Psychiatry, the Uncertain Science

by Richard Lemon

Saturday Evening Post August 10th, 1968

Psychiatry the Uncertain Science by Richard Lemon, Saturday Evening Post cover August 10, 1962

Part 3 of 4

Since Hippocrates's time, man has sought an organic explanation for his troubling emotions, and during the past 15 years he has often seemed on the verge of finding it. He has not yet succeeded, although there are scientists who think he will.

What he has acquired instead is a large, steadily growing number of drugs which cure nothing, but which relieve symptoms and make the mentally ill accessible to other forms of therapy.

These drugs fall into four main categories. [as of 1968]

There are the derivatives of chlorpromazine, which relieve excitement and confusion. There are the tranquillisers, mostly derived from meprobamate, which calm agitation and relieve anxiety. There are the amphetamines, commercially marketed as Dexedrine, Benzedrine, and so on – which relieve the symptoms of depression. And there is a large group, the M.A.0. inhibitors and imipramine, which are basic anti-depressants.

One fourth to one third of all prescription written today are for these psychoactive drugs, but, like most revolutions, the new drugs have also created problems. A number of psychiatrists are concerned about the extensive use of such drugs, especially tranquillisers. "What most people need," Dr. Menninger has said, "is not to care less, but to care more."

The mind drugs have proved less effective at keeping patients out of hospitals than at getting them out once they are in, partly because many patients get careless about taking the drugs, but also, some psychiatrists believe, because some psychiatrists and many general practitioners, who often take care of discharged patients, are not sufficiently skilful at prescribing mind drugs.

A tranquilliser whose side effect is to increase sexual appetite, for example, would be inadvisable for an anxious woman suffering from feelings of guilt. Yet very little psychopharmacology is taught in medical schools; doctors get much of their knowledge of mind drugs after graduation, from the drug companies, and many psychiatrists are critical of the extravagant claims made by some companies.

The most ironic side effect of the drugs is that their use has proved markedly less satisfying to most psychiatrists than other, more creative therapies.

Dr. Nathan Kline, director of the research unit at Rockland (N.Y.) State Hospital, is, one of America's leaders In the field of, chemotherapy and also one of the bluntest critics of the way it is being practiced. While treating with drugs Dr. Kline has written, a psychiatrist may find out "that the patient's wife is sexually unresponsive or that he has intermittent spastic colitis or that he dreams about zebras. If the I.Q., education, income or social class of the patient approximates or surpasses that of the therapist, the probability is that he will be found in need of long-term intensive therapy." But if the patients are poor, dull or uneducated, Dr. Kline says, no one "presses them about their dream life, their wife's responsibility, or the condition of their gut," and they are counselled to accept their problems.

He is particularly critical of the tendency to downgrade chemotherapy as an auxiliary procedure, thereby discouraging its development. Therapy cases are generally taken by the senior staff members in hospitals, while drug treatment is left to the most junior. "Drug treatment," Kline has concluded, "is routinely given to second-class patients by second-class doctors."

The modern drug revolution began in 1951, with the introduction of chlorpromazine and later reserpine. That year 10 patients who had not responded to any therapy, including insulin and electric shock, were given chlorpromazine, and seven of them showed marked improvement or tentative recovery. When reserpine was given to 150 chronically disturbed patients who had responded to no other therapies, 84 percent were declared improved, and 21 percent could be discharged. About 70 percent of the discharged patients maintained their improvement even after reserpine was discontinued. (Most patients will relapse, some almost instantly, if chlorpromazine is withdrawn, but they then respond well to lesser doses of the drug.)

The principal effects of chlorpromazine are to eliminate hallucinations, improve judgment, and bring the patient to recognize the unreality of his previous feelings. There is still no real knowledge of how the drug does these things. It is believed, however, that both chlorpromazine and reserpine block the emotional circuit in the hypothalamus and thereby reduce fear, anger and excitement. In the same way, the anti-depressant amphetamines and M.A.0. inhibitors are believed to stimulate the hypothalamus, and thus enhance excitement, activity and pleasure.

Other chemical substances in recent years have seemed to promise clearer insights into the workings of the mind, but the promises have not been fulfilled. LSD produces many strikingly schizophrenic-like reactions, but research to date has been inconclusive, and the similarities are generally considered coincidental.

