May 12th, 2012  My second post in this series on sloppy thinking in psychiatry is devoted to polypharmacy, the medical term for prescribing multiple medications at once, especially for the same problem. Polypharmacy is at best a risk thoughtfully taken because nothing simpler and safer will do. At worst it’s a dangerous error, exposing patients to unnecessary hazards purely as a result of laziness and sloppy thinking by their doctors. Unfortunately, the latter is all too common in psychiatry. Let’s look at why.
It has been said that the less we know about an illness, the more treatments we have for it. Instead of one definitive cure that attacks the root of the problem, various remedies ease symptoms — not the cause — often via different mechanisms. A good example of a definitive cure is a specific antibiotic to treat a bladder infection. We know how bacterial infections work, and we have antibiotics to attack the root of the problem. Ancillary treatments for fever or pain are sometimes used, but they are clearly secondary, and often optional. In contrast, the pathogenesis of psychiatric disorders is not known, thus we have no treatments to attack the roots of these problems. For example, antidepressants affect neurotransmitters that appear implicated in depression, but the exact way these neurotransmitters relate to the syndrome of depression is unknown. Thanks to our ignorance, we have medications that affect serotonin, and others that affect norepinephrine and/or dopamine. In recent years atypical neuroleptics (antipsychotics) have been approved as add-ons for treating depression, a worrisome development given their risks.
Since we don’t have a definitive cure for depression, many patients report partial (or minimal) improvement from any one medication. The prescriber may then add another on the theory that it may help via a different chemical mechanism — a theory that is difficult to confirm or refute, as we don’t know the mechanism in the first place. The original medication is not stopped: If the patient improves, why disrupt a winning combination? And if the patient doesn’t improve, we wouldn’t want to withhold an antidepressant from a depressed person, would we? Sloppy thinking all around, yet sadly common.
Similar arguments can be made for the treatment of bipolar disorder and schizophrenia. Lacking a true understanding of pathogenesis, we treat empirically. And empiric treatment, while often compassionate and necessary and helpful, invites the shaky logic of adding more medications hoping for more empiric benefit.
Compounding and worsening this situation is psychiatry’s abandonment of parsimony in diagnosis and clinical assessment over the past 30 years. Prior to the publication of DSM-III in 1980, psychiatric evaluation was an attempt to explain a patient’s seemingly unrelated complaints using a single theory (often psychoanalytic, but possibly biological or even behavioral). The introduction of phenomenological diagnosis in DSM-III encouraged multiple diagnoses in the same patient, say Major Depression and PTSD on Axis I, and a personality disorder on Axis II. There was no longer any attempt to tie it all together. This has encouraged a piecemeal approach to treatment: a medication for depression, a different one for PTSD, maybe something for sleep, and something else again for agitation due to the personality disorder. That’s four different psychiatric medications already, and we’ve hardly even started. Patients with personality disorders often complain of “mood swings,” so let’s add a mood stabilizer like lithium or Depakote. And they’re anxious, so we could add a benzodiazepine tranquilizer like Ativan, or a beta-blocker like propranolol, or an atypical neuroleptic. Or what the hell, all three! We’re up to seven or eight medications now, and we haven’t even considered a stimulant for their ADHD — because, after all, the patient is having trouble concentrating… funny how it was never diagnosed before. And we haven’t augmented the antidepressant with thyroid supplementation, nor have we added a second antidepressant…
While 10+ psychiatric medications is clearly over top, I’ve evaluated a number of patients who arrive on six, often an (1) antidepressant, (2) mood stabilizer, (3) tranquilizer, (4) sleep aid, (5) stimulant, and (6) another antidepressant or mood stabilizer. Almost without exception, I’ve been able to cut this list in half, and in some cases down to zero, or more often, one medication. It’s less a matter of expert medication choice, and more an aversion to sloppy thinking. According to one study, antipsychotic polypharmacy can be simplified without harm 2/3 of the time.
Psychiatric polypharmacy is often intellectually lazy. Needless to say, there are far more drug combinations than there are studies assessing the risks and benefits of these combinations. Polypharmacy is nearly always an educated guess, not “evidence based medicine.” It’s not even good single-case research, where one would ideally change a single variable at a time. All too often, medications are added to treat the side-effects of other medications, as with “ADHD” in the case above, a tail-chasing exercise that only gets worse over time. With every added medication there are added side-effects, and sometimes adverse interactions that can be more harmful than the original problem. In my experience, generic side-effects such as weight gain and cloudy thinking are more the rule than the exception in patients taking multiple psychiatric medications. It should happen a lot less than it does.
