallowing, and peristalsis of the gastrointestinal tract.  Absorption of the nutrients of the milk into the blood stream slakes the hunger, restores the homeostasis, and ends the secretion of stress neurochemicals which were stimulating the brain, and with this reversal of  neuronal tension, there is experience of satisfaction and generation of pleasure. It may be speculated at this point that with every relief from unpleasurable emotions there is a release of dopamine neurotransmitter which strengthens(reinforces) those perceptions and behaviors, and their associative links, that participated in satisfying the pressing need.  Through this reinforcement a select group of  perceptions, thoughts and behaviors get preferment over other perceptions and their associations, and when similar situation arises the next time they are the first set of memories to get activated.  Those perceptions, thoughts, activities, and their interconnections, that are repeatedly strengthened by dopamine secretion and are frequently renewed for expediency in achieving our aims, gradually prevail over others perceptions and associations to such an extent that they form indissoluble bonds between them, creating our sense of individuality and subjectivity.  Since these indissoluble associations are constantly called upon for executing behaviors to deal with one need or another some aspects of it are always active (cathected) throughout our waking hours,  and to a lesser extent during sleep, and because of this omnipresence they develop the illusion of being uniquely different from rest of the universe, indestructible and immortal. It is a short step from there to get convinced about possession of a soul  that survives even when the body dies, made up of more than matter, leading to the belief that mental and physical world are fundamentally different, one superimposed upon the other. It is not too difficult to work out from here the riddle of consciousness. The continuous selection of some perceptions over others with every success makes the sense of self so finely exclusive from the vast network of all the anatomically existing memories, that it picks from its sensory modalities only the tiniest fraction of the quantitative signals emanating from the external world sensing them qualitatively.  For sensing all the quantitative signals bombarding the nervous system to satisfy one's needs would be too mind boggling and thus counterproductive. Quality is shorthand, the essence of the quantitative data impacting the perceptual surface, developed for expediency. Qualitative perceptions give the illusion that they are superimposed upon the quantitative world, and not just a refined part of it. The view that two separate worlds exist, one of the mind and one of matter, and the former actually preceded the latter, existing inside a supreme being who from this mind of His created matter is simply untenable.  Qualitative experience or consciousness is no more than selective uploading of the quantitative world.  Since out sense of self is made of qualitative perceptions and we can perceive the outside world only by comparing (measuring) it with ourselves the world is perceived  only through qualitative glasses. We perceive the world on the basis of how we perceive ourselves, and our sense of self being a patchwork of qualities (though with feet of quantitative world) our consciousness is no more than a projection of this qualitative sense of self upon the external world. The quality exists in our selves not in the external world where it is projected by us.  The great befuddlement over finding the specific neurons that harbor consciousness will remain an bafflement  for consciousness arises as soon as our sense of subjectivity and ability to perceive qualities arise with enough stimulation of the neuronal networks from neurotransmitters. Any arousal that is enough to start sensing qualities is enough to generate rudimentary consciousness, and the latter does not reside in some inner core of neurons within the bigger network.

Emotions may appear to be innumerable but just like all shades of colors are derived from three primary ones, red, blue and green, all emotional tones are endless combinations of just two primary emotions: pain and pleasure. The qualitative dimension of emotions are derived from the organ from which the need arose. Different qualities of distress emerge from different bodily systems gastrointestinal (hunger and thirst)  cardiovascular (gasping for breath and fear for life) genitourinary (reproductive pressures). But more than the somatic sources the uniqueness of emotional feelings is derived from their  associations with the memories of the people who had aided or hindered us in getting our needs fulfilled. Since the same people, at least in the earliest years, functioned as helpers as hinderers,  or were helpers and hinderers to varying degrees simultaneously, the feelings that emerge with the rise of needs or the hindrance in their satisfaction, are admixtures of pain and pleasure sometimes weaved into most complex patterns of paradox and ambivalence. The memories of the people from the earliest periods of our lives when cognition had not developed enough to give them any perceptual character other than  feeling their presence, all languages without any physical touching involved invariably describe emotions as feelings.  Emotional feelings are a hallucinatory revival of past touching by others that resulted in the sensations of pain and pleasure. Since the cry for the mother was followed by the sounds of her approach, all music is an extension of the duet between mother and the child, first sung as as lullaby and then extended into all back and forth sound coordination between people signaling the need for touching and love. The feelings generated by sound, especially from lyrics and well harmonized  music, which captures the richness of the mother-child bond, move us to the very core of our being. The feeling of the perpetual  presence of God, or other patron entity as guardian angel, is just an extension of the subliminal presence of these earliest significant people. Creation of places of worships, sanctuaries, nativity scenes, reliefs of mythological figures on the walls of Indian and Buddhist temples, even arts and dramas, are attempts to recreate these lost memories and emotions of these parental figures in newer and more majestic dimensions.  

Since Antonio Damasio's book "Descartes Error" was published in the 1990s it has become fashionable to amplify the view that emotions and reasons are not at odds as philosophers through the ages have claimed and it is wrong to disparage affect as an enemy of good thinking; for they both work in tandem and our emotions refine our thinking. Unfortunately  philosophers were more right than Damasio.  The strength of the emotion is derived from strength of the pressing need and greater the frustration less likely the person is going to undertake sound thinking in its impulsion to initiate action. Emotions are the energy dimension of the biological drives. When frustrated they can become demonic in their ferocity as the lay person rightly fears the madman's inhuman strength.  Emotional pain is what induces one to explore means to escape from it fueling complex thinking and new ways of conceptualizing the world.  In that sense emotions enhance our thinking. Though this is impelling to think more and does not contribute towards thinking better. Emotions just add bias and steal from thinking out all the options, settling quickly on the first one that comes to the mind. Thinking develops gradually and in the following order. The specific action of others that satisfy one's needs leave perceptual memory traces. To these are added, as one becomes more and more self-reliant, specific actions of one's own, modelled after others behaviors that had brought relief from tensions, and ending of negative emotions. These memories rapidly multiply and with the multiplication comes the option to choose amongst them the ones which is the most expedient for a particular situation. The process of choosing the most suitable course of action is what thinking is.   

What exactly are thoughts? They are "trial actions". They are going over different competing courses of actions in the psyche before putting one of them in to motor behavior. We rehearse numerous scenarios  before choosing one to find relief from the pressure of emotions.  But let us be clear that it is not thoughts that bring relief from emotions, it is the behavior which gets the object needed to restore the homeostasis that ends the emotions. You can think all you want but until you act upon your thoughts your need is not satisfied. Thinking is the intermediary link between emotions and behaviors coming into the picture much later after a cascade of other cognitive functions (representations of the cause effect relationships of the outside world) find a foothold in the psyche. Its primary purpose is to increase the efficiency of one's behavior by choosing the best course of action from the many options available. Of course thoughts can also do the additional task of bringing temporary relief from the pressing emotions by creating the illusion (false scenarios) of the need getting fulfilled without undertaking the behavior necessary for achieving it. Dreams are the best example of such wishful thinking. Dreams are hallucinations - physiological not pathological for normal perceptual consciousness returns without any problems as soon as one comes out of sleep - which enable ones wishful thinking to be seen in action bringing temporary respite from unfulfilled needs to allow the dreamer to keep on sleeping.  But just like happiness in dreams is just a dream and the worries and frustrations of existence return as soon as we wake up, the emotions that thinking can influence by creating the illusion that one's unsatisfied needs do not count and just changing our thinking about them is enough, last only as long as one is in transferential attachment with the therapist. Relationship with the therapist substitutes for lack of libidinal satisfaction with others. Thoughts can put emotions upon hold but cannot end them effectively without obtaining their satisfaction from real relationships. This is in direct contradiction to the CBT's primary postulate that thoughts generate affects and changing thinking pattern is enough to bring back  pathological emotions to normalcy.  "'My father and mother were honest, though poor—'"

"'Skip all that!'" cried the Bellman in haste.