The most controversial biochemical claims have been made by Dr. Abram Hoffer, [1] director of psychiatric research at the University Hospital in Saskatchewan, Canada, who in 1966 reported that the drug niacin had within three to five days erased symptoms of schizophrenia in 13 out of 17 patients, all of whom had been institutionalised for many years. A separate study, under the sponsorship of the American College of Neuropsychopharmacology, was made of Dr. Hoffer's claims. The doctors found no consistent differences between a group receiving niacin and a group getting a placebo.

[1. ]

Nonetheless, Dr. Hoffer and Dr. Humphry Osmond [2] have founded the American Schizophrenia Foundation, [3] one purpose of which is to arouse public support and solicit donations for niacin research. A booklet called What You Should Know About Schizophrenia, [14 pages] published by the foundation for the public, flatly defines schizophrenia as "a physical disease," and says that "a large body of scientific evidence" indicates that the schizophrenic is a victim of a 'metabolic error' in the chemistry of his body." [4] Dr. Hoffer's critics challenge his claims and his methods of publicizing them, but the issue may not be decided until completion of a half-million dollar government-sponsored test of niacin at Marlboro State Hospital in New Jersey. [5]

[2. ]

[3. Renamed: Brain & Behavior Research Foundation.]

[4. The views in the booklet are ridiculed in Schizophrenia: The Sacred Symbol of Psychiatry, Thomas Szasz, 1976. Pages appear at this link at: Google Books ]

[5. The study found no evidence to support the claim. See "Niacin in the Long-Term Treatment of Schizophrenia," March 1973, abstract ]

Besides the mind drugs, three other organic methods of treating mental illness have had wide use in recent years: the prefrontal lobotomy, Insulin-coma therapy, and electric-shock treatment.

The prefrontal lobotomy, in which nerve fibres connecting the frontal lobes with the rest of the brain are surgically severed, first came into use in the 1940's, and during the next 15 years the operation was performed on more than 20,000 people, many of whom had been judged incurable. In one report of 604 lobotomised patients in the United States, 401 were judged either substantially improved or recovered. There is little understanding of just how the operation works, but its effect is to reduce the violence of the patient's mental conflict. However, it may also produce complacency, a loss of interest in the feelings of others, and a loss of imagination and sensitivity. The operation is not common today.

Insulin-coma therapy, introduced in 1927, employs Insulin to put the patient into a deep sleep and then into a coma for roughly half an hour, The danger here is that the induced coma may prove irreversible – and therefore fatal. The treatment has generally been abandoned in favour of electric shock.

Electric-shock treatment, in which convulsions are induced in an anaesthetised patient by means of an electric charge across the frontal area of the brain, has been widely replaced by the use of drugs. Nonetheless, 91 percent of U.S. general hospitals report that they use electric shock occasionally or frequently. (The same percentage use drugs frequently.) One private hospital in Colorado is said to use electric shock on 90 percent of its patients.

"I'm scared every time I give electric shock, and I stay scared until it's over," a psychiatrist in Idaho has said. "I still find convulsions terrible to watch." Nonetheless, the unconscious patient experiences no pain, and the physical hazards are not considered great. The treatment is given in series, and its effect is to temporarily impair memory and relieve depression, but there is no sure knowledge of how it works. One theory is that the shock is a massive attack on the patient's entire system, forcing it to organize and respond. Another theory is that by temporarily blocking memory, it allows, new ways of reacting to develop. Another is that the process satisfies a need for punishment; still another is that it makes the patient temporarily dependent on the doctors and thus speeds up therapy.

Since the introduction of the mind drugs, electric shock has most often been given to severely depressed patients with suicidal tendencies. A depressed patient is likely to try suicide not at his lowest point, when he is virtually unable to function, but after he has started up out of the depression, when he is capable of organizing an attempt. Drugs bring the depressed patient up relatively slowly, over a period of weeks, while shock brings him quickly past this critical period. The greatest danger of electric shock is the risk of permanent dullness, and the treatment is generally used, in the words of Dr. Sidney Cohen, "when the risk of keeping people in depression is greater than the risk of permanent shock."