Once again, photo courtesy of Petr Kratochvil.
April 29th, 2012  There’s a lot of sloppy thinking in my field. This troubles me. While psychiatry inevitably deals with the speculative and poorly understood, this surely cannot excuse faulty logic and intellectual laziness. Worse yet, this laxity of thought extends across the field, from biological psychiatry to psychotherapy, and from the general to the specific. My next few posts will address what I see as major areas of psychiatric sloppiness.
“Chemical imbalance” is a phrase used by psychiatrists and laypeople alike. When a mental problem seems to arise from within instead of without, it is said to be due to a chemical imbalance. In truth, however, no chemical imbalance, nor any structural abnormality in the brain, has ever been found to account for anything we currently consider a psychiatric disorder. Historically, whenever chemical or structural abnormalities were found to account for abnormal mental functioning, those conditions were no longer considered psychiatric and were adopted by another branch of medicine. If this trend continues, psychiatry will never include pathophysiology in the usual medical sense. It certainly does not at present.
Like many paving stones on the road to hell, the phrase “chemical imbalance” was sincere and well-intended at first. It originally referred to the biogenic amine model of depression, i.e., the hypothesis that a lack of excitatory neurotransmitters such as norepinephrine and serotonin underlies depression. While it’s a fairly compelling concept, it suffers from a lack of solid evidence. People who are depressed do not have “decreased serotonin in the brain,” and taking an SSRI does not “correct” the serotonin level. Such drugs may offer benefits as a result of boosting serotonin, but that’s not because serotonin levels were low to begin with. Moreover, the fact that SSRIs increase the amount of serotonin in brain synapses says nothing about the ultimate cause of depression. A cascade of downstream effects follows from tinkering with serotonin, including receptor down-regulation and probably new protein synthesis. If there’s any inherent chemical imbalance being remedied, we don’t know a thing about it.
Population studies show subtle changes on average in the brains of patients with certain psychiatric disorders. However, the findings in subjects with psychiatric diagnoses overlap so much with those of normal subjects that no blood test or brain study can diagnose mental illness in an individual. (Dr. Daniel Amen claims otherwise regarding SPECT scanning of the brain, but many critics are skeptical. Likewise, a putative new blood test for depression raises many questions.) At best, “chemical imbalance” is shorthand for a presumed brain abnormality that no one has yet proven. At worst, it is disingenuous hand-waving aimed to add medical legitimacy to the field of psychiatry.
Why is “chemical imbalance” so often advanced as a pseudo-explanation for mental illness? Many psychiatrists confidently proclaim that psychiatric disorders “are medical conditions just like diabetes and hypertension” to justify chronic ongoing management and the need for medication even when the patient feels subjectively well. Suffering a “chemical imbalance” implies that proper medication will correct a pre-existing, permanent organic abnormality. The problem here is that the end (patient cooperation) does not justify the means (lying). The honest answer is that we psychiatrists believe our medications help relieve psychiatric symptoms and distress — although even that is hotly debated — including maintenance treatment to forestall relapse. This belief is based on outcomes research and clinical, aka anecdotal, experience, not on knowledge of biological mechanisms.
Psychiatry has long been the red-headed stepchild of medicine. In medical centers we’re often in a separate building across the street from the main hospital. Other physicians sometimes don’t understand what we do and make nervous jokes. Critics accurately note that psychiatric disorders are never found in standard pathology textbooks, and some claim the field is baseless and harmful. “Chemical imbalance” gives some psychiatrists the medical bona fides they crave, but at the price of intellectual laziness and sloppy thinking. This serves no one. Psychiatry must embrace uncertainty, and not seek false security in empty phrases. Physicians prescribed aspirin for pain and fever long before we understood the intricacies of these conditions, or the mechanism by which aspirin affected them. We simply knew it worked — no one claimed that a subtle “aspirin imbalance” was being corrected. Like it or not, psychiatry is in much the same place now.
I’m hardly the first to critique “chemical imbalance,” although some still defend it. I started with this as the prime example of sloppy thinking in psychiatry. But as we shall see, there are many others.
Photo courtesy of Petr Kratochvil.