 And herein lies the crucial difference between psychoanalysis and CBT. Psychoanalysis postulates that the pathological affects due to painful experiences come first and it is the painful memories, conscious and unconscious, that are changing the role of affect from prodder of thinking and action to their paralyzer (depression). Per psychoanalysis problem lies in addressing the reminiscences from the past which are acting as engines of pathological affect and not consider poor thinking and defective perception as the cause of illness. If CBT's contention was right, depression would be least in geniuses and overwhelming in idiots. But it is just the reverse. Nobody has ever heard of an imbecile in a Developmentally Disabled Group home committing suicide.  While New York Times obituary stories, virtually half of their reporting, is full of excessively sensitive and gifted person checking out of this world prematurely for not being even more successful than they are.  CBT omits the step of exploring the traumatic memories that are generating the negative affects. The dictum you are today for what happened to you yesterday and unless you come to terms with it you will repeat it, CBTs approach is that there is no point in crying over spilled milk, let bygones be bygone, you may be today because of what happened to you yesterday but like the hasty Bellman in Lewis Carrol's 'Hunting of the Snark" cries we have no time for all that, our marketing is based upon the motto that we get you well in 16  to 20 weeks, so 16 weeks is all you have to snap out of it. Just pull yourself up by the bootstraps and wriggle out of your doldrums by us giving you uplifting talks and you doing your part of right thinking. It puts all its eggs in the basket of converting pessimistic thinking to optimistic by the power of persuasion. It avoids the patient's past as undeserving of therapeutic attention. But as Freud put it “a thing which has not been understood inevitably reappears; like an unlaid ghost, it cannot rest until the mystery has been resolved and the spell broken.” The past returns regardless of whichever modality of treatment you are getting.  You may refuse to acknowledge it as such by calling i as "automatic thoughts" - and they are not past in its pure form but a truncated condensed distorted version of it sometimes crammed into a single symbolic senseless thought - and pooh poohing them as unnecessary nuisance and exhorting one to banish them with  the 3 Cs  catch, check, change. And they can even be banished for a while just like the Tourette patient can for a while check his coprolalia, but they keep returning like unlaid ghost,  if not in the same wordings and forms, in new avatars.    

It also begins to dawn upon us that banishing mental pathology by power of persuasion is modelled after the mechanism of repression itself, the very cause of the psychopathology.  The ego, under the Oedipal fears, defended itself by banishing the aggressive and sexual impulses and their associated affects and thoughts, out of its organization and had fortified itself by installing in their place myriad social and cultural strivings. And it was the most apt solution then. Given the four year old child's physical and mental immaturity his Oedipal wishes had no chance of getting fulfilled in reality.  And  later in life while tackling life's other tasks and failing in surmounting them, feeling the same helplessness they had faced during the Oedipal phase, it attempts the same banishment upon them, as it had done with earlier conflicts. The repressed Oedipal memories waiting in the unconscious pull them alongside itself. CBT joins with the patient in reburying these new conflicts and whatever memories of the repressed had returned. With one important difference. The ego of the child when the original Oedipal defeat took place, besides instituting the repression, used a whole range of additional defenses -  displacements, distortions, reaction formations, reversal,  regression, turning the impulses against one's own self, and thus had given a kaleidoscopic richness to the the personality.  CBT on the other hand relies solely upon  just one defense: the defense of reaction formation. At bottom CBT's therapeutic technique is limited to strengthening of the ego through the defense of Reaction Formation (replacement of bad with the good).  All Johnny-one-tune therapies are based upon replacing the evil with a silver bullet of over arching good through the power of positive thinking. Mentally ill can easily be convinced that eating vegan, or eating gluten free diet, or not eating at all for days or for at least 14 hours (intermittent fasting), can cure all their woes. On the same lines eschewing  processed food, pursuing perfect sleep (orthosomnia),  doing endless Hail Marys, or yogically breathing through the corners of the eyes instead of nostrils, or rather pretending to do so, or twisting one's eyes in a particular fashion (EMDR), or tapping or puncturing the body's meridians (Tapping and Acupuncture Therapies) to spraying one's ass with "psychic vampire repellent", all have their own swathe of followers. But they are all nothing but practice of obsessive compulsive disorder. They all hang their hat of healing upon the oppositional defiance of  some reaction formation.  They promise cure through keeping the repressed impulses repressed through a relentless practice of this single defense. Obsessive compulsive neurotics harbor reaction formations of the most varied kind to avert their death wishes coming to their consciousness and finding expression in motility. CBT is nothing more than just more elaborate version of these OCD  therapies posing as evidence based medicine. CBT when closely examined is litany of obsessive compulsive rituals. Implementing the 3 Cs of cognitive restructuring, 4Ps of procrastination, 2-minute principle of  productivity, 6 stages of CBT in 16 weeks, 5 factors, 5 modulations and 5 components of Depression. Does it not it sound queer about  a science that draws its  strength from the abracadabra of  mnemonics. It dawns upon us that CBT is no different than the 12 steps of Alcohol Anonymous;  no better than the self help books with alluring titles like "The 7 Habits of Highly Effective People," "How to win friends and influence People,"  "The Power of Positive Thinking," "The Power of Now", "Think and grow Rich." etc.  Now let us not deny that these self-help books help. And they do teach us a lot about how humans think and and they do give us valuable tips on how to strengthen our ego and polish our behaviors. But to call them evidence based medicine is wrong. 

A decade ago at a CBT conference I asked, Judith Beck, the heiress of CBT empire - not in quite the same irreverential words as I narrate here but at least in spirit it was no different  - that once you straighten the depressed person's negative core beliefs, assure him how to interpret correctly all his body sensations so he no longer panics, talk him out of misperceiving so he notices only the brighter side of life,  improve his self esteem through ignoring all failures and putdown, focusing only upon accomplishments,  and your efforts succeed, succeed in fact so admirably that his core belief flips and  he is in Cloud 9 or mania, what kind of psychoeducation do you give him now? Tell him no brother, no! We overdid it. You are not such a God's gift to the world. Your childhood was not full of adversities but a cakewalk. That alone explains why you are acting like an idiot. Your misperceptions are beginning truly only now. Your enthusiasm about the world is misplaced. The world is really a dangerous place, more so for you who has thrown all caution to the wind, and if you keep it up you will be in jail soon. What you all do to magnify his shortcomings to pull him down from his high horse?  Unfortunately, she could not answer my question as her entourage booed me into silence.  

A depressed accountant before coming to me had gone to a "CBT guy", who, he claimed, had him and two other of his other consumers plugged to the same manual doing identical prefabricated lessons, while he did paperwork to the insurance company to provide "proof" of how we were improving. "It was like we were cattle eating out of the same trough rather than individuals with distinct experiences, resulting in our unique issues, requiring individual attention. Are we so alike? How can these guys get away with charging us so much for telling us which all of us know already know and console each other with in our times of need, which is I guess sufficient for some but it certainly was not enough for me,  and neither for my brother, who unfortunately did commit suicide. And why would not the mood improve and apprehension be gone at least for a while if someone acting so wise is holding your hand and expressing such warm regards about your worth, excusing your every gaffe as fault of others. But in reality it is a dog eat dog world and for how long I could have held up this propped up improvement on the strength of this sugar coating of reality and not committed suicide like my brother did." 

