On Being a Gurdjieffian Psychiatrist

Paul p. Roberts, MD

s I wrap up a career in psychiatry and psychoanalysis, it’s not clear to me whether my involvement in the Gurdjieff work ever did much good for my patients. But I do believe that my patients have done a lot of good for my own inner work.

Before I was a psychiatrist, I was a specialist in Infectious Diseases, a field that seemed satisfyingly no-nonsense, offering deadly diseases that often could be cured, and drugs that worked predictably even when they didn’t work as well as one wanted. The stakes were high. One felt engaged in a struggle against deadly enemies. And yet there were these people, these patients, who were entangled in my battle with the germs. They made my life difficult with their weird obsessions and beliefs and decisions. There were the innumerable ones convinced despite all lab evidence to the contrary that they had Lyme disease that would be cured if I would only give them potentially toxic drugs with sufficient abandon. There were people certain that their bodies, or the bodies of their children, were harboring bizarre parasites unknown to science. There were people with AIDS who chose to die rather than be treated with antiretroviral drugs because they’d rather be dead than face the next phase of their lives. (One lady wrote a letter of complaint to my clinic, that I persisted in reminding her a few times a year that with two pills per day she could probably live a normal life; she died a week later.) There were people who refused HIV treatment because they were attracted to theories of smug Nobel prize winners that HIV does not cause AIDS. (Winning a Nobel prize, it turns out, can have a bad effect on a person’s reason, probably by suppressing self-questioning.)

I remember well many arguments with a young man who got sicker and sicker until finally he could see that his friends who took antiretrovirals were getting better; he reluctantly accepted AIDS drugs while assuring me that eventually I’d see that the meds must work by some unknown mechanism, since HIV is harmless. I remember hours of arguments with a mill worker who was certain that his illness was caused by exposure to cedar dust and not by the staphylococci that were destroying his heart valves, and a young athlete who couldn’t believe that the big abscess in his buttock was related to the black-market anabolic steroids he injected there. Of course, the ones I remember thirty or more years later are only the most spectacular.

The question grew in my mind, “What makes people choose what to believe or disbelieve?” It was clear enough that these people were not so different from others who had better luck and were not so sick, and that the human belief-generating mechanism, including my own, is unreliable.

Gradually, though, my frustration came to be with the nature of my practice rather than with patients who wanted to go their own way. All these people had a story. Some of the stories led to a weird place, and some just led to the present remarkable or unremarkable situation, but because there are only so many working hours in a week I had to focus on the germs and not the story. A dozen or so times a day, for example, because antibiotics were so central to my work, I had to ask, “Do you have diarrhea?” In the midst of a thousand other facts, my brain only had room, and I only had time, for a Yes or a No. But more typically, a patient would become thoughtful and recount, “Well, you know, about two weeks ago my wife came back from visiting her sister in Atlanta; now, that’s a woman who really knows how to cook Mexican food, and …” A story whose ending I would never know, because I had to break in and say, “I only want to know if you have diarrhea or not,” although I knew that the story of his sister-in-law’s cooking was likely more interesting than his bowel movements. I was missing a lot of stories about people for the sake of stories about germs. I began to envy the psychiatrists who could sit and listen to the stories the patients wanted to tell. I retrained as a psychiatrist.

Psychiatry, it turns out, is a very diverse field with many branching channels. The channel with the most activity now, the mainstream if you will, is at least as biologically minded as Infectious Diseases and strives to define experience in terms of genes, receptors, neural networks, diagnoses, and drugs. That channel is interesting but less attractive to me than psychotherapy (talk therapy, which can be combined with meds), and particularly psychodynamic psychotherapy (which I would briefly define as talk therapy aimed at teasing out what’s going on inside, behind the screen of the story one tells oneself). I can come up with several reasons why. For one, the drugs and the various electronic and magnetic brain zappers have effects that, although quick, are disappointingly broad, soft, and unpredictable, at least in comparison with antibiotics. A superficial analogy is that if what is going on in your head is a cocktail party, taking a psych med is like changing the background music, while psychotherapy is more like a proficient hostess who tactfully introduces one guest to another that they ought to get to know. Another explanation is that, maybe as a result of my years in the Gurdjieff work, experiences and how they are structured seem to me more to the point than their biological scaffolding; more to the point of why people are unhappy, and more to the point of what is real.