April 1st, 2012  I just finished a day of jury service in criminal court, and have some thoughts about the whole process. Some relate to me as a psychiatrist, some are more generic. I’ll start by admitting I’ve never served as a juror in an actual trial. Doing so would interest me, and I do appreciate the role of juries in our legal system, yet the hassle of missing work and other obligations outweighs these factors in my mind. Thus, I’m happy I’ve escaped so far. Years ago I wrote to be excused whenever I received a jury summons. I argued that my patients needed me more than the legal system did. That argument worked once or twice in the distant past: I was excused for the year without having to appear at all. However, the last couple of times I tried it my request was denied. I was instructed to show up like everyone else. So I don’t fight it anymore, although I still feel the argument has some merit.
Do psychiatrists, and possibly other mental health professionals, have a valid claim that their jury service risks hurting their patients? As described here, jury duty presents a unique uncertainty for psychiatrists and patients, one that isn’t the same as a planned vacation or even a sudden illness. (The issue is also discussed toward the end of this 1996 article in the New York Times.)
In my jurisdiction, the recipient of a jury summons is “at risk” for a week, and must call each evening to learn whether to appear the next morning. Canceling patients for this entire week would be incredibly wasteful, resulting in many treatment disruptions and the forfeiture of a week’s income, usually for no good reason. The alternative is to warn patients in advance that they may be canceled the evening before their appointments — which is less advance notice of cancellation than a psychiatrist typically expects of his or her patients. Some patients react poorly to last-minute cancellations, some cannot reschedule (or the psychiatrist has no other times to offer); as a worst case scenario this may constitute a “last straw” that ends a treatment. Even when bad outcomes are avoided, it adds a wrinkle to the treatment of all affected patients.
When I warned my patients that I might be away for one or more days last week, several expressed surprise that I would receive a summons at all. Realistically, there’s no reason I wouldn’t. Potential jurors are selected randomly from voter and DMV lists; it’s a pretty safe bet that one’s psychiatrist is on such lists. Perhaps this is another instance of patients having difficulty imagining their psychiatrist living a normal life outside the office. In other words, it’s a transference phenomenon.
Psychiatrists are rarely kept on juries. The procedure for selecting a jury for a given trial is called the voir dire. Prospective jurors state their names, occupations, and other key facts. The attorneys then ask questions to elicit potential bias that would be unfavorable to their side. The attorneys use peremptory challenges or challenges for cause to excuse problematic jurors. Each time I’ve made it to the voir dire, I’ve been excused by peremptory challenge, which means no reason was given. Attorneys prefer not to have “experts” on juries, i.e., legal experts such as other attorneys or police officers, or mental health experts who, they fear, may “see through” their arguments, or come to our own conclusions regarding the thoughts and motivations of the involved parties. In any event, it’s frustrating to cancel or reschedule a day of patients, and languish at the courthouse for most of the day, when I’m virtually certain never to serve on a jury.
While I was languishing, I contented myself by observing the process and the people involved. Like mass transit and some public events, jury service offers a cross-sectional look at one’s neighbors. Adults of all ages, levels of education, and political views answer the call. A 20 year old sits next to a 70 year old, a professor next to a factory worker. Everyone gets along, mainly by benign indifference — and all of us are clearly subordinate to the people who work there: the bailiffs, the attorneys, and of course the judges.
A few potential jurors stand out by revealing their hatred of jury service. Several have interesting stories or perspectives to relate in the voir dire. A young woman is wary of police since her partner runs a medical marijuana dispensary. A young man feels gun laws are too restrictive. There were a surprising number of tech-workers — maybe I shouldn’t have been so surprised.
The “presumption of innocence” in a criminal trial (i.e., innocent until proven guilty) seemed lost on many jurors; judges and attorneys must find it tedious to repeat over and over that a criminal defendant need not offer evidence or argument of any type to be acquitted. But the main thing I found fascinating was how jurors in the voir dire defend their capacity to be unbiased and objective, even after they express overtly biased views, and even when they presumably would prefer to be excused from service. Bias sounds like a weakness, a character flaw. Perhaps for this reason many jurors declare themselves neutral and completely open-minded when that cannot possibly be the case. I wonder to what degree the whole institution of trial by jury relies on pride — the pride of individual jurors in their own objectivity, and a social pride we feel in the “wisdom of the common man,” despite clear evidence that basic legal tenets, like presumption of innocence, are often unappreciated.
I would prefer to avoid too much pride myself. Psychiatric work is not the easiest kind to set aside for the obligations of jury duty, but I doubt it’s the hardest either. I don’t plan to ask for special exemptions in the future. All the same, I don’t mind if attorneys continue to believe we can see through their arguments, and read the minds of their clients. A little transference can be a good thing.
