Vol. 4, 2001

Vol. 3, 2000

Vol. 2, 1999

Vol 1, 1998

by Eric Berne, M.D.

The problem is that in spite of everything there are still half a million or possibly a million patients in state hospitals, so there has been a great demand for psychiatry resulting in one million vegetables walking around taking phenothiazines, and estimates are that there are a hundred and twenty million people who need psychotherapy. So the problem is how are we going to cure patients, which is what I want to talk about. And I have some questions like: How many cured patients do you know? Have you ever cured a juvenile delinquent by psychotherapy? How many? Have you ever cured a schizophrenic and if not, why not?

The basic thing I'm going to talk about is that psychotherapists, like poker players, are winners and losers. If you have permission to be a winner from your parents you can cure patients, in which case you might not be in psychiatry, you might be a surgeon or a real doctor of some kind. Maybe the reason that people go into psychiatry is that they're not required to do very much except to have staff conferences to explain why they can't do very much. The analogy with poker is that you can tell, in about three hands, who's a winner and who's a loser by the way players react to what happens. And I think patients can tell in about three hours which therapist is a winner and which is a loser. And since most patients don't really want to get well they're very likely to stay with the losers, but if they do want to get well they may find a winner.

I'm going to try to talk about how people make themselves into losers, particularly in the social sciences where there seems to be a tremendous resistance against knowing anything. The one thing that you can't say in any kind of a social science meeting is that you really know something because the reaction will not be, "tell us what you know," but it will be, "I'm going to show you that you don't really know anything," which doesn't occur in any of the other sciences.

The title of this talk, as you may have already figured out, is a put on. If you didn't figure it out you're lucky you're here. "Away from a theory of the impact of interpersonal interaction on nonverbal participation" - I think we got everything in there except "toward". We figured we'd leave out "toward" and put in "away from" just for fun. There are lots of papers coming out called "Toward" and you wonder when they're going to get there. And if you ask toward people when they're going to get there, they say, "Well, we don't know how to get there, and we don't even know where we're going". Well, I think real people know where they're going. One example is an airplane pilot. I once got on an airplane, and the pilot come over the loud speaker and said: "This flight is going toward New York". I said: "Let me out of here, I want to go to New York." Then I went to the hospital to have my tonsils out, and the surgeon said: "I am going to take some steps toward taking out your tonsils". In other words: real people don't say "toward". They say, "That's where I'm going and that's where I'm going to get". Well that takes care of toward and away from, and maybe away from is even better than toward. At least if you get away from, you can look at it more clearly.

About theory; a theory is one of two things. It's either a bright idea, like - I don't mind being specific - the kind of thing they do in psychology at the Rand Corporation where somebody sits down with a little computer or a very sophisticated adding machine and makes a theory of human behavior without ever having looked a human being in the eye, possibly. Or it's a real theory which is an abstract from experience. The more thousands of patients you see, the better your theory is going to be, or the more hours you spend with one patient and the less time you spend with the adding machine the better your theory is going to be.

Then the word impact is very fashionable. Everybody wants to make an impact. Now an impact, to me, is not a dull thud. Bang! Bang! That's what you should be doing with your patients, not making dull thuds. 'The phrase "interpersonal interaction" to me is usually the mark of a jerk. I just don't see any point in that expression at all - just the opposite: an impersonal interaction, an interpersonal superaction, or infraction. Actually this is sort of a chicken phrase because it means: "if I use a lot of big words I don't really have to find out what's happening, and it sounds good". Of course, my tendency is to propose the term transaction. The value of the term transaction is that you're committed to something you're saying that something is exchanged. Whereas if you use interaction you're saying, "I don't know, I'm only going toward it." Transaction means: "At least I got to the first stage. I know that when people talk to each other they are exchanging something, and that is why people talk to each other."

The fundamental question in social psychology is: Why do people talk to each other? Interaction essentially means no action, in most cases. People who are really going to do something do not use words like interaction. That reminds me of an old joke of mine about the way that patients are diagnosed in the average clinic; the person who has less initiative than the psychotherapist is called passive dependent. The person who has more initiative than the psychotherapist is called a sociopath.