This exceptionally intelligent accountant had an interesting psychopathology. It may be worth our while to go into some aspects of it to highlight the point as to how important it is to see the underlying psychopathological motives before trying to get rid of the surface symptoms by simply declaring it as a result of irrational thinking and misperception of the real state of affairs.  He was obsessed with getting a nose job, convinced it would cure his woes, despite there being nothing wrong with his handsome face. It was another of his long list of self-punishing behaviors. He had a long history of sabotaging himself, including undermining promotions at work, stealing from stores with the motive of tempting fate to catch him red handed, gambling at casinos to reverse his fortune in one stroke but achieving just the opposite,  buying things from mail order for things which he had no use. This self punishment continued in his dreams where he would wake up from nightmares of losing his wife, alternating with losing his mother, especially while on trips in foreign lands, the loss happening in the surreal darkness of the night. He would have affairs not because he did not love is wife but for brinkmanship. CBT guy had actively encouraged him to get his nose cut, providing him with all the right "cognitive reasons" as to why the surgery would improve his self esteem if he his automatic thoughts tell him his nose is weird. hat there is something wrong about his nose, not unlike how a large swath of Mental Health Professionals are encouraging people who having reached a block in their psychosexual development, and have slipped into bisexual fantasies to help them get past their impasse, to get their genitals mutilated.  The nose job had two motives, symbolic castration for his sexual transgressions, which had its roots in his excessive love for his beautiful mother and a great guilt towards his harsh abusive father and also for the satisfaction to be derived from the expense of the surgery - cosmetic surgery was not covered by his insurance. So feel good therapies, do have a negative side to them.  If you affirm everything about the patient under the dictum that the customer is always right instead of going to the very core of the origin of his symptom, the sycophancy can cause serious harm to the patient. .  

But you are now incredulous at such a blithe portrayal of CBT. Is it a blind embittered prejudice on my part? Some twisted revenge for CBT's rout of psychoanalysis? Surely CBT thought leaders do not believe that all mental illnesses can be reduced to the formula of bad thinking causing bad emotions causing bad behaviors due to unspecified childhood adversities and all you got to do is to use the superior thinking of the therapist to replace the patient's inferior one, and voila bad emotions will become good, and you will be on your way to good behavior?  Well for the first decade or two of CBT's advent that is exactly what it was all about, and given the human penchant for reveling in any simplistic dogma as long as it spares them dealing with multifactorial truth it was enough for  the CBT pioneers to ply their trade upon, and get lionized for coming up with a brand new scientific discipline.  But you are right, after a little while  Beck's Cognitive Triad as the alpha and omega of psychology became too difficult a trick to continue playing upon the public without sounding like a broken record. New theoretical fragments began appearing in the discussion section of their papers which hitherto had been limited to wildly praising the double-blind character of their science and how it had the Midas touch of working  better than other therapies with every disorder it touched. Unfortunately none of these theories originated from detailed observation of individual patients. Case examples provided were claimed to be composites, schematic to the boot, and hard to tell whether they were based upon genuine clinical observations or simply speculated to support their theoretical presuppositions. For example they will come up with an example like the following that I came across while surfing on the Internet. 

Joan received a performance review in which 90% of the feedback was positive, and 10% was somewhat negative. Afterward, she found herself seething with rage, unable to concentrate, and eventually leaving early to have a drink at home.

Dante, on the other hand, received the same exact feedback and afterward found himself to be in a good mood the rest of the day. When it was time to go home, he decided to spend a little more time working on a presentation he would be giving next month. 

A case example like this is supposed to teach us if I may be granted some levity in this otherwise serious undertaking that Joann felt this way because her [automatic] thoughts stink while Dante's [automatic] thoughts smell like roses and herein lies the reason why she is sick and he is a future CEO. The cure lies in for Joann to turn into a Dante, while Dante as a matter of prophylaxis should avoid Joann, for she has "stinking thinking". And this discussion would then be touted as the scientific proof that our thoughts affect our mood which in turn affect our behaviors, and the matter of treatment lies in changing our thinking, not that of Dante, because he is a sterling fellow, but that of Joann. Not a word would be there in this clinical case example as to why these two individuals developed such diametrically opposite thinking in the first place."

And the examples and theories attached to them, far from being stepping stones for exploring deeper strata of human psychology, do not even have any internal consistency nor they build upon each others findings. They all seem to come up with their own theory, dancing to their own tune, with the only thing common to all of them is as to never end before reiterating as to how whatever they have done or presented today is evidence-based science. For example Cognitive Behavioral Therapy Institute of Los Angeles tells us that "anger is usually a response to mistreatment of ourselves or someone we care about." This causology of anger is fine and dandy. but a little reflection shows that it is meaningless without addressing what anger is, why it is generated by mistreatment, and is it only generated by mistreatment, and if not, what are other sources of anger, and whether mistreatment causes just anger or other emotions like sadness, fear, indifference, and paradoxically pleasure as well and why. There is no metapsychology of anger in CBT, no cues as to why the mind generates emotions in the first place. Just line diagrams as to how thinking causes emotions, and emotions cause behavior and behavior causes thinking and CBT folks from Bombay to Beirut, from U-tube to Tik Toc, with or without any education in psychology, are making videos and podcasts teaching each other how to wash your bad emotions right out of your hair by the three Cs of cognitive restructuring.

Lets examine their theory building of anorexia nervosa, where CBT claims its undoubted superiority to other approaches. The etiological explanation for anorexia nervosa, per CBT theorists, is that the  anorexic girl has cognitive distortion over getting fat, and it arises from  fat-shaming. And if there is no evidence of it in real life than it has to be from her imbibing such fat shaming from the social media, which is full of it. Messages proclaiming that thin is beautiful, and the ideal body shape and size is wisp-like, got drilled into her brain and now it has taken control of  her entire psyche. An overvaluation of looking like a twig, and the horror of being perceived as a fatty, has led to such a an aversion to food that even ingesting a morsel has become catastrophic. 

No explanation is provided as to how something as minor in the general scheme of things as being fat  can hijack the most powerful instinct of all the will to live and the first imperative of all living beings the will to eat. The CBT specialist may counter that the power of social approval and/or maintaining one's prestige in eyes of peers, if driven by TikTok, and who dare  question that its power cannot override the will to live, no different than how the soldier can lay his life for his country if you brainwash him enough with patriotic songs belted out by a marching band.  But a closer scrutiny shows that a patriot's choosing death over life is not quite the same as the anorexic's determination to starve herself.  For in the former choosing death is for a huge common good and one knows that without this willingness for sacrificing even one's life as a group , one's own survival is anyway short lived. "If we do not hang together we will hang separately," And the patriot does not give up his life while there is no war going on, unlike the anorexic who starves to death amidst plenty. Is it biologically possible to give up one's life for the sake of social approval?  The phenomenon becomes more puzzling when the thinness that was presumably pursued for social approval meets the reversal in that the folks who were the patrons of wisp look, horrified at her looking like a scarecrow, change course and beg her to eat more not less, the factor of social approval ceases to function. But that is against all the tenets of Behaviorism. Just like Archimedes claimed that given a big enough lever he can move the world, the behaviorists cannot be more proud that given unlimited pairings of variables and endless supply of reward and punishment  they can initiate and extinguish any behavior. Why then classical conditioning is one way street only with anorexics?  Thin-shaming makes no dent. And neither does CBT style attack upon the irrationality of  not-eating. No amount of psychoeducation that scarecrow look is neither ideal body shape nor socially attractive has any effect. When we confront the CBT theorist with this paradox and press as to why someone who idealizes great looks would envelope herself with skeletal hideousness, we are given yet another ingenuous explanation -  perfectionism. Anorexics pursue perfection. If eating less is good than not eating at all is perfect. But with the world full of competitive endeavors to show one's superiority and uniqueness from growing the world's biggest moustache to adorning every inch of one's body surface with tattoos  to dying one's hair pink to winning  gold medals in the Olympics, why choose the perfectionism of starving oneself to death?