Image: “Justice,” Edwin Austin Abbey (American, 1852 – 1911)
February 17th, 2012  Several recent articles, blogs, and even my participation in HealthTap (discussed in my last two posts) have led me to think about how psychiatry, and mental health treatment generally, are increasingly viewed as commodities. In the language of economics, a commodity is a physical good, such as food, grain, or metal, which is interchangeable with any other product of the same type. Commodities are carefully specified, e.g., “Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico,” but the supplier is immaterial. Everything one needs to know about a commodity is in the specification. Based on that alone, a smart buyer seeks the lowest price.
Much has been written lately about the psychiatric “med check,” a 10 to 20 minute encounter every few months for patients who take psychiatric medications. A New York Times profile of one such high-volume practice generated notoriety for this approach, well deserved in my view. Even the profiled doctor had reservations, but succumbed to the lure of higher income as compared to the traditional model of one patient per hour.
Although psychiatric medication management can be done well, the “med check” is often critiqued as an assembly–line approach that treats collections of symptoms, not people. The assembly-line metaphor highlights the commodification of both parties. On an assembly-line, each “part” moving down the line can be treated as any other. Likewise, each worker is interchangeable with any other having the same qualifications. In commodity psychiatry, any fully specified “Major depression, single episode, moderate severity” can be treated as any other. Mental health workers of a given specification (psychiatrist, nurse, counselor) are interchangeable as well. The only thing left is to let the marketplace (or government) set the price of this commodity transaction.
While commodity treatment is easiest to recognize in the stereotypical “med check,” it is rampant in the rest of the field as well. Suicidal patients should immediately be sent to the ER, yes? Because all patients who declare themselves suicidal are the same, just like “Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico.” Well, no. In supervising residents and talking with colleagues, I’m amazed how often patients cool their heels, and spend thousands of dollars, in three-day inpatient stays triggered by a threat of suicide. I claim no magical gift for curing depression or suicidal urges, and I’ve had my share of patients who scream, “I’m heading for the Golden Gate Bridge right now!” Nonetheless, I can’t recall the last time I hospitalized anyone for suicide risk, and I’ve never had a patient die by suicide. Why? Because it means something when someone threatens suicide, and that meaning varies from person to person. “Suicidality” isn’t a commodity specification, and it should not be treated as such.
Nor is psychotherapy immune from commodification. “You have social anxiety? We offer a 16 session cognitive-behavioral treatment for that.” As though people who are anxious in social situations are interchangeable — and as though any practitioner who conducts a brand-name 16 session intervention is the same as any other who offers that brand. The specification is all that matters, the supplier is immaterial. Perhaps the ultimate example of therapy as commodity is when there is no therapist at all, as in this recent article about a smartphone app designed to decrease social anxiety. Here, however, the app really is a commodity: Every copy of the app works the same, and it treats all users exactly the same as well.
With an ever-expanding diagnostic manual, and with a pharmaceutical, electronic, or scripted cure for every ill, psychiatry speeds toward a future where it no longer matters who has symptoms, it only matters what the symptoms are. Likewise, practitioners are interchangeable and thus should be chosen for the lowest cost, just as a buyer spends the least possible on a certain grade of wheat. It makes no sense to pay for an expensive psychiatrist or psychologist to perform psychotherapy, when psychotherapy is a commodity that can be supplied by people who charge less, or perhaps by a computer program, website, or smartphone app.
To be sure, there are areas of medicine well-served by rote protocol. Thankfully, no one stops to “customize” CPR during a cardiac arrest. But in most health care scenarios, treating patients as commodities is dubious. And in the subtle realm of emotional health it’s tragic. As I wrote in my post about nomothetic versus idiographic thinking in psychiatry, western medicine derives its considerable power from lumping patients into a disease category, and then applying statistically proven treatment to members of that category. For example, in psychiatry we are not forced to approach a new case of bipolar disorder in complete ignorance; among other things, we know lithium is apt to relieve the signs and symptoms. But if we stop there, at the nomothetic level of knowledge, we are treating the bipolar disorder, not the patient. The “supplier,” the person suffering the disorder, is immaterial. We are doing commodity psychiatry.