It is easy to forget that psychiatry is still a young and changing profession. Freud died in 1939, Jung in 1961. Electric-shock therapy and Insulin-coma therapy were considered major advances in the '30's, and the lobotomy was considered a major advance in the '40's and early '50's, and all are now in moderate to infrequent use. It is impossible to foresee what such a profession will be like even 10 years ahead, but the most basic change during psychiatry's past decade has clearly been the increase of interest in what is called the "problem of living" approach to mental illness. Analysis, psychotherapy and the chemical and physical therapies all treat the patient alone, in the traditional medical way. The social therapies, whether out of conviction or necessity, approach him as a social creature who cannot profitably be treated in isolation.

The various social therapies are often dissimilar in execution, but they share a tendency to treat patients in groups and a tendency to emphasize the present over the past. At the most innovative end of the social-therapy spectrum are those psychiatrists who tend to favour much shorter treatment and the use of briefly trained personnel, working under a psychiatrist's guidance.

Each form of social therapy has its critics and its clear-cut dangers. Dr. Lawrence Kubie has noted that the shortest treatment is not invariably the best one, and that an insufficiently treated patient can create havoc in a family. ("Instead of curing one person, you've wrecked four," the husband of one prematurely discharged woman told her psychiatrist.) Traditional psychiatrists tend to feel that the shelter of a hospital is more beneficial than the pressurized world that produced an illness, and some who applaud the broad approach are concerned over the growing tendency to turn such treatment over to non-psychiatrists.

The overriding feeling of many – and perhaps most – psychiatrists today is that individual treatment cannot cope with the amount of mental illness that exists. The Menninger complex, which has trained one out of every 20 U.S. psychiatrists, and includes one of the most prestigious hospitals in the world, has 80 doctors for its 200 patients, but only one or two patients are ever in analysis, only one third are in any form of individual psychotherapy and all are in milieu therapy.

"Direct, individual treatment will never be the answer," says Dr. Roy Menninger, president of the Menninger Foundation and son of the late Will Menninger, Karl's brother. "We'll never have the resources. Our focus is away from the individual and onto the networks – the family, the Friday-night bridge club, work."

In many other hospitals, less amply staffed, the social therapies are a matter of necessity, and they are often closely tied to community mental health programs. At the San Mateo Community Mental Health Centre in California, each patient has 11 group therapy sessions a week, families are encouraged to visit ("Nothing de-institutionalises a place more than having a couple of little kids running around," says one doctor), and the community plays a vital role.

"We get a minimum of anxiety about going back to the community, because walking out the door doesn't terminate the support a patient gets from the program," says Dr. Richard Levy. "Because we have a lot of resources in the community, we can focus on what strengths the patient has. If all you looked at was the magnitude of the illness, you'd be overwhelmed. You don't just say, 'He's a paranoid.' You say, 'Yes, but he can hold a job.' I've been amazed at the very sick people who go and get good, responsible jobs, and do them well."

Of all the social therapies the most pragmatic is group therapy, which consists simply of a group of patients discussing their feelings and problems, with a psychiatrist acting chiefly as a referee. (In some groups the psychiatrist is more active; if a patient shows signs of transference in dealing with other group members, the psychiatrist points that out and discusses it.) More than half of the country's general hospitals now use group therapy, usually as an auxiliary treatment, and for many non-hospitalised patients it is the only treatment. In marathon therapy, group therapy is carried on for as long as 30 or 40 hours, during which familiarity and fatigue tend eventually to break down all resistances and barriers.

The unique power of group therapy is its ability to bring problems out into the open. The members of a group are all equal, the session itself is close to real life, and reactions come not from one person but from many. The patient is both a participant and a therapist, and his usefulness to others increases his self respect. The most important single characteristic of successful group therapy is the patient's realization that problems he thought were unique and shameful are in fact shared by other people. The benefits may be far reaching. In one striking experiment, patients suffering from peptic ulcers who were given group therapy improved far more than a control group given the same medical treatment but no group therapy. Furthermore, 80 percent of the group therapy patients had maintained their improvement three years later, while most of the control group relapsed within three months.

While group therapy treats patients in terms of the outside world, family therapy brings the outsiders directly into treatment. Family therapy may be group therapy with relatives, or individual therapy applied to all members of a family at once. (In multiple-family therapy four to six families are treated at once; this is said to break down the barriers that a single family may throw up against a therapist.) Mental illness is contagious and seldom isolated, and some families are able to remain stable only by assigning one member to be sick; it is common for one member of a family to get better only to have another break down. Family therapy is often an analytic exploration dealing in resistances, transference and interpretation, but the focus often shifts from person to person as treatment progresses.