Non - verbal, of course, is very fashionable. The thing that bothers me personally about non - verbal is using it as a kind of shibboleth. There are lots of things people do with their faces and their bodies, but as soon as you call it non-verbal it makes it sound a little phony. Also, people don't understand the verbal. There's still plenty of work to be done in the field of verbal activity so don't be discouraged if you are not going along with the nonverbal crowd.

Participation usually means talking my way. I ran across a very interesting example of that. I was feeling very good one morning, and I walked into the group therapy room at the hospital, and somebody had piled up a lot of coffee tables. So instead of going around them I sort of leaped over all the coffee tables, and the patients cheered. I thought it was neat and so did they. Later on in the session a man said: "I don't have any feelings. I never get angry." This guy had been in many kinds of therapy groups so after a while I said: "Well, you look as though you're feeling good now. Isn't that a feeling?" And he was really surprised because it had never occurred to him that feeling good was a feeling. So that's one of the problems with participation. Another very interesting thing is that laughing is not considered an expression of affect. In certain parts of the East which have a cultural lag of twenty or thirty years, the only thing that counts in groups is expressing anger. If you go and visit their big city you can see why they're all pretty mad at each other. If somebody has a group meeting and everybody laughs for a whole hour then the therapists go out looking very gloomy and say: "Nobody expressed any feeling. That was a bad group meeting, and a good group meeting is a group meeting where somebody expresses anger."

I once visited a clinic and passed through a group meeting, and at the staff conference afterwards everybody was saying, "Gee whiz, that was a good group meeting," except one nurse who looked sort of glum. I asked, "Don't you think it was a good group meeting?" She said no, and I asked why. She said, "Well, 1 was just transferred here from the medical service, and in the medical service patients are supposed to get better. I don't see why they're calling it a good group meeting because nobody got better." Which I thought was a very acute observation, but obviously she's going to be rapidly couch-broken so she'll soon think like all the others.

Properly played by the right people played seriously, poker is one of the few really existential situations left in the world. Now here's what I mean by existential: everybody's on their own. Nobody's going to feel sorry for you. You're fully responsible for everything you do. Once you put the money in the pot, you've put it in the pot. You can't blame anybody else. You have to take the consequences of that. There's no copping out. You can't talk your way into being a winner or a loser. All that counts is how much money you've got in your pocket when you hit the sidewalk, and that determines whether you're a winner or a loser, and nobody has to have a conference about it. It's really existential, and I think that's why people like it, and why a lot of people are quite devoted to it.

Another thing about it is you don't get any grants to play poker. Now grants are good in the physical sciences where people want to build an accelerator, and they have to go to the hardware store and need some money. In the behavioral sciences a grant is usually something you get when you don't know what you're doing. If you know what you're doing you usually don't need money. I never understand why people need money to do research unless they've got to go to the hardware store and buy something. And not a computer because I don't understand why people use computers in the social sciences when they're dealing with a few cases because you can do it yourself in an hour without bothering with a computer.

So in a way therapy should be like a poker game. In other words, the result is what counts. You're responsible for what you say. You shouldn't cop out and go and cry on somebody's shoulder at a staff conference. And if it is like a poker game, then there are certain unique features about it. For example, if you're a straight therapist then all your cards are up, while the patient has the privilege of keeping at least one of his cards turned down, so you're at a disadvantage. Of course you're supposed to be a professional and he's an amateur that's why he's allowed to have that advantage. And another thing about therapy is that the patient always has the joker. In other words, no matter how well it's going, how well you understand each other, the patient always has a thing that he can do that will really upset the applecart and there's nothing you can do about it. You can have the most beautiful therapeutic situation in the world and all the patient has to do it reach into his pocket, and he can destroy the whole thing or one of you. There's no towarding in poker. You either win or you lose. Your theory has to be based on practical things. All the armchair theories, like the rhythm theory, don't work in poker. There really isn't any rhythm to it. You've got to know what's happening with each hand. Also, nobody in poker ever ends the evening by saying, "We sure had some nice interpersonal interaction tonight, didn't we?" They say, "Well, that was a good game" - they use one syllable words. Another thing is there's lots of non - verbal stuff in poker. In fact a lot of the game depends on getting to know the other guys and what they are doing. So maybe what I'm saying is that big words are hiding the reality of what's going on between people.