As a psychiatrist I discovered a big dichotomy in how one can receive a story. In the mainstream, the paradigm I’d call the medical model, which I followed as an Infectious Disease doctor and which remains foundational to my work as a psychiatrist, you interview the patient to get the facts of his illness, in order to know the best treatment to apply. The doctor should know what questions to ask, to elucidate the relevant facts. The problem with that approach is that if you ask a person about themselves, what they tell you is, at best, the story they tell themselves about themselves, a story which is inevitably distorted by the forces that distort all our understanding. A story about events of the past is a sort of crystallized residue of past experience, that has been through the filters of vanity and anxiety and education, etc., remembered and revised through many iterations. It is a useful clue to how they’re feeling now about those events, not so useful with respect to facts. In this other paradigm, which I’d call the psychodynamic model, questions from the doctor are not so useful, because the facts they elicit are unreliable, and they may divert the patient’s mind from more lively considerations. An example seen so often that it’s almost a cliché is the person who relates at the start of therapy that their childhood was idyllic, with loving parents, camping trips, and security. After about a year problems with Mom emerge; Mom starts to seem like a troubled character who should never have had children. In another year or two Mom might be rehabilitated into a garden variety neurotic, and Dad takes on a darker and darker aspect. A shared understanding of the present situation arises gradually by taking lightly the question of fact and letting associations that might have seemed irrelevant build a new picture.

That understanding typically sheds light on the mystery of strange opinions and beliefs, which are part of the complex armor of interlocking, mutually-reinforcing buffers that keep a person feeling safe-enough and good-enough through the challenges of life, even though they curtail that person's possibilities and may lock them into a pattern of unhappiness and failure. A therapist who tries over time to penetrate this shell gets a new appreciation for the power of the “inner evil god self-calming.”

Having been a medical doctor before my psychiatry career, I noticed immediately after the changeover that psychiatric patients are the best patients. The short explanation is that when a person calls a psychiatrist, they’ve accepted that something is not right about the way they are seeing life. When a person goes to a medical doctor, on the other hand, they are typically thinking that the problem is a malfunctioning gizzard or whatever, and as far as their approach to life is concerned, they think that it has nothing to do with why they’ve consulted a doctor now. Like most people, they believe that they are one of the sane ones who see reality objectively. And the medical doctor has to collude in that self-deception. Psychiatrists are much luckier.

That’s not to say that a big percentage of psychiatric or even psychoanalytic patients are interested in working to develop being or search for what’s going on behind the screen of illusion. But they are often interested in penetrating to some extent the web of buffers, or as we say now ego defenses, that systematically distort one’s experience.

One of the attractions of psychiatry for me is summed up by the saying, “The great thing about the mentally ill is that they’re just like everybody else, only more so.” That is, notwithstanding the fact that many people have what I’d call hardware problems, nearly all the varieties of mishegas that one encounters in psychiatric practice are exaggerations of styles of distortion that I see in myself and the people I deal with in daily life, not excluding the Gurdjieff work. But in daily life one has to collude with the pretense of normality, while in psychiatry and psychotherapy the strangeness is right there between us in the room and one can (with suitable tact) speak about it, even if the recognition is not always digestible to both parties. The wishful and magical thinking, the blaming, the self-pity and self-justification, the intoxication of anger and indignation, the certainty that I deserve better than this, tidying up the self-image, seeing things topsy-turvy with values and priorities reversed—one watches these wheels turning, first with interest, and then with recognition, and a sense of seeing my own inner world reflected.

I used the familiar metaphor of wheels turning, but the mind’s processes often seem more to me like the behavior of subatomic particles, local intensifications of mysterious fields which attract and repel each other in some n-dimensional space, sometimes sticking tightly together, or flying apart, approaching and diverging in complicated groupings that might have names like “the tree,” “my analyst,” “my wife,” “Paul Roberts,” “the United States of America,” “my life,” “loneliness,” “the Work,” and so on. Most of the time these swooping and oscillating forms are what seem to me to be Everything There Is, but this view also seems to facilitate startling moments when the forms are just forms, movements of crystallized data in fields of energy, witnessed by an unknown watcher whose nature is different.

Of course, all these events take place in “me,” otherwise they would be of only technical interest. I give my patients credit for helping me see them.

Dr. Paul Roberts is an internist and psychiatrist in Seattle, now specializing in psychoanalysis. He is active in the Gurdjieff Foundation of Washington where he is Co-President and also coordinates the Movements program.