The alternative is not to abandon the hard-won knowledge of western medicine and nomothetic research. It is to acknowledge that every person sharing a diagnostic category is unique — that no individual experiences major depression or bipolar disorder in quite the same way as anyone else. Understanding and enhancing each patient’s unique experiential reality is the essence of psychiatric practice, and mental health care generally. Since these nuanced goals cannot be accomplished without considering the “supplier” — the person with the disorder, as well as the person offering care — the commodity model will forever shortchange psychiatrists and their patients.
January 19th, 2012  As posted below, I joined HealthTap a month ago, impressed with its vision of bringing real medical expertise to the public in a Yahoo Answers type format. Since then I’ve participated actively. As of today, I’ve answered 40 questions, and I’ve been thanked by 30 members — it’s tempting to call them patients, but they’re not. Other physicians have agreed with my answers 60 times; I’ve agreed with some of theirs as well. HealthTap claims I’ve helped over 4000 people; I have no idea how they calculate that. I’ve earned 3600 points and 13 rather trivial “awards” by virtue of my activities, granting me “Level 7” status as a “Leading Medical Expert.” I haven’t yet used the mobile app or social networking links (i.e., to Facebook, LinkedIn, or Twitter), nor have I written “tips” or “health guides,” collections of answers and tips under a defined theme. I also haven’t done much with the networking feature: I “follow” one other psychiatrist, and eight physicians follow me, which basically means they find out immediately if I post something (and their dedicated readers see it as well, like a Facebook “wall”). Today, HealthTap reposted my piece on support and insight in therapy to their blog.
All in all, it’s been fun. The awards, points, and “levels” are a bit silly, but they add some zing. Answering questions in 400 characters isn’t as hard as I expected, and part of the fun is deciding what to say in so few words. It’s also interesting to read what other MDs write, especially in fields other than mine. And it does feel nice to volunteer simple answers to real questions people have.
HealthTap democritizes medical knowledge, and brings the public closer to instant “ask your doctor” convenience than other health sites I’ve seen. But looming over the enterprise is the reality that we are not “your” doctor. The terms of service and legal disclaimers underscore that no doctor-patient relationship exists via the site, and that medical answers are intended to be generic, not for an individual. But patients, I mean members, mostly ask first-person questions that address their personal medical concerns. That’s the whole idea. And very often we doctors reply that there are many possible diagnoses or etiologies to consider, but that only an in-person medical evaluation can sort them out.
While HealthTap is an inspired effort, in my opinion it is hampered by the wrong model. It tries to be a social networking site, when in reality it’s a knowledgebase. Social networks derive value from interconnected communications among members; think Twitter and Facebook. But people don’t chat about health issues on HealthTap, nor do they befriend others. They seek answers to questions. HealthTap’s social network model encourages asking the same questions over and over, since quick access to doctors is emphasized, not the fact that thousands of questions have already been answered. For example, in my one month on the site several members have asked how to treat anxiety. It’s a good generic question, but it’s already been answered a number of times — at least as well as one can answer such a broad question in 400 characters.
HealthTap encourages doctors to create a Virtual Practice to “enhance your reputation, get new patients, and improve practice efficiency.” I don’t quite see the utility, but perhaps this works better for other specialties. I can imagine a family physician pointing real patients to his or her HealthTap page for tips or guidelines about common complaints.
I think HealthTap would serve its members better by embracing the knowledgebase model. Make prior questions and associated answers more easily searchable, and give searching priority over asking anew. If a user’s specific question is not found, it could be submitted to HealthTap staff for vetting. Duplicate or incoherent questions could be rejected, grammar and spelling cleaned up, and meaningful tags added to facilitate retrieval later. To encourage participation, doctors could still be recognized for answering quickly or often, or with answers colleagues agree with. Thanks could still be offered by members for helpful answers, and everyone could still log into personalized pages as they do now.
HealthTap is reportedly popular and growing rapidly. HealthTap Express, the mobile app, is the #1 Staff Pick on Android Market. As long as people seek health information online, and as long as doctors volunteer to provide it, HealthTap’s future seems bright. But it could be so much more if its architecture better matched its primary purpose. Social networks are great for social networking. Knowledgebases are great for organizing, storing, and retrieving knowledge. The doctor-patient relationship, a small social network, cannot exist on HealthTap, but a great deal of medical knowledge already does. Its organization and accessibility could be greatly enhanced without sacrificing the responsiveness and personalization that brings smiles to the HealthTap team and its members.