 And two peculiarities of anorexic patients show that  the doctrine of Perfectionism has feet of clay as well. First, the anorexics show an unshakable, almost delusional, conviction that no matter how grossly thin they get, they are still fat. A normal woman with normal degree of female hormones circulating in her system does not pursue the perfectionism of growing moustache, nor does an amputee practices becoming an Olympian high jumper. Pursual of perfectionism is for achievements within the realm of possibilities. Death by thinness in pursuit of thinness still makes sense, but one finds in the anorexic it is not so much pursuit of thinness per se but to combat the unshakable belief that she is fat.  It is an isolated non-sensical obsession. Failure to explain this semi-delusional conviction renders the cobbled together theory of perfectionism useless. It leaves no choice but to invoke the psychoanalytic concept of neurosis in that the dreaded fat is symbolic of something else,  displacement of some other aspect of oneself that must be perfectly starved. Could it be the rejection of the femininity/passive sexuality, symbolized by the "passive useless fat" upon one's body, which must be extinguished. For only on the elimination of all femininity will one be granted  the coveted male genital? Second, that out of nowhere the anorexic, every once in a while, gorges herself with food till she can stuff herself no more (bulimia/binge eating). If the pursuit of being perfect is not eating why in the world out of nowhere she wants to overeat? The CBT thinkers have no  problem in cobbling together another theory to account for this variation. It is the perfectionism itself that undoes the perfectionism of not eating!  You see what happens with anorexic is that they are so perfect that one downfall from this perfect vigilance impacts them so profoundly that they they say something like this to themselves "What the hell, darn it!  I already lost the battle of the day by this  slip. Now it would serve me right to punish myself by eating all I can eat. Since I failed to be perfect I will spite my perfectionism by cutting its nose by eating endlessly today."  It is hard to believe that anybody with cognitively intact mind will come up with such Double-Dutch but it is the official theory of CBT folks from the Beck Institute itself. Here is its essence verbatim.

.DECEMBER 19, 2023  

Understanding the Interplay Between Disordered Eating and Perfectionism

Jenna DiLossi, PsyD, ABPP

...The combination of dietary restraint, under-eating, and perfectionistic thinking (e.g., “I can’t have any sugar at all today”) creates a perfect storm for binge-eating to occur. A patient who makes the decision to binge-eat after having one cookie because “the day was already ruined” is a classic example of how clinicians see perfectionism manifest in BN maintenance. While it may seem illogical to equate eating one cookie to eating a whole box of cookies, it is not unusual for individuals with BN to truly believe that an entire day has been tarnished from even the slightest break in their self-prescribed rules.

But if to humor the CBT experts we for a moment accept the explanation that it is the shame over  ruined perfectionism that underlies bulimia, we are faced with the problem that Bulimia Nervosa occurs not just as a reaction to the failed perfectionism of anorexia but is found quite often all by itself. In fact Bulimia may be the real McCoy and anorexia  just a reaction to control it. But no videos of  thin-shaming exist in the social media where fat people parade themselves wallowing in their fatness, their admirers gasping at their chubbiness, fat being beautiful. 

It dawns upon us that CBT theories are not based upon hearing the patients but constructed ad hoc to provide theoretical scaffolding to justify whatever CBT treatment ritual is being unloaded upon the patient. For what I have seen of anorexic patients  they give no causal explanations for why they don't want to eat except that there is something grossly wrong about their body, with only way available to them to deal with this wrongness being to not eat, over which there is volition, there being no volition over having a feminine body. It may be the best example of using Alfred Adler's terminology dissatisfaction with "organ inferiority".  The greatest inferiority in this Men's World, is to be born as a woman, that is without a penis, from which all power and success in society flows. Alfred Adler taking one aspect of castration complex spun out an entire theory of mind, reducing all mental problems' origination in masculine protest. Everybody is striving from passivity to activity, from feminine side of the spectrum to the masculine side. It is not surprising he was the acknowledged Guru of Albert Ellis, and initially of Aaron Beck as well, who first propounded that his CBT theory was a continuation of "ego psychology", though later decided it was better for the PR to keep mum about it being ego psychology and declare it all as his own original idea. If the greatest organ inferiority is having clitoris instead of penis, with its very muted sensations of masculine pleasure in females, it perhaps is not too out of line to conjecture that behind the rejection of food is rejection of femininity to the point of death. The delusional obsession that one is fat, while all evidence in the mirror show that it is just the opposite, is similar to when this organ inferiority of one's clitoral and penis size is expressed not in oral phase of psychosexuality but in obsessive-compulsive anal phase, body-dysmorphic disorder, where the preoccupation that there is something defective in one's appearance can often crowd out all other interests in life. That defect dysmorphia) which often makes the individual unable to face other people is shame over one's inferior organ vis a vis clitoris in women, and feelings of being castrated in comparison to other men in men, displaced from the genitals to some real or imagined scar or actual physical defect in upper part of the body.   

At this point we are left with little choice but to pose the question whether the explanation of fat shaming as the cause of anorexia is not a camouflage (secondary revision/rationalization) to pull wool over the real  motive? If we consider that no shaming is more devastating than racial, since while we can do something about our body size by eating less or more, we can do nothing about our skin color  and which when used as a means to humiliate is more painful than any other form of aggression because it is not based upon one's merit or lack of it but one's racial origin, yet nobody hears of someone committing suicide over racial-shaming. Yes getting picked upon for racial handicap is the most powerful prescription for premature metabolic syndrome, yet it does not lead to giving up the striving for redressing the wrong, and curiously goads the victimized to have even more children than the norm, the nearest thing to the opposite of suicide. So what lies behind anorexic's not eating? If it is a disorder of eating, should we not look for its cause in the oral phase of psychosexual development? Perhaps it is not disorder of eating but something else the mouth wants to do which the person's pride finds it impossible to give into. Perhaps it is the return of this mode of sexual satisfaction obtained from sucking upon the mothers breast but now admixed with the genital phase, with the penis substituting for the breast,, that has become so repugnant to the anorexic's ego (aesthetic sensibilities) that eating itself has become disgusting. A rejection of the desire for impregnation through oro-genital contact.  Perfectionism in anorexic perhaps is less about excelling in looking hideous through starvation (which also may be a motive for ugliness will save oneself from appearing as a sexually attractive object)  and more about taking pride in having conquered sexuality completely. Ascetism at its zenith. Reminds one of Jain religion's ultimate call of duty, to depart from this life voluntarily (Samadhi) through voluntary starvation to the applause of other mortals who still want to cling to life. But the CBT practitioners have no interest in exploring any such theoretical consideration in cracking the riddle of anorexia nervosa or in any other disorders of the mind, happy with getting respectable results on rating scales with  mere 16 sessions.  