Dr. Alfred Messer, a professor of psychiatry at Emory University, has reported the results of family therapy for a 30-year-old bachelor who had made no progress after four and a half years of analysis. The patient told Dr. Messer on his first visit that he had reached an intellectual understanding of his troubles through analysis, but that it hadn't helped him any. As the family treatment progressed, its focus shifted gradually to the relationship between the young man and his father, and finally the father became the principal patient. He was a strong, self-made man, whose own father had deserted his family. He could not tolerate competition, and it gradually became clear that he completely dominated the son. One day, while describing how he had helped an associate whose father had turned away from him, he suddenly burst into tears, astonishing his son, his wife and himself. Eventually the man became aware of his bitterness against his father and his resultant difficulty in risking affection for his own son. Dr. Messer concluded that the original patient had been so humiliated by his father's domination that no treatment could work until the relationship had been straightened out.

By far the broadest of all the social therapies is milieu therapy, [6] which knocks down all barriers between life and treatment. Milieu therapy consists of the manipulation of the patient's environment, and treatment in terms of that environment. "Everything that happens gets looked at," Dr. Roy Menninger has said. "Each person is examined in terms of various sectors, work, play, learning, creativity." At the Menninger hospitals the patient's activities are tailored to his troubles: for example, a bank president may be put to work scrubbing walls as a means of venting his need to punish himself.

[6. ]

A far more controversial form of milieu therapy is the one in use at the Fort Logan Community Mental Health Centre, a cheerful, seven-year-old state hospital on the rural edge of Denver, Colorado. Fort Logan is probably the most controversial and avant-garde public hospital in America. The hospital has no locked wards; it simply discharges uncooperative patients. The therapeutic benefit comes almost entirely from group activities; there is virtually no individual therapy. The staff works in teams, all members of which are considered equal, and a psychiatrist may do less direct work with patients than a social worker or psychiatric technician.

Physically, Fort Logan could be a high school or small college. Its campus is roomy and green, its rooms are colourful and cheerful, its few security measures are invisible, and its staff wears street clothes. A few years ago the hospital made a movie in which a fearful incoming patient pictured herself behind bars, watched over by stern, white-coated attendants. The white coats had to be borrowed from the state hospital at Pueblo, and the bars were oven racks from Fort Logan's stoves.

The Fort Logan program is based on the "therapeutic-community" concept which Dr. Maxwell 0. Jones, a Scotsman, devised while working with English veterans during World War 11. In this community each staff team consists of a psychiatrist, a psychologist, two social workers, a head nurse, an activities therapist, six registered nurses and seven psychiatric technicians, and everyone is subject to analysis and criticism. The psychiatrists are not presumed to be more authoritative than anybody else, and since many of them have rebelled at this circumscribed role, there has been a high turnover in the psychiatric staff. Fort Logan believes, however, in the theory that water will find its own level, and that all its staff members will come to function in accordance with their abilities and experience.

Fort Logan's patients are given varying degrees of freedom and are offered a share in decisions, among them passing on fellow patients' applications for increased privileges. The hospital's restrictions come from its group approach.

In some groups every activity is compulsory for all, and some patients complain of a lack of solitude. Responsibility is demanded. "We say, 'You came here because you needed help, so you don't have to act crazy to let us know you need it,"' a social worker explains. "'We expect you to help the man next to you. And if you should break one of the community's rules, your behaviour affects the whole group, because the whole group will be punished.'"

Fort Logan's re-admission rate has been climbing, and so has the number of its long-term patients, but its recovery rate and its confidence are still high. "I think the enthusiasm of the staff is a result of the team approach," says Dr. Alan Kraft, a former director. "In larger institutions you don't feel your importance. The traditionalists' argument with Fort Logan is often intense – there's a feeling of 'What right have you to question what we're doing? Aren't you patriotic?' Well, individual psychiatry is one tool. But to pick the cream of the crop, to take those people off in a corner – this is criminal. It's inexcusable. At Fort Logan the psychiatrist has thirty-eight arms and nineteen heads.

"I have a private practice, and there I am for personality reorganization. I see very little of the patient's behaviour, and I assume his behaviour is intact. My attention is on his psyche, and he has to identify his problems. At Fort Logan the goal is social rehabilitation. If the patient never understands anything about his Oedipal complex, they don't care at all."