Since we got poker into this, let me talk a little more about it. How you win at poker: First, it's a game of skill, not luck, in which you're dealt cards, and if you lose a hand that's not luck that's skill - you shouldn't have been in the hand if you lose the hand. So that's pure skill. And it's the same way, I think, in psychotherapy. If the therapy doesn't come out right you shouldn't have been in it or the cards weren't right, and you should have waited around a little longer or something should have been done. A lot of therapy is not scientific and is regarded as a matter of luck. Like people hold things called encounter groups. Now this may hurt your feelings. I don't understand encounter groups. They're purely empirical. Nobody really knows what they're doing. Nobody really offers to do anything, actually. But you do get good results. And that applies to a lot of therapy.

In other words, roughly speaking, most of the group therapy done in this country - by most I mean 51% could probably be just as well done by a sophisticated scout master. You know we all have a lot of education, and we use our degrees probably even less well than a good scout master would use his group skills. So if we took the trouble to go to all that college we should use that knowledge and not be trusting to luck or the fact that being in a room together is good for people in any case, so that an encounter group makes people feel good. Which brings me to another name for encounter groups which is sensitivity groups. My definition of a sensitivity group is a group where sensitive people go to get their feelings hurt, and I'm not sure that's all that good for them.

Another thing about poker is you've got to know what you're there for. You're there to win money, and that's all you're there for. And if you're not there to win money you're not going to have any fun and neither are the guys you're playing with. Then you have to know certain facts. You have to know the rules of the game. You have to know what the stakes are. And that's something you have to know in therapy as well. Another sort of analogy is that you can always tell a loser in poker, as I say, by the first three hands because he says "I should" or "If only" or "I want to see the next card." "I want to see the next card" is a staff conference. In other words, "If I had done it differently or if I had stayed in, what would have happened?" So after the patient's quit you go to the staff conference to see why he quit which is like seeing the next card, and the other guys will tell you what they should have done, but they don't know either so it's just sort of a mutual stroking situation.

I can think of several conversations I've had lately. I called a very, very well trained therapist about a patient, or rather he called me. For some reason those people always want to do a lot of talking about the patient when anything comes up. Well what happened is that he's seeing the wife five times a week and I'm seeing husband once a week, and he wanted to have a long conversation. And I said, "Well, the husband looks a little paranoid to me, and I'm afraid to cure paranoids because in my experience when you're just about to cure paranoids they often get a very serious physical disorder like a perforated ulcer or diabetes or a coronary." When I talk about being about to cure a paranoid I mean when he has talked about his anal - sadistic fantasies.

About the word "sadistic." Sadistic means hurting people and getting erections - that's sadistic. Masochistic is being hurt and having sexual pleasure. But sometimes people use sadistic or masochistic symbolically. So now anytime you don't like somebody you can say they're sadistic. But I like to stick to the original definition. Sadistic means somebody is getting pleasure out of inflicting physical injury. Otherwise the word is sort of useless. Well, paranoid people have sadistic fantasies, anal-sadistic fantasies. Now anal doesn't mean "I don't like you so I'm going to call you anal or compulsive or something," it means anal. So a paranoid has fantasies of sticking traumatic objects up people's rectums, like billy clubs - that's what he has. That's anal-sadistic fantasies, there's nothing symbolic about it. Now, if the paranoid patient gets so that he can talk about those - and I don't mean you just say, "Hey, man, let's bear your anal-sadistic fantasies." Say the relationship or the transference or whatever it turns out to be is good enough so that he is willing to tell you those fantasies, he's about ready to give them up and start living decently. And at that point, in my experience, he often gets physical illness, all of a sudden. There's nothing more sudden than a perforated gastric ulcer, for example.