 The CBT advocates will object that all these psychoanalytic gobbledygook of oral impregnation etc. is all fine, but where is the brief.  How come CBT provides better results in 16 weeks than psychoanalysis does in 16 years?

This is a legitimate question and deserves a careful analysis.  

Psychoanalysis is based upon listening to and observing the patient, with minimal variables (interventions)  introduced from the side of the therapist, while encouraging the patient to hold back nothing, and, other than physically acting them out in the person of the therapist, to express everything about himself that crosses his mind, and while doing so allow oneself to feel all the emotions that are associated with these mental streams. In contrast, CBT starts with the unloading of a bundle of variables upon the patient by the therapist, beginning with a detailed explanation as to what the treatment is all about, including a lecture on how scientific this approach is as proven by double blind studies, how  confidentiality and HIPPA law will be respected here to the utmost, and how thoughts give rise to emotions and emotions give rise to behavior, and how the three, thoughts, emotions and behaviors, are like three peas in a pod, and if you restructure your thoughts by good sound reasoning to generate only those emotions that make you feel good and shut out those that are a downer,  you are on your way to health. More variables are quickly introduced - prefabricated hypothetical scenarios of mental difficulties and how they are supposed to be solved - based not upon what the patient tells the therapist, but from manuals put together by what the CBT institute think tanks think is how mental difficulties should be solved, and these ready made solutions do not fill the therapy sessions but go with the patient as homework assignments. Elicitation of the patient's own experiences is hardly pursued if pursued at all - recall here how the mental dimension of the patient has no place in Biological Psychiatry which aims to treat everything mental by physically manipulating half a dozen  neurotransmitters - with only 16 sessions at one's disposal, and so many beautiful things to tell the patient as to what his problem is and how it can be solved. Overwhelmed with so much attention being showered upon such a  wretch as a melancholic, it is not surprising that he immediately improves.  

Why does he do so if the theoretical underpinnings of the approach is pseudoscience?

 Maybe the way to solve this riddle is to see if anything similar had been attempted before. For nothing in  God's world arises without antecedents. 

 What were the antecedents of Cognitive Behavioral Therapy? Boosting up another person's morale is in the mammal DNA for tens of millions of years. Anybody who has taken his dog to a dog park will find two animals of the same bent of mind immediately perk up on laying eye at each other.  Chimpanzees cheer each other up by mutual back scratching. English when they were laying rail tracks in the Raj, noticed that the native laborer when isolated was listless and forlorn unable to go on for more than couple of hours but as part of a singing gang  he could work all day long. Humans befriend to raise each others morale and mood. So CBT has been with us as long as we have been here. And this morale boosting works the best when delivered by an entity which has parental authority over us. Touch by the king could make the lame walk and the blind to see, not always but if hysterical in nature not infrequently. Less miraculous but certainly more important healing took place from the lifelong ongoing dependency bonds with deities. Complementing going to the local temple was sporadic visits to holy venues of higher stature, the healing springs, pilgrim spots, oracles, and holy characters with reputation for possessing supernatural powers, the soothsayers, fortunetellers, exorcists, crystal gazers, psychics, and other medicine men of every ilk.  

But suggestibility arising from priests and healers - the two professions were one in the ancient world -as a method of cure had its limits. When the neurosis crossed reality itself - psychosis being just a deeper shade of neurosis where the displacements gets so profound they no longer respect  ego's allegiance to the perceptual apparatus itself  -  God based therapy had to be put aside  in favor of the Devil based treatment. The mental illness was viewed as demonic possession and the cure in making the person's life a living hell so the evil spirit that had taken over him takes off.  From smelling salts, to hanging one up side down from rafters, to locking up and chaining and whipping, every sort of punishment was deemed as therapeutic Some behavioral therapy! As world became more prosperous and people had the leisure and patience for even the most annoying,  even the seriously mentally ill started looking less as nuisance and more as objects of sympathy and compassion. With Pinel in France and Tuke in England spearheading the moment,  the idea took hold in the late 1700s that perhaps reasoning with mentally ill may yield better results than just condemning, ridiculing and beating them.  Pinel and Tuke undoubtedly were the first CBT therapists of the modern era. 

The next person who deserves that distinction was Franz Mesmer. A German physician, who after a few years of great success in Vienna got expelled from there as a charlatan, ending up in Paris in 1978. Paris at the end phase of the Age of Enlightenment and at the dawn of the Revolution and at the epicenter of fads was just the place for Mesmer to ply his unique approach. He bypassed compassion and reasoning with the insane and instead reasoned that pretense of reasoning was enough to get results. By simply going through the physical motions of doing something reasonable, something like running magnets or simply one's hand over their body and behave that it works because it is based upon science is  quite enough to get relief.  Anything would work as long as it is presented as respectable scientific enterprise and more so if the practitioner was himself convinced of its scientific merit. The scientific logic that Mesmer advanced - no inferior than the scientific theories modern CBT advances to legitimize their trade - was that those hand motions and magnets were unblocking the body's pent up magnetic force. Magnetic force modelled after the gravitational force -  discussing Newton's theory of gravity in the social parlors of Europe was the rage of the day -   beaming out of the stars and planets and pervading all living organisms with good health  requiring their free flow.  Interestingly the idea of animal magnetism was not too off the mark in capturing the principle upon which the nervous apparatus actually functions.  Mesmer had grasped in his own way Magendie-Bell's Law of reflex arc and the libido theory of psychoanalysis. Magnetic force running through the organism and on getting blocked causing mental tensions is not too different from psychoanalytic theory that libido flowing from the afferent end (sensory and instinctual sources) to the efferent end (motor outputs) of the nervous apparatus in the manner of the reflex arc, on getting obstructed  due to repression, results in neuroses and mental issues.

Mesmer besides moving his hand and magnets like modern reiki and tai chi over the patient's body also gave special attention to the painful areas, touching them liberally, which, not surprisingly, were usually in the proximity of the genitals - which makes mesmerism a forerunner of chiropractic, massage therapy and other forms of spinal manipulation. Additional shenanigans of science like dunking people in magnetized water - recall here the born again cure that comes from  baptismal rituals -  subjects swallow iron filings and getting them directed to the  diseased areas, playing of healing music - forerunner or music therapy-,  sitting on oversized wooden box filled with magnetized water ("Baquet"), holding hands doing seances, plugging the supposedly pathological spots to iron rods out of Baquet, were part of the technique.  All this looked as scientific to the eighteenth century intelligentsia as CBT does to us. How can one not appreciate the beautiful simplicity that thoughts generate emotions, emotions generate behaviors, and behaviors generate thoughts and to achieve cure all you have to do is to pop the defect in any one of them and the other two come tumbling after.  Since junk science has nine lives, Mesmer's techniques to this day keep returning in endless new forms, currently, to name a few, as Reiki, Tai chi, aquapuncture, bio-meridian therapy, rectal ozone therapy, tapping therapy, and the most successful of them all, the one and only Cognitive Behavioral Therapy. Though it is unjust to lump Mesmerism with CBT.  Mesmerism had more class.  If one ignores Mesmer's paranoid diathesis from which arose its internally consistent delusional hypothesis of systematic magnetism, he. unlike the CBT's cut and dry rationality approach, interacted with his subjects as they were real people with real feelings, and could draw out of them profound emotional response, his famous "emotional crisis".  Patients under his spell would cy, laugh, jump with joy, enter into ecstasy and profound sadness,  including convulsions and trance states, something akin to the current attempts that are going on with psychedelic therapies. "Emotional crisis" of Mesmer of course was nothing more than cathartic transference reaction - what Aristotle considered to be the function of arts though in a more restrained fashion and which Breuer and Freud described in their "Studies in Hysteria" as "chimney sweeping" and as abreaction of "strangulated affect". CBT's  reliance solely on logical persuasion does not even include in their therapy the release of the patient's pent up emotions. CBT's theories have no openings for the phenomenon of transference and yet it has become the be-all and end=all of psychotherapy.  