December 19th, 2011 Last week I was invited to join an online service called healthTap. I signed up this weekend, and have been enjoying it so far. It’s a free membership site where users ask brief medical/health related questions. The questions are then answered, also briefly, by one or more physicians in the “Medical Expert Network.” Each doctor has a personalized page listing all questions he or she has answered so far, some additional related material, as well as practice and contact information. There is no compensation for the doctors other than this publicity, including easy, built-in ways to spread one’s thoughts using social media such as Facebook, LinkedIn, and Twitter. There’s also a free mobile app to access the site.
My early impression is that healthTap started with a Yahoo Answers model, then greatly improved it by vetting professional respondents. Answers are a maximum of 400 characters (a short paragraph), so the information comes in small, bite-sized chunks, not long monographs. The quality of the answers varies of course, but it’s generally pretty good given the space limitations.
I just added a healthTap widget to the right-hand column of this page. It shows some of the questions I’ve answered. You can read each answer within the widget by clicking, and it also aims to sign you up on healthTap. I see no harm in doing so. You’ll have access to a well-meaning group of 6000 US-licensed physicians in all specialties, who volunteer to answer your health questions. Note that there is no doctor-patient relationship formed this way: Having questions answered online is no substitute for a real in-person consultation.
December 3rd, 2011  Tonight I was invited to an advance screening of “A Dangerous Method,” a film about the early days of psychoanalysis. It stars Keira Knightley, Michael Fassbender, and Viggo Mortensen, and will be in wide release by Sony Pictures Classics this month. The invitation was extended to Psychology Today bloggers, among others, in the hope we’ll publicize the release. Since I was gifted with a free viewing, I invite readers to consider this review with my potential conflict of interest in mind.
Overall, I was pleasantly surprised by the film, which has received mixed but mostly positive reviews so far. It humanizes both Freud and Jung, and introduces us to Sabina Spielrein, a real-life patient of Jung who later became a renowned psychoanalyst herself. Jung’s reputed sexual affair with Spielrein is treated as fact in the movie, and serves as the main dramatic focus. Some reviewers feel Knightley overacted the part of Spielrein. I thought it was pitched about right: a troubled young woman having illicit sex with her therapist would naturally be agitated and volatile. I did find Spielrein’s willingness, from the first session, to participate in newfangled psychoanalysis to be a bit optimistic. Also, her suggestion at one point that “there is man in every woman, and woman in every man” too-neatly implies that she gave Jung his idea of the anima and animus. Nonetheless, Spielrein is very well played.
In contrast, I found Fassbender’s portrayal of Jung more vague and wooden. The film suggests he was a psychic who could foretell the future in dreams and premonitions. His feelings toward Spielrein seem confused, not merely ambivalent or conflicted. And he refers to countertransference years before Freud published the term, although it could be argued the two historical figures may have discussed it between themselves earlier.
The decline and fall of Freud and Jung’s collaboration is the secondary theme, and here I was particularly impressed with the believable way Freud was portrayed. A pioneer, pragmatist, and controlling intellectual, he knew his treatment approach was controversial and sought to rein in Jung’s more expansive and spiritual predilections, which the elder Freud saw as giving ammunition to his enemies. Instead of the usual stereotype as a gruff, unyielding father figure preoccupied with sex, Mortensen plays Freud as somewhat authoritarian, but fundamentally smart, affable, and very concerned about the future of his psychoanalytic movement. Their famous 1909 falling-out on the deck of a ship sailing to America is played with a soft touch: Freud refuses to let Jung analyze his dream for fear of losing his authority (something Jung later recounted as due to Freud’s secrecy over his affair with his sister-in-law Minna Bernays). In the film, Jung is hurt by this non-reciprocity, and goes on afterward to develop his own theories of the psyche.
The film is beautifully photographed, and has a number of nice touches. The opening and closing credits are shown over a close-up of handwritten correspondence, the main way Freud and Jung communicated with each other. In one scene Jung conducts a word-association test using physiologic data collection — an accurate depiction of some of his research at Burghölzli, the psychiatric clinic of Zurich University, where he worked from 1900–1908. I even liked how the film showed the evolution from horse drawn carriages to automobiles, which of course happened in the same time period.
The American physician-psychologist William James was Freud’s contemporary and wrote: “I can make nothing in my own case of his dream theories, and obviously ‘symbolism’ is a most dangerous method.” The film “A Dangerous Method” is not nearly so dismissive of psychoanalysis. Yet, in its depiction of the dueling dream interpretations of Freud and Jung, and the complex relationship between Jung and Spielrein, it deftly highlights how symbolism is indeed a dangerous method of transacting human relationships.
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