So I said to this psychotherapist, "Whenever you try to cure paranoids..." and he said, "Oh, you don't want to cure them, just make them feel good or make them feel comfortable, make them able to live with it." Which I thought was rather typical of the common therapeutic attitude that you're not supposed to cure anybody.

And to another intensive psychotherapist I said, "Wow, I've just started with the brother and you've been seeing the sister for five years - you must know a lot about them. When is she going to get better?" And he said: "I'm in no hurry." And here's this woman with three little kids, and the therapist isn't in any hurry. Well, I'm in a hurry. I want to cure people. And I'm not interested in progress - progress is like trying. When a patient says, "I'm going to try to stop drinking," you know he isn't going to stop drinking, and that's that. So progress doesn't help anything. You get the patient well or you've got to win the pot.

And here I want to say something real dirty which is about psychoanalytic therapy. Now there are two different things - one is called psychoanalysis and the other is called psychoanalytic therapy. And, of course, everybody in the Psychoanalytic Institute knows, and a lot of other people agree with them, psychoanalysis is the real thing. The psychoanalyst says, "I can cure people" but if you learn psychoanalytic therapy you're not supposed to cure anybody because you don't know as much as the analyst and you're only supposed to make progress. So in a way the whole business of psychoanalytic therapy sounds to me like a joke laid on the residents by the instructors in which they're saying, "We'll teach you to do little things around the operating room but when it really comes to taking out the appendix you have to be like me." Well, surgeons don't teach their pupils that way - they tell them how to take out an appendix.

Another thing which is allied to that is the problem of comfort. "I'm not comfortable doing that kind of therapy." My reaction to that is if you're not comfortable why don't you be something else other than a psychotherapist? You have no business there. You're not there to be comfortable. You're there to cure patients. And the analogy is that you're a surgical resident and you say to the chief surgeon, "I'm uncomfortable in the operating room with gloves on," the chief surgeon doesn't say, "Well of course we can't have our residents being uncomfortable, you just come in the way you are - you don't even have to put a gown on." He says, "If you're not comfortable doing it right then go into some other specialty, like psychiatry."

Another one is: "You can't help anybody, they've got to help themselves." Now that is sheer baloney. People who are working in organizations don't really have to do anything as long as they follow the rules of the organization and play the game and don't cure too many patients (that really bugs the hell out of the people in such organizations; you will literally ,act fired, as we know from experience). But if you're in private practice and you're getting large fees for doing psychotherapy, you have got to produce. You can't sit around saying to a sensible person, "I can't help you. You've got to help yourself." You can say that to a jerk or somebody who has been couch-broken by previous therapy, but with real people you can't say that. If a guy who really knows his own job comes for psychotherapy and you say, "I can't help you; you've got to help yourself," he'll just walk out. And I don't blame him.

For instance, you know very well that you can talk people into killing themselves. You know you can talk people into getting drunk. Therefore, you can talk someone out of killing himself and out of getting drunk. But you've got to know how to tell him, what to do, and what to tell him. You can say to a Patient: "Don't kill yourself." Now if you say it wrong, you can then prove that you can't tell people anything because you said it to three patients and they all jumped off the bridge. They didn't jump off the bridge because you told them not to kill themselves, they jumped off the bridge because you told them wrong in order to prove that you can't help patients.