Mesmerism spawned hypnotism. Mesmerization, the human capacity to  rapidly enter into libidinal bonds of suggestibility on part of a dependent party towards a dominant one, with submissiveness, in some so profound as to melt all of one's ego resistances, and in neurotics to give up their symptoms, at least for a while,  remained the core of  hypnotism, but without the drama of magnets, magnetized water and hand movements over the diseased parts of the body - though swinging of a clock pendulum still remains a fixture of hypnotism displaying from where it originated - and the suggestibility is obtained from direct commanding. The difference between CBT where the ego is reasoned with instead of being overpowered and set aside as in hypnotism, is that hypnotism directly orders the symptoms to disappear while CBT plays 16 week long game of doing cognitive and behavioral rituals in asking the same thing. 

At this point it begins to dawn upon us that all these approaches, religion, spirituality, and the 50 shades of punishment and reward with or without CBT rituals, they all work by either producing pain or pleasure in the ego to give up the insanity. They are all different variations of Theodore Meynert's theory, the true father of Behaviorism - wrongly attributed to Pavlov, Thorndike and Skinner - that all behaviors directly or through association are strictly determined by the sum of pain and pleasure they invoke. One thing however is common to them all. They are all top down approach to healing. They all in different ways attempts by external forces to strengthen the ego to restore the balance of power between the ego, the rational part of the self, and the id, the instinctual conglomeration of the individual, in favor of the former.  

None of these approaches attempt to understand why the instinctual impulses chose the path of insanity and instead of repelling that insanity through pain or pleasure into choosing even more crazier paths for expression try to undo the blocks present in their natural path through  understanding,  so they can do rest of the work of correctly  interacting with the world on their own.   Psychoanalysis met this challenge and embarked upon what looked like an impossible task: decipher neuroses and instead of suppressing it paradoxically encourage its expression, after analyzing it of course, so instead of appearing formidably incomprehensible they make sense, and are amenable for modification. For example a patient who was greatly disturbed that he can only be sexually potent with his wife when he watches masochistic Tranny porn, and had thus given up having sex for aesthetic reasons and thus was  filled with anxiety and depression, found much relief and started having sex again without feeling great shame and consternation when analysis showed that all women had become representative of his mother in his unconscious and he could make love to them when he substituted himself for her and submitted himself to his father as a compensation in fantasy while making love. So what looked like perversion was not irrational and repulsive per se.  It made perfect sense when the fantasy which was giving an outlet in displacement to his intrapsychic sexual conflict occurring in his unconscious was analyzed. When untangled, the majority of  id impulses that are being rejected have no opposition from ego in finding expression, for it is only their fusion that makes them rogue.  

One would think the world would have been overjoyed for at last being provided with a technique that promised unravelling the knot of madness from its inception to its final form.  Alas liberating mankind from its chains is not something that inspires gratitude.  In his "Moses and Monotheism"  Freud tells us that hardly had Akhenaten, the Egyptian Pharaoh who gave us monotheism, taken his last breath, when the priests of Thebes waiting for this moment made their comeback, rolling back his reforms, restoring back all  the old Gods of Egypt. There was too much to lose financially with just one God directing human affairs, and who worse still was not only indifferent to sycophantic praises and rich offerings as the condition for granting favors,  as composed simply of sunrays which are free for all. Those who made their living with pandering 50 shades of psychotherapy struck back at psychoanalysis and not even waiting for Freud to die, before making their move to dethrone psychoanalysis.  Alfred Adler was the first rebel. Downplaying the role of unconscious motives, in fact taking no heed of the unconscious altogether, he brought back the idea of curing the person as a whole - excluding his sexuality in this whole of course - by strengthening his personality (ego) through meaningful relations, social connectedness, goal-oriented living, enhancement of one's competence and by turning one's natural inferiority into superiority through moving from the inferior feminine end to on-the-top masculine end.  And above all cultivating a unique lifestyle of thinking, feeling and behaving. Was Alfred Adler the father of the cognitive triangle of CBT, half a century ahead of its time?  

The summarization above of Alfred Adler's Individual Psychology, or more correctly Ego Psychology - for the misnomer Individual Psychology, a reflection of Adler's muddled thinking, actually makes no sense. It begs the question are we to view it as one person's psychology versus mass psychology with his intent to address only the former or such a moniker was an attempt by Adler to break free of Freud to be on equal footing with him, and do it by peddling a competing brand of psychology and opening the gate for all individuals to practice psychotherapy as it pleased them without being hampered by the strict and untendentious  psychoanalysis - a forerunner of the mindset of DSM III authors.   

Other attempts to dislodge the importance of studying the origins of mental symptoms (id)  in favor of manipulating their end manifestations by force or rational persuasion or simple buffaloing followed. The most notable of them would be the Analytical Psychology of Jung. It once again derailed proper scientific approach towards neurotic illnesses and it still stays under its influence now as CBT. Jung was sexually abused as a boy by a man he hero-worshipped. He had a bias towards obliterating this memory and by displacement to underplay childhood sexual fantasies and experiences having a role in shaping one's behavior as an adult or causing mental illnesses. If he could prove this he could prove to himself his sexual molestation had not damaged him and he was a normal adult. And he weaved a whole system of therapy to make this assumption sound true. He did not simply take the side of the ego against the id as Adler and all their predecessors had done from antiquity till  Freud challenged the approach. Jung was ego psychologist too, just like Adler and CBT is, and advocated strengthening of the ego and saw the etiology of mental illnesses in failing to master one's life tasks. But compelled to bury his humiliating sexual assault he added another twist namely that the sexual phantasies which analysis reveals through free associations are not real events at all but false memories, projected upon the childhood because of failure to achieve life-goals in the present.  If one takes Jung's claims to its logical conclusion it claims that if you do not do your life tasks correctly in adulthood you become mentally ill and in addition to doing other crazy things become a pervert and project into your childhood sexual fantasies of seduction and incest, which are concocted and which had never happened, and as to why the mentally ill does that we need not bother much about for one is better off just concentrating on getting well by developing interest in spirituality and eastern mysticism and exploring the treasure trove of our  collective unconscious.  He kept the facade of being a psychoanalyst, at least in paying kip service to it, but the interpretation he made from the clinical material were "wild psychoanalysis"; utter nonsense but so cleverly weaved that the intelligentsia readily welcomed them as profound wisdom. With human penchant for favoring fake over the real, it is no wonder he quickly became the blue eyed boy of not just psychology but of  hooey of every ilk.  And  his example in mind as to how much quick recognition can be plumbed by pandering horseshit instead of painstakingly collected unbiased observations opened the door for other charlatans. Melanie Klein, Wilfred Bion, Donald Winnicott, in fact all those who take their cue from Melanie Klein, who seriously propounded the theory that during the period of 0 to 5 months all babies go through paranoid, schizoid and depressive phases, and think that such a deranged theoretician can be taken seriously for any of her other writing and can be used as a  starting point for their own theories, are certifiable lunatics, not psychoanalysts. And that is what is wrong with current psychoanalysis and why it cannot compete with CBT in getting better result. Far from observing and analyzing the id correctly, they inundate their treatment with all kinds of nonsensical interpretations, and add to the patient's neurotic misery their own confused understanding of the nature of mental problem. In fact more insanity exists in the collective consciousness of psychoanalytic institute members than the  collective unconscious of all mad people. The world of psychology still functions under this derailment and would be some time before it gets out of the wilderness. 