The day at Fort Logan begins with a cottage report on the previous day, written and read by one of the patients ("Albert slept for two hours before midnight. There was a complaint about popcorn on the floor"). Afterward there is a brief meeting of the staff team and then group therapy, with nine patients and three team members.

In the group-therapy period, after a long awkward silence, a heavy blond woman begins to talk. Haltingly, but with growing eagerness, she tells about her disastrous honeymoon, her hysterectomy, an attempt at suicide, and the inattention of her husband. The great, unbroken flood of grievances and failures ends, there is another pause, and then several people question whether the fault is all on the husband's side.

A nervous, sharp-featured woman named Ethel says that the blond woman should try being more responsive, and several people berate Ethel for being too critical of everybody. Then an energetic Negro woman tells a silent, timid little woman beside her that she is entirely too passive and ought to be more positive about things. The little woman thinks a moment, then says uncertainly, "What would you suggest, Martha?" and the group breaks up, laughing.

Afterward there is another staff-team meeting. The talk is inconclusive and interspersed with long stretches when no one says anything:

"I wonder if we're going through a phase where we have to get back on the feel level."

"Ethel got openly angry at the group, and the group got angry at her."

"Yesterday was terrible. The whole damn hospital was bad."

Next, five members of the staff team go to practice psychodrama. In psychodrama each team member or patient plays himself or another member of the team or another patient, trying to express the way they think that person feels. The director is a beautiful, cool, red-haired former actress, and she starts with a short lecture: "If you know the group is destructive, I would not hold the psychodrama. I am not going to let anybody get up there and expose themselves and be torn to bits." Then a single chair is placed on the small stage, and after a little hesitation, a social worker goes up on the stage beside the chair.

I am putting the staff in the chair, at a team meeting," she explains. To the staff in the chair, she says, "I am sorry that I have let Ethel drive me away." She describes at length her impatience with Ethel, who is often cantankerous. "I can't work with her any more until I can work out my feelings," the social worker concludes unhappily.

A Negro technician gets up and says he will talk to Ethel on the phone. "Ethel, I don't know how much you can ask of the staff," he says. "They give, give, give, and I think it's about time you did something."

"Respond as Ethel," the director says, and when he does, she says, "You don't sound as though you mean it."

After lunch in the cafeteria, most of the group watch a movie about alcoholism, and the discussion that follows goes far afield, A large, slow boy on day care says he has been drugged many times and resents it, then turns to a pretty young nurse and says, "Why don't you talk about your problems?" She covers her face in embarrassment. "I'm a nurse," she squeals.

"Psychiatrists are nuts," somebody says.

There is another staff-team meeting that afternoon, about an ex-patient who has been doing well in family care, about another who is being re-admitted, and about a 15-year-old boy, ready to go home, whose parents have manufactured a story about his being away which could put a strain on him.

That evening, while the patients watch TV or play games, two nurses from the team go to a group session of 16 outpatients, during which a lonely old woman starts to cry while telling about a nice girl next door who once brought her a slice of cake. Afterward the nurses distribute handfuls of drugs, about half a dozen bottles per patient. "The system at Fort Logan is so unstructured, it took me two years to get comfortable," one nurse says later. "Now I love it. It isn't dull. You're on your own. You can take initiative. ..."

It is hard to catch people in the act of getting better at Fort Logan, but they do. "I had been in private treatment," says the heavy blond woman, and when I first came here I couldn't believe I could discuss my problems with a group, and that people would be interested." "I get up every morning," the boy on day care says "and all I can think about is getting to Fort Logan."

"There are three elements in treatment here," Dr. Kraft has said. "One, the removal of the patient from the immediate area of pressure. He can rest, think and recuperate. That's very important, not to be underestimated. Two, the drugs. Three, the living-learning situation, the school for living.

"We're becoming adept at treating certain kinds of patients, but there are dozens we don't know a damn thing about. But there's willingness to question, in psychiatry, that hasn't been around before. Gerald Caplan of Harvard can conceive of a psychiatrist who never sees a patient but works entirely through the police, educators, and so on. The mentally ill are one among many disadvantaged groups, the elderly, racial minorities, and the political atmosphere of our country is stimulating scientific advances in these things. There's a new pizazz."