Another way that we get out of doing anything is the fallacy of the whole personality. "Since the whole personality is involved how can you expect to cure anybody, particularly in less than five years?" Okay. Well here's how. This has to do with a splinter in the toe. Now if a man gets an infected toe from a splinter, he starts to limp a little, and his leg muscles tighten up. Then as he keeps walking around, in order to compensate for his tight leg muscles his back muscles have to tighten up. And then in order to compensate for that his neck muscles tighten up; then his skull muscles; and pretty soon he's got a headache. He gets a fever from the infection; his pulse goes up. In other words everything is involved - his whole personality including his head that's hurting and he's even mad at the splinter or whoever put the splinter there, so he may spend a lot of time going to a lawyer. It involves his whole personality. So he calls up this surgeon. (The same surgeon who said: "If you're not comfortable you may come in and operate in your street clothes without wearing gloves.") He comes in and looks at the guy and says, "Well this is a very serious thing. It involves the whole personality as you can see. Your whole body's involved. You've got a fever; you're breathing fast; your pulse is up; and all these muscles are tight. I think about three or four years - but I can't guarantee results - in our profession we don't make any guarantees about doing anything - but I think in about three or four years - of course a lot of it is going to be up to you - we'll be able to cure this condition."

The patient says, "Well, uh, I'll let you know tomorrow." And he goes to another surgeon. And the other surgeon says, "Oh, you've got an infected toe from this splinter." And he takes a pair of tweezers and pulls out the splinter, and the fever goes down, the pulse goes down; then the head muscles relax and then the back muscles relax and then the feet muscles relax. And the guy's back to normal within forty - eight hours, maybe less. So that's the way to practice psychotherapy. Like you find a splinter and you pull it out. That's going to make a lot of people mad, and they'll prove that the patient was not really cured, or they'll prove that the patient was not completely analyzed. And it's not cricket to say, "Okay, doctor, how many patients have you completely analyzed?" Because the answer to that is: "Are you aware of how hostile you are?" So everybody's writing papers. And there's only one paper to write which is called "How To Cure Patients" - that's the only paper that's really worth writing if you're really going to do your job.

Let me talk about a couple of other things - sort of anecdotal. I have a friend in Czechoslovakia who was a creative writer and was publishing books. Now she writes me and asks for two things: One is American short stories, so I send her the "New Yorker," and I get Groovy Press to send her some books of short stories. And the other thing she wants is a sedative. So that's what there is to do in Czechoslovakia. There's nothing they can do except take sedatives or get killed, so that if you're not ready to get killed you take a sedative. So that's how politics fits into psychiatry which I'm sure my friends in radical psychiatry will be interested to hear. So it's very much the same as giving your patients pills; it's great, but it doesn't sound to me like a very nice idea to have patients walking around vegetating. Running through this I think you will hear the dread medical model of psychotherapy, which scares the hell out of people - gives them nightmares. But I think it's a very good model. That's because it works for other conditions, and if you are going to cure people's heads I think you should use the medical model.

Personally I'm a head mechanic - that's all I am. Like you come in with wheels wrong in your head, and I'll say, "Okay we'll try and fix your head. What goes on outside your head belongs in a different department than I deal with, and I might be interested in dealing with it but I don't feel that that is my primary job." And if you're going to do that then the first thing you have to learn is simple, pure psychotherapy. In order words: there's a patient sitting there in a chair and you're sitting there in a chair, and there's no gadgets. There's just two people - that's all there is. And two chairs for comfort. Some people don't even use the chairs. So a real psychotherapist's problem is: What do I do when I'm in a room with a person who is called a patient if I am called the therapist? Absolutely no gadgets - no note papers, no tape recorders, no music, nothing. That's how you learn to do psychotherapy. Now once you learn how to do that and are an expert at that, then you can start introducing trimmings. But to me the introduction of devices and trimmings into any kind of psychotherapy usually means that the therapist doesn't know what he's doing. It's pretty hard to know what you're doing in psychotherapy because most of it is about at the level of the University of Paris faculty of medicine in the 16th century when people were using a lot of big words and they were having a lot of staff conferences, but none of the patients were getting better. Okay. I guess that's it.

Eric Berne (1910-1970) was the founder of Transactional Analysis and The International Transactional Analysis Association. This lecture was his last public speech. It was given on June 20, 1970, at the Golden Gate Group Psychotherapy Association's yearly conference. He was the keynote speaker.