And this is the reason why CBT shows better therapeutic results than psychoanalysis. It at least adheres to practicing ego psychology to the best of its ability. What it practices is still within bounds of normalcy.  It is common sense homilies that it delivers, and since it delivers it with full sincerity, along with the libidinal bonds that develop between two individuals who undertake a common task and spend time exclusively with each other, it is not surprising that it gets respectable results. 

It is not that psychoanalysis shuns ego psychology and does not think that final cure does not come from bringing the ego to normalcy. As Anna Freud put it in her Ego and its mechanisms of defense:

There have been periods in the development of psychoanalytic science when the theoretical study of the individual ego was distinctly unpopular. Somehow or other, many analysts had conceived the idea that, in analysis, the value of the scientific and therapeutic work was in direct proportion to the depth of the psychic strata upon which attention was focused. Whenever interest was shifted from the deeper to the more superficial psychic strata—whenever, that is to say, research was deflected from the id to the ego—it was felt that here was a beginning of apostasy from psychoanalysis as a whole. The view held was that the term psychoanalysis should be reserved for the new discoveries relating to the unconscious psychic life, i.e., the study of repressed instinctual impulses, affects, and fantasies. With  problems such as that of the adjustment of children or adults to the outside world, with concepts of value such as those of health and disease, virtue or vice, psychoanalysis was not properly concerned. It should confine its investigations exclusively to infantile fantasies carried on into adult life, imaginary gratifications, and: the punishments apprehended in retribution for these. Such a definition of psychoanalysis was not infrequently met with in analytic writings and was perhaps warranted by the current usage, which has always treated psychoanalysis and depth psychology as synonymous terms. Moreover, there was some justification for it in the past, for it may be said that from the earliest years of our science its theory, built up as it was on an empirical basis, was pre-eminently a psychology of the unconscious or, as we should say today, of the id. But the definition immediately loses all claim to accuracy when we apply it to psychoanalytic therapy. From the beginning analysis, as a therapeutic method, was concerned with the ego and its aberrations: the investigation of the id and of its mode of operation was always only a means to an end. And the end was invariably the same: the correction of these abnormalities and the restoration of the ego to its integrity. 

Furthermore it is not psychoanalysis does not believe in psychoeducation and exposure therapy to supplement figuring out the patient's unconscious through free association. Here is an excerpt from Freud himself which puts him as the father of ERP (exposure response prevention) which Behaviorist claim as their innovation.

Our technique grew up in the treatment of hysteria and is still directed principally to the cure of that affection. But the phobias have already made it necessary for us to go beyond our former limits. One can hardly master a phobia if one waits till the patient lets the analysis influence him to give it up. He will never in that case bring into the analysis the material indispensable for a convincing resolution of the phobia. One must proceed differently. Take the example of agoraphobia; there are two classes of it, one mild, the other severe. Patients belonging to the first class suffer from anxiety when they go into the street by themselves, but they have not yet given up going out alone on that account; the others protect themselves from the anxiety by altogether ceasing to go about alone. With these last one succeeds only when one can induce them by the influence of the analysis to behave like phobic patients of the first class - that is, to go into the street and to struggle with their anxiety while they make the attempt. One starts, therefore, by moderating the phobia so far; and it is only when that has been achieved at the physician‘s demand that the associations and memories come into the patient‘s mind which enable the phobia to be resolved. I

However, psychoanalysis thinks ego's healing should take place by analyzing the working of both the ego and the id. In fact not just the working of the ego and the id but that of the superego, as well, a division of the ego. The technique is best described in this highly illuminating paragraph from Anna Freud's "The Ego and its Mechanisms of Defense."

We all know that the three psychic institutions vary greatly in their accessibility to observation. Our knowledge of the id—which was formerly called the system Ucs.—can be acquired only through the derivatives which make their way into the systems Pes. and Cs. If within the id a state of calm and satisfaction prevails, so that there is no occasion for any instinctual impulse to invade the ego in search of gratification and there to produce feelings of tension and unpleasure, we can learn nothing of the id contents. It follows, at least theoretically, that the id is not under all conditions open to observation. The situation is, of course, different in the case of the superego. Its contents are for the most part conscious and so can be directly arrived at by endopsychic perception. Nevertheless, our picture of the superego always tends to become hazy when harmonious relations exist between it and the ego. We then say that the two coincide, i.e., at such moments the superego is not perceptible as a separate institution either to the subject himself or to an outside observer. Its outlines become clear only when it confronts the ego with hostility or at least with criticism. The superego, like the id, becomes perceptible in the state which it produces within the ego: for instance, when its criticism evokes a sense of guilt.

And the way the pathological ego should heal itself is not as to what the therapist thinks is best for the patient (as CBT and all top down therapies do) but as the patient with his life experiences, now that the conflict laden areas are laid bare for him through analysis, chooses as to what is best for him, what he should incorporate and what he should reject as incompatible with his sense of himself.  Its not therapist who knows what is best for the patient but the patient who knows what is best for him. The therapists role is just to remove the unconscious resistances that were keeping his ego divided against itself .  

The problem with CBT is that it thinks that only addressing the ego is sufficient, and just its conscious part. It is what Freud put it as taking part of the psychoanalysis and claiming it to be the whole. Nothing like listening to the Master himself. Here is what he says about it in "From the history of an Infantile Neurosis":    

I may here venture to point out that the antagonistic views which are to be found in the psycho-analytic literature of to-day are usually arrived at on the principle of "pars pro toto". From a highly composite combination one part of the operative factors is singled out and proclaimed as the truth; and in its favor the other part, together with the whole combination, is then contradicted. If we look a little closer, to see which group of factors it is that has been given the preference, we shall find that it is the one that contains material already known from other sources or what can be most easily related to that material. Thus, Jung picks out actuality and regression, and Adler, egoistic motives. What is left over, however, and rejected as false, is precisely what is new in psycho-analysis and peculiar to it. This is the easiest method of repelling the revolutionary and inconvenient advances of psycho-analysis. 