One of the most dramatic products of psychiatry's new pizazz has been the number of programs which drastically shorten hospital time or treat patients briefly without any hospitalisation at all. (As radical as Fort Logan's program is, its patients spend an average of 145 days in treatment, 35 of these as residents, the remainder in day and outpatient care.) Because of the shortage of psychiatrists, brief psychotherapy is often justified as the only alternative to no therapy, but several recent surveys have strongly suggested that it is at least as effective as long stays in hospitals, and is much preferred by patients and their relatives. Many psychotherapists are convinced that changes also continue long after the treatment stops, and that brief therapy can promote basic changes in character.

In California, San Mateo County's hospitalisation rate is 148 people out of 100,000. This compares with a national rate of 238 and a rate of 264 in neighbouring San Francisco County. The San Mateo Community Mental Health Centre program consists on the average of six days in the hospital followed by several months of day and outpatient care. "We're simply finding that it's not advisable to keep psychotic people in the hospital more than seven days, because if they stay longer, they begin to adopt the hospital atmosphere," says Dr. Joseph Downing, the director. "The chief of our inpatient services came here five years ago, feeling strongly that we were sending people out too soon. Now he's completely changed his mind and we're sending them out even faster than we were when he came."

An important factor in San Mateo's low hospitalisation rate is the mental health centre's home evaluations of patients for whom commitment has been asked. As a result of these evaluations, half the patients involved have been able to stay outside the hospital altogether. "I make one visit, it can run a couple of hours trying to figure out what has upset the apple cart," says Dr. Gerald Lutovich, a private psychiatrist who makes many of the evaluations. "If I can't make a decision, I come back two, three, even five times. These are mainly the hard core, who deny completely that they're sick, and many of them won't get much better or much worse. I tell them, 'I'm really here to get your side of the story.' Diagnosis is not the most important thing; the question is whether they can function without being a danger to society or themselves.

"The danger is that in our enthusiasm to treat outside the hospital, we may be keeping out people who could be treated better inside. Sometimes we put too much of a strain on a family that's already pretty weak. Sometimes a decisive, dramatic gesture does more for the family. But very few of these people are a danger to themselves or others. The axiom used to be, 'If in doubt, hospitalise.' We're kind of working on the theory, 'If in doubt, don't hospitalise.'"

An even more dramatic anti-hospitalisation program has been set up in Portland, Maine, by Dr. Richard A. Levy, a tall, dark, briskly informal young psychiatrist, born in New York and trained at Mt. Sinai. Dr. Levy has a private office in Portland, where he keeps a portable heater at the foot of the couch for the convenience of patients who want to take off their shoes. The Portland clinic, where he is now an adviser, is equally down to earth. The clinic is the only public psychiatric facility in the city; as such, it treats only the most severely ill and tries to keep them functioning outside the state hospital in Augusta. The entire treatment program consists of six visits over three or four months, and it relies on rapid diagnosis, reassurance, drugs, and the help of visiting nurses, homemakers, employers and especially members of the patient's family. The clinic treated 500 people during its first 14 months, and only seven of them went on to the state hospital.

"I used to worry a lot during the first fourteen months," Dr. Levy once said. "Would we have a suicide or a homicide? I send a lot of rocky people home. But acute illnesses are usually related to specific events. At the beginning you explore the immediate crisis and give the person reassurance; he's not the only one who ever felt that way, and there's a big difference between having bizarre thoughts and acting on them. When you've sat with depressed patient after depressed patient, you get a feeling for the intensity of the depression. If I do my job fairly well, and don't accuse them of being murderers in the first five minutes, they'll generally relax.

"Our patients are suffering from severe anxiety, or panic, or depression to the point of suicide, or complete psychosis, with complete loss of control. The odds are favourable that you will find out the true cause of the trouble in six visits.

"Probably most psychiatrists would find it difficult to believe that so much could be accomplished in so short a time. I myself felt that way at one time. And I've been astonished at the low number of returnees. In five years only 27 have made a return visit, and we've never had to give a complete second series of treatments to anybody."

The clinic's program is precise and efficient. While Dr. Levy is getting the patient's history and prescribing medication, a social worker interviews the family and enlists its aid. In subsequent visits Dr. Levy explores the crisis further, helps the patient to recognize the characteristic and inappropriate way in which he reacts to problems, and, at the last visit, assures him that he may come in again if he feels the need.

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