Above all CBT is a fur-lined mousetrap. By obtaining quick therapeutic results, rather relief than true  permanent changes, it buffaloes us to the obvious that its theoretical underpinnings are hastily put together falsities that sends further research in psychopathology, even psychotherapy itself, into a blind alley. Research based upon the concepts of  Cognitive Triad, Cognitive Triangle and 3 Cs of can only be fit for AI generated chatbot science and Tik Tok video wisdom. Science cannot be built upon false premises. It is easier to illustrate this with a clinical example. An attractive, intelligent businesswoman, who came for treatment for general unhappiness, panic attacks, and fear that she will lose her livelihood due to inadvertently committing some criminal error at work - the fear continuing into her sleep, translating into frequent nightmares of being locked up in a prison after getting arrested for business improprieties  - she is a scrupulously honest and straight as an arrow when it comes to money  - confessed, after months of treatment, that she suffers from IBS, manifesting primarily as constipation. Now if I was a CBT therapist I would have embarked upon convincing her as to how wrong it is for her to be unhappy when everything is going so well for her -she earns 300K a year besides having a doctor husband  - just think of all the people who are starving in India, who would  change places with you in a heartbeat. For her panic attackI would have entered in to psychoeducating her on recognizing  the impending signs of panic attacks and drilled her on its causes, and how nobody dies despite from them despite feeling that they are about to do so, explained the role of yogic breathing in halting them and the wisdom of mindfulness, which the ancients knew, putting us modern to shame. Then gone into many sessions of theoretical explanation about the interlocking of thoughts, emotions and behaviors, and when she is prepped up by the overwhelming complexities of these concepts, gone into  are what maintain panic and why it makes sense to disregard this unnecessary fear, even challenge it by gradually going into ever bigger crowds while holding back the panic with sheer  will power, and then pooh-poohed her dread of going to prison as she knows better as to how honest people do not go to jail, and anyway it is all due to misperception and the idea that she will steal from her own business.  But all these CBT approaches would not have thrown a single ray of light upon one aspect of her problems,  her constipation.  The science of CBT would have gone no further than declaring that this is outside the scope of their practice or given off label counseling as to which would work better with her Miralax or Ex-lax. But her whole psychopathology was hidden in this symptom. Her problem had nothing to do with her stealing from herself and panicking over it and going to jail as a consequence. She was in her late thirties and was in throes of a deep conflict over to have or not to have a child. Among many other things which were impelling her not to the main one was the presence of an endless back and forth bickering, in her unconscious, with her highly anxious mother who while she was growing up was relentlessly critical of her, intolerant of any lapse, especially of appearance  - her whole narcissism was concentrated upon her good looks and marvelously thin body which would be ruined by the pregnancy -  and she was afraid she will repeat the same crime (hypercriticalness) against her child if she had one. Her being in prison was fantasy of being punished of course but also of being pregnant, with jail cell symbolizing the womb, where she would be back as her own child if she got pregnant.  The stealing from herself was a displacement of the impulse to steal from her own husband, his penis. Penis being a substitute for a child in the unconscious (See Freud's ‘On Transformations in Instinct as Exemplified in Anal Eroticism’ (1917) she was trying to convert the impulse to have a child with impulse to have her husband's penis for herself. If she could only become a woman with a penis there was no need for to have a child and it would also avoid having to repeat her mother's cruelty to herself upon her child.  Her being constipated was the satisfaction of the wish to be pregnant, but with bowels substituting for the genital canal. By remaining constipated she was being pregnant and yet not delivering the baby and avoiding having a child - killing two birds with one stone. 

All these rich insights into the working of the psyche, which is the real evidence-based psychiatric research would have remained a closed chapter with this patient if I had pursued just "cognitive restructuring" for immediate improvement.  Practicing psychiatry with patients using CBT is a devil's bargain in that for quick results we  give up doing genuine analysis of the human psyche and thus close the door upon scientific exploration of the deeper strata of human mind.  .

***

Footnote on Repression

Repression, a psychological mechanism that keeps the instinctual impulses within the id (at the earlier unorganized unconscious part of the psyche) and thus incapable of getting converted into purposeful motor action and discharge, for that can only happen as organized behavior (through the agency of the ego). Repressive process is a derivative of the death (aggressive) instinct. The external world besides being the source of all things necessary for the continuation of our existence is also the ever present threat relentlessly striving towards our end. The objects that nourish us and eventually enable us to reproduce also, embedded within them, contain the elements that destroy us. The sustaining aspect of the outside world is Eros, the Life Instinct, while its destructive aspect is Thanatos, the death  instinct. Both wings of this external reality find equal representation in all animate organisms (perhaps the entire animate and  inanimate universe works under this principle of endlessly striving to unite and disintegrate). The incorporated destructiveness of the outside world within the organic world, from the protoplasmic irritability of unicellular organisms to the organized skeletal musculature of human beings, is redirected by the living organisms back upon the  the external world as counter aggression (sadism), and what cannot be discharged there is  turned against one's own self (masochism). When this aggressive instinctual energy against one's self is utilized to block the instinctual impulses (which, as representative of the life instinct, are constantly seeking union with the outside from where they originally came from and from which they got sequestered through entrapment in the living organisms) it does so by inflicting pain upon the ego, directly, or through the agency of the superego, repulsing the movement of the libidinal impulses from finding a foothold in the ego and thus obtaining discharge. The repulsed libidinal impulses left on their own in the unconscious, move laterally to find spots elsewhere in the ego from where they can make inroads in the latter without invoking infliction of pain upon it (the ego) from the punitive aspects of  the superego, the representative of the external world, or directly from the external world itself. In short repression is an expression of the death instinct as libido is of the life instinct.   

This conjecture also explains as to why in Parkinson's disease the patient becomes increasingly immobile. With no dopamine left to spark the preferred chains of associations over others like Buridan's ass, it is left with immobility. 

indissoluble bonds develop between them,  which gives us our sense of self,  our ego. To view dopamine as the neurotransmitter that sparks pleasure is erroneous. To assume that positive emotions can be generated simply for their own sake and not strictly as a response to a relief from negative emotions has no place in the economy of nervous functioning. Nervous system evolved from the extension of the protoplasmic irritability of the unicellular organisms into now the most complex mechanism in the known universe, on the principle of getting rid of all sensory burden coming from the receptive end of the animal organism, including sensations coming from within, which broadly can be classified into that of hunger and reproduction, by moving them towards the motor (thinking and behavioral) end.  There is no scope, or need, for the generation of positive emotions per se in such a system. For doing so would only increase the sensory burden by impelling the organism to search for the cause of such a pleasure and embarking on a wild goose chase, seeking  activities that are not rooted in taking care of one's instinctual needs for which alone the nervous system evolved.  Dopamine is released only as a response to the kinesthetic reports of motor discharge reaching  through sensory feedback loops to the perceptual system, signaling reduction in nervous tension and by implication satisfaction of instinctual needs. Its purpose is to strengthen and pay attention to those perceptions, thoughts and behaviors, and their interconnections, that immediately preceded and accompanied the motor discharge.  Dopamine is released as a response to pleasure from satisfaction of needs and not as a means to create pleasure. High intake of amphetamine or cocaine that causes  massive release of dopamine may create a sense of euphoria  - without there being satisfaction of some need through motor discharge - but only because of its association with past pleasurable memories which are triggered that are , but that is a byproduct of dopamine activity which does not contradict the contention that the brain does not have centers or neurochemical processes dedicated to spark pleasure.

 All these processes which at the very root are the play of the Thanatos (death instinct)  seeking seeking separation and quiescence in contrast to the Eros (libido) striving for unions and activity, with the phases of the struggle taking place outside the domain of secondary process thinking and consciousness, can be constructed by the investigator of human psychology with lesser and greater accuracy but never with complete certainty. 

The sustaining dimension of the outside world is Eros, the Life Instinct, while its destructive dimension is Thanatos, the death  instinct. The internalization of these two aspects of the universe - the life sustaining and life destructive - are played out in individual living organisms in the form of the libidinal impulses seeking union while the destructive part among many other activities through repression blocks their union.

Not different in essence from how the entire person traverses through life concealing its real intentions. From the camouflaging plants and animals that blend with their surroundings like chameleons to deceptive humans -  towards the outside world to escape harm and retaliation while helping themselves to its bountifulness. Our dealings with the external reality as a whole person is mirrored in id's dealing with the ego. For ego is nothing but the representation of the external world's functioning in the outermost layer of our psyche. In fact it is this camouflaging towards others when done with style becomes art and culture, and when done imperfectly becomes object of ridicule to creepy and